surface tesselation language  split-thickness skin graft  transverse cervical artery  temporalis fascia  transfixion incision  tetanus immune globulin  temporomandibular  temporalis muscle flap   Positron emission tomography and other radioisotope imaging  Picture archiving and communication systems    Maxillofacial imaging has evolved in parallel with the  development of newer imaging technologies. Traditional  plain radiography and dental imaging are now frequently  supplemented by cross-sectional modalities such as com-  puted tomography (CT), magnetic resonance imaging  (MRI) and ultrasound, together with functional imaging  modalities such as positron emission tomography (PET).  It is important to be aware of the benefits and limitations  of such imaging examinations as they are applied to the  appropriate clinical scenario.    Some imaging investigations use ionizing radiation which  has the potential to result in biological damage. The  aim of radiation protection is to provide a safe environ-  ment for the worker and patient. The Ionizing Radiation  (Medical Exposure) Regulations 2000 (IRMER) lays  down basic measures required for protection against the  harmful effects of medical radiation exposure. There were    minor amendments to this legislation in 2006 and 2011.  There are duties of the ‘employer’ who provides a frame-  work within the area where the exposures take place, the  ‘operator who carries out the exposure, the ‘practitioner’  who justifies the exposure and the ‘referrer’ who request  the exposure. Key principles are that (1) the examination  should be of sufficient benefit to justify radiation expo-  sure, (2) dose is optimized by the ALARA (As Low As  is Reasonably Achievable) principle and (3) dose limits  should be recorded.    X-rays are produced by a point source and, after passing  through the body part of interest, are detected by non-  screen (dental radiography) or intensifying screen/film  combinations (extraoral radiography). Selected facial  radiographic views are listed in Table 1.1. Tomography  refers to a technique whereby the x-ray source and film  move during the exposure. The aim is to demonstrate only  a ‘section’ which is in focus whereas structures outside  this section are blurred. Applications include conventional    4 Imaging techniques, including computed tomography-guided biopsy and fluorodeoxyglucose-positron emission tomography    Mid and upper third  OF 25 (modified Caldwell view)  Occipito-mental (OM)  OM 10  OM 30   Superior view of malar arches and inferior orbital margins  Preferable to submentovertical (SMV) view    dental panoramic tomography, tomograms of the tem-  poromandibular joints and mandibular tomograms for  implant planning.   Digital radiography units (using digital receptors to  intercept the x-ray beam rather than intensifying screens)  are now replacing conventional units. This allows trans-  mission of data to image processing and storage devices as  well as communications networks.    Contrast media may be introduced into a vessel, lumen or  cavity in order to render it radio-opaque and hence radio-  graphically visible. This may then be viewed ‘real time’ with  fluoroscopic imaging or with serial radiographs. Contrast  media used for this purpose include barium sulphate sus-  pensions and non-ionic iodinated contrast agents. There  is a small risk associated with the intravascular iodinated  contrast agents which must be weighed against the poten-  tial benefits. Information which should be sought from  the patient before contrast injection includes previous  contrast reactions, asthma, renal problems, diabetes and  metformin therapy.    1. Angiography: Conventional angiography is generally  performed as a precursor to interventional radio-  logical techniques. CT and magnetic resonance (MR)  angiography have largely replaced diagnostic appli-  cations in maxillofacial pathology. It remains appro-  priate for the planning of embolization of high-flow  vascular malformations and tumours (Figure 1.1)  and for the evaluation of arterial injury (traumatic  or tumour erosion). Angiographic catheters are gen-  erally introduced over a guidewire via a common  femoral artery puncture. Small calibre microcatheters  may be introduced into distal external carotid artery  branches.    2. Barium/contrast studies: Contrast swallows, with bar-  ium or iodinated contrast medium, may be required  to evaluate for high dysphagia and pain or for post-  operative anatomotic leaks. Rapid serial radiography or  video recording may be used to assess the hypopharynx  and upper oesophagus during deglutition (Figure 1.2).  Barium may be combined with a gas-producing agent  and an intravenous smooth muscle relaxant to produce  ‘double-contrast’ images of the lower oesophagus. If  aspiration or tracheo-oesophageal fistulation is sus-  pected, then a low osmolar iodinated contrast medium  will be used.   3. Sialogram: Iodinated contrast medium may be intro-  duced into the salivary duct ostium via a polythene  catheter. Fluoroscopy or radiography is used includ-  ing delayed images after administration of a siala-  gogue. This is compared with preprocedure ‘control’  films.    Figure 1.1 Lateral projection in the arterial phase of a com-  mon carotid angiogram demonstrates a vascular blush arising  from the maxillary artery secondary to a juvenile angiofibroma.    Figure 1.2 Oblique projection of a barium swallow dem-  onstrates a pharyngeal pouch (white arrowhead).    4. Sinogram/fistulogram: A sinogram involves the inser-  tion of a fine catheter into the orifice of a sinus and  injection of contrast medium to delineate a sinus or fis-  tula. If there is a complex tract then it may be combined  with CT.   5. TMJ arthrogram: lodinated contrast medium is injected  into the joint under fluoroscopic guidance and double-  contrast studies may be achieved by contrast with-  drawal and replacement with air, although this is now  rarely performed.   6. Dacrocystogram: The nasolacrimal sac and duct may be  cannulated and injected with contrast medium in patients  with epiphora. The lacrimal drainage system may also  been evaluated with CT and MRI following conjunctival  application of contrast medium.   7. Percutaneous venogram: Percutaneous venography may  be used as a precursor to sclerotherapy for the assess-  ment of volume and venous ‘run off’ in the sitting of  low-flow venous malformations. A similar technique  (lymphogram) is used for a lymphatic malformation.  Ultrasound is used to guide the needle placement if the  lesion is not clinically palpable.    CT is an imaging modality which is rapid and widely avail-  able. A CT scanner consists of an x-ray tube which sends a  fan of x-rays through the patient and the attenuation of the  beam by the patient is detected. The process is repeated as  the tube and detectors rotate and the patient is advanced  through the scanner. The degree of x-ray absorption by    each volume of tissue (voxel) is displayed as a pixel which  is allocated a number (Hounsfield unit) (Table 1.2). This  information may be digitally manipulated so as to best  demonstrate the tissues of interest (e.g. by changing the  range of ‘numbers’ in the grey scale or ‘window width’ or  by using algorithms to alter the ‘sharpness’ of the image).  The same information may be used to provide multiplanar  reformats or rendering of three-dimensional (3D) objects  to facilitate visual assessment. Imaging of soft tissues gen-  erally requires the administration of iodinated contrast  medium to enhance pathological tissues and help delineate  vascular structures from other soft tissue such as lymph  nodes. Artefact from metallic materials such as dental res-  toration may markedly degrade imaging of the face due to  ‘beam-hardening artefact’; however, there are methods to  reduce this, such as specific angling of the scan plane or the  use of specific image reconstruction techniques. The avail-  ability of CT fluoroscopy and ‘in room’ CT controls/moni-  tors has improved the safety and efficacy of CT-guided  biopsies of deep facial and skull base lesions (Figure 1.3).   Contemporary multislice computed tomography (MSCT)  differs in that a number of slices are obtained per tube rota-  tion. Current scanners are typically 64 slices with 256 or  320 slices being used for some applications. MSCT has the  potential to scan standard volumes with shorter acquisition  times so reducing movement artefact (e.g. due to swallow-  ing) or requirement for sedation and optimizing vascular  opacification (e.g. for CT angiographic studies) (Figure 1.4).  It also allows the scanning of larger volumes or the use of  narrower section thickness (as low as 0.3-0.5 mm) so opti-  mizing the 3D data set for post-processing and interactive  3D image-guided surgery. The large number of images gen-  erated by MSCT potentially impacts on workstation perfor-  mance and picture archiving and communication systems  (PACS) archiving/networking.   The benefits of CT (Table 1.3) should always be weighed  against the risks of ionizing radiation exposure. Whilst  imaging of soft tissues requires higher radiation doses and  hence strong clinical justification (typical effective dose  for brain CT is 2 mSv which is equivalent to 100 chest  radiographs or 10 months of natural background radia-  tion), low-dose imaging focused on bony detail (e.g. “den-  tal CT’ for implantology) may be performed with 0.2-0.3  mSv whilst 3D cephalometric bone landmarks may be  identified at doses approaching a radiographic series.    6 Imaging techniques, including computed tomography-guided biopsy and fluorodeoxyglucose-positron emission tomography    (a) Computed tomography (CT) displayed with  soft-tissue windows demonstrates a preclival abscess and cen-  tral skull base destruction resulting from tuberculous osteo-  myelitis. (b) CT displayed with bone windows delineates the  core biopsy needle within the abscess.    Manufacturers have developed various dose reduction  techniques on contemporary CT scanners.   Cone beam computed tomography (CBCT) has devel-  oped as a technique which provides high-resolution 3D  data at low-radiation doses (e.g. equivalent to 2-8 OPGs).  The equipment may resemble that of a conventional dental  panoramic tomography unit (patient erect) or may mimic  a conventional CT scanner (patient supine). A cylinder- or  sphere-shaped volume of data is rapidly acquired with a  single tube rotation. Some CBCT equipment is designed to    Lateral maximum intensity projection of a CT  angiogram demonstrates a post-traumatic pseudoaneurysm  of the internal carotid artery.    Advantages and disadvantages of computed  tomography (CT) and magnetic resonance imaging (MRI).    simulate intraoral radiographs by imaging small volumes  (e.g. two to three teeth) at high resolution, whilst other  equipment is designed to image the whole maxillofacial  region (e.g. 15 cm? spheres). The low tube currents utilized  to reduce the radiation dose unfortunately preclude ade-  quate imaging of soft-tissue structures. Evidence-based  guidelines for the use of CBCT in dental and maxillofacial  radiology have been produced by the SEDENTEXCT proj-  ect (www.sedentexct.eu/files/guidelines_final.pdf).    MRI does not require ionizing radiation so should be pre-  ferred in cases where it would provide similar information  to CT and both are available. Advantages and disadvan-  tages relative to CT are shown in Table 1.3. There are con-  traindications to the use of MRI including metallic foreign  bodies in the orbit as well as many intracranial aneurysm  clips, cardiac pacemakers and cochlear implants. There is  guidance from manufacturers and additional third-party  testing of many medical devices, implants and materials  and they are classified as ‘safe’, ‘conditional’ (no known  hazard in a specified MRI environment under specified  conditions) or ‘unsafe’.   The MRI signal is tissue dependent and is based on  the behaviour of protons within the tissue when they are  exposed to radiofrequency pulses within a magnetic field.  Signal can be resolved into two components (T1 and T2).  Selecting appropriate pulse sequences allows images to  reflect the T1-weighted (T1-w) or T2-weighted (T2-w) char-  acteristics of tissues. Most pathology results in increased  water content relative to normal tissues and thus is shown  as decreased signal on T1-w images and increased signal on  T2-w images (Figure 1.5). There are various other tissues  and substances which may be distinguished by differing  MRI signal (Table 1.4). MRI contrast enhancement may be  achieved with gadolinium-based agents. Patients requiring  gadolinium are evaluated for the presence of severe renal  insufficiency as there is a rare association with nephro-  genic systemic fibrosis (NSF). Pre- and post-gadolinium  (contrast medium) sequences should be performed with  T1-w. T1-w sequences may also be combined with fat satu-  ration post-gadolinium such that increased signal due to  enhancement is not masked by that due to fat. Pathological  lesions undergo variable enhancement and gadolinium is    Figure 1.5 Axial T2 weighted fat saturated magnetic res-  onance imaging (MRI) shows a T2 hyperintense left second  branchial cleft cyst.    used to help characterize lesions. Normal structures that  markedly enhance include mucosal linings and lymphoid  tissue. The short-time inversion recovery (STIR) sequence  has been shown to be very sensitive to pathology which  generally demonstrates increased signal. Multiplanar  imaging (coronal and axial imaging as a minimum) is rou-  tinely performed with 4-5 mm section thickness. There is  continued improvement in the diagnostic quality of volu-  metric sequences which are likely to be increasingly used.   Typical imaging sequences for a study of the face and  neck would include Tl-w axial, T2-w axial, T1-w post-  gadolinium axial, STIR coronal and T1 fat saturated post-  gadolinium coronal images. Diffusion weighted imaging  (DW]) is also a routine sequence in many centres, and has  a developing role, being particularly useful in the assess-  ment of post-chemoradiotherapy residual tumour.   MR angiography may demonstrate flow in relation to a  vessel lumen with or without the use of gadolinium. Other  MRI techniques (such as spectroscopy, diffusion and per-  fusion imaging), higher field magnets (3 T as opposed  to standard 1.5 T) and novel contrast agents, have been  applied to the face and neck although clinical utility is not  yet established.    Table 1.4 Magnetic resonance imaging characteristics of tissues relevant to face and neck MRI.    Proteinaceous secretions, fat, gadolinium enhancement, subacute haemorrhage, slow  flowing blood (e.g. veins)    Most pathology (note: cellular tumour is intermediate T2-w signal, whereas necrosis/cyst/    8 Imaging techniques, including computed tomography-guided biopsy and fluorodeoxyglucose-positron emission tomography    PET differs from the previously mentioned anatomical  techniques in that it provides functional imaging of meta-  bolic activity. This has proved very useful in the setting  of maxillofacial malignancy (Figure 1.6) with improved  diagnostic accuracy relative to CT and MRI. Most PET  imaging studies of the head and neck use the short-lived  radiotracer 18-fluorodeoxyglucose (!*FDG) which allows  an examination of altered glucose metabolism as a marker  of tumour activity. This unstable radioisotope releases a  positron over a short distance after which it annihilates  with an electron and emits the photons that are detected.  This process of photon production implies a lower limit  of spatial resolution (3-4 mm) so PET does not provide  the same anatomical detail as CT or MRI. To improve the  localization of pathology, PET images were initially co-  registered with CT or MR images; however, techniques  have now progressed such that functional and anatomi-  cal CT images (PET-CT), and now MRI images (PET-MR)  may be obtained on the same scanner.   It should be noted that the CT component of such  PET-CT scanners may be performed without contrast  medium and does not generally use the same param-  eters as diagnostic CT so it may not be a direct substitute.  Multiple slices are obtained and multiplanar reformats  are routine. A dedicated head-and-neck field view may be  followed by a separate half-body study. PET-MR is only  currently available at a few centres and its exact role in  maxillofacial imaging is yet to be defined.   PET must be interpreted with an awareness of the limi-  tations in detecting small volume (particularly <3-4 mm)  disease, including superficial mucosal lesions, lymph node  micrometastases and necrotic lymph nodes. Some tumours  such as salivary gland tumours are not *FDG avid. Some  centres use an objective measure of FDG uptake (SUV) to  help distinguish a malignant lesion. There are also pitfalls    due to false-positive findings resulting from normal tracer  distribution (e.g. salivary and thyroid gland, muscle activ-  ity and Waldeyer's ring) and inflammatory tissue (e.g. lymph  nodes, early stages post-tumour treatment and healing bone).   Other radioisotopes used in the investigation of maxil-  lofacial disease include the following:    1.°°™Tc-MDP for the evaluation of bone disease (e.g.  condylar hyperplasia, degree of activity in fibroosse-  ous lesions, bone metastases, bone invasion by tumour,  osteomyelitis, integrity of blood supply in radionecrosis  or vascularized grafts).   2. "Indium-labelled and °°™Ic-HMPAO-labelled leuko-  cytes together with °’Ga-gallium citrate for the diagno-  sis and localization of infection or inflammation in soft  tissues.   3. °™Tc-pertechnetate for dynamic salivary gland imag-  ing or to detect ectopic thyroid tissue.    PACS is a technology which enables the storage and  archiving, retrieval, secure networking and display of  imaging studies. It overcomes the difficulties of manu-  ally storing and reviewing traditional hard copies. The  universal format for PACS image storage and transfer  is DICOM (Digital Imaging and Communications in  Medicine). Additional advantages of PACS are the abil-  ity to access remotely, to help manage workflow and to  interact with other systems (e.g. radiology information  systems).    Tables 1.5 through 1.16 provide information on imaging in  different clinical scenarios.    Figure 1.6 Axial sections of a positron emission tomography-—computed tomography (PET-CT) study: CT (left), PET (middle),  fused PET-CT (right). Patient presented with a right level 2 lymph node and an unknown primary tumour. 18-Fluorodeoxyglucose  ('8FDG) uptake is demonstrated within the lymph node and related to a right tonsilla fossa primary carcinoma. Note the physiological   Low-dose CT with 3D Delineate extent and Always consider intracranial and cervical spine imaging in the early  post-processing displacement of management of high energy facial injury   Standard CT fractures CT is also required for suspected craniofacial injury or when there is    displaced fractures of _as a precursor to surgery  frontal sinus posterior Standard (non-low dose) CT may be used to evaluate orbital or  wall cranial soft-tissue complications  3D data set post-processing may be used for modelling of implants  and to aid surgical planning in patients with complex fracture  geometry (Figure 1.8)  MRI Soft-tissue (including  intracranial)  complications  Others: ocular ultrasound, Soft-tissue Selected cases depending on clinical findings  dacrocystography, sialography, CT complications  cisternography    Figure 1.7 (a) Occipito-mental (OM) view demonstrates a  right orbital floor fracture with soft tissue prolapsing into the  maxillary antrum and a fluid level. (b) Coronal CT study in a  patient with an orbital floor fracture and persistent diplopia  reveals prolapse of orbital fat and distortion of the inferior rec-  tus muscle.    Figure 1.8 Volume-rendered lateral projection of a 3D CT  data set. There is a comminuted left zygomatico-maxillary  fracture (arrows).    10 Imaging techniques, including computed tomography-guided biopsy and fluorodeoxyglucose-positron emission tomography    Isolated sagittal, metopic or unilateral coronal synostosis may  be confirmed with radiography   CT with post-processing is more definitive and superior for  defining foci of sutural closure. Required for surgical planning  and for assessment of complex craniofacial anomalies/petrous  temporal bone anomalies   3D data set may be used for pre-operative surgical stimulation  with stereolithography or fused deposition modelling    MRI better for assessing deep extent and for further  characterization of lesions   For assessment and potential embolization of high flow  arteriovenous malformations/fistulae and tumours (alone or as  precursor to surgery)   For assessment and sclerotherapy (STS, alcohol) of low-flow  venous malformations and lymphangiomas   Contrast-enhanced CT and gadolinium-enhanced MRI  equivalent for assessing phlegmon versus abscess (Figure 1.9)    signal corresponds to active  infection in the medullary cavity  Osteolysis in the acute phase with  subsequent periosteal reaction  Sclerosis sequestration in subacute/  chronic osteomyelitis  Multifocal disease    OPG helpful for assessing dentition and predisposing  conditions such as fractures or systemic bone disease   MRI should be primary cross sectional imaging for acute and  chronic osteomyelitis    CT superior for detecting the degree of cortical destruction,  presence of sequestra and the degree of cortical removal that  would be required (Figure 1.10)    Figure 1.9 Axial contrast-enhanced CT section reveals ring  enhancing abscesses (arrows) within the left masticator space  including the left submasseteric region.    Figure 1.10 (a) Orthopantomogram (OPG) and (b) axial CT  section imaged on bony windows. There are medullary lysis,  cortical irregularity and sequestration related to left subacute  mandibular osteomyelitis.   Nodal metastases (especially if outside area of  intended neck dissection and for radiotherapy  planning)   + Any potential skull base or intracranial involvement  (e.g. nasopharynx) (Figure 1.11)   + To attempt better definition of poorly defined  primary lesion on CT, particularly for radiotherapy  planning (e.g. oropharynx)   MR and CT complementary for paranasal sinuses  tumours and mandibular invasion (CT initially  preferred)    12 Imaging techniques, including computed tomography-guided biopsy and fluorodeoxyglucose-positron emission tomography   * Conventional (CT/MRI) assessment not fully  delineated recurrence (due to scar tissue)   + Occasionally before undergoing treatment with  curative intent to exclude other synchronous  primaries/metastases   3. In the setting of an unknown primary tumour  ideally prior to panendoscopy and biopsy  4. Rarely for assessment of primary or nodal disease  for primary staging  Ultrasound + There are advantages of ultrasound (relative to  MRI/CT) for nodal assessment   + Ultrasound uses additional criteria to detect  smaller pathological nodes and may also be used  to guide fine needle aspiration (FNA)    Chest staging: CT chest (usually including upper abdomen) usually  CXR, CT indicated but depends on local protocols  note high incidence of non-specific small nodules  which will be detected    Figure 1.11 Coronal post-gadolinium T1-weighted MR image demonstrates intracranial extension of a nasopharyngeal carci-  noma with widening of the foramen ovale (arrow) and infiltration of the cavernous sinus.   MRI (with gadolinium) has potential to distinguish  between cysts and benign tumours (Figure 1.12)    (a) Multiple expansile lucencies within the  maxilla and mandible bilaterally are seen in this patient with  cherubism. (b) Bilateral well-defined soft-tissue opacities  expand the maxillary antra (more markedly on the right) and  displace left-sided teeth superiorly. Bilateral odontogenic ker-  atocysts were discovered at operation. (c) T2-weighted axial  MR image demonstrates a complex (partially T2 hyperintense  and isointense) ameloblastoma involving the parasymphyseal  mandible and displacing the extrinsic tongue muscles.    14 Imaging techniques, including computed tomography-guided biopsy and fluorodeoxyglucose-positron emission tomography    Tomography or cone beam computed  tomography (CBCT) required for direct  measurement of prospective implant site   Tomography adequate for limited region  and where there is no significant anatomical  variation   CBCT is ideal for implant assessment  Conventional-conventional CT has increased  radiation dose and cost   3D data sets and new 3D cephalometric landmarks  will overcome the problems of magnification and  distortion due to severe facial asymmetry   Diagnosing ductal obstruction (calculi and  strictures) and demonstrating appearance  of ductal system (e.g. in connective tissue  disease)   Delineating extent (e.g. deep lobe of  parotid, perineural extension) of salivary  gland tumours    Ultrasound is the primary imaging modality for  most salivary gland disease and guides FNA   Indicated if proximal extraglandular calculus  demonstrated by ultrasound (as a precursor to  potential radiological intervention for smaller  calculi)   In the presence of severe obstructive symptoms/  sialadenitis (if no calculus demonstrated) in  order to detect stricture    MRI is ideal (and superior to CT) for assessing  deep lobe of parotid masses (Figure 1.13),  perineural extension of malignant tumours and  recurrent tumours   MR sialography is used in some centres to  evaluate ductal disease    Figure 1.13 T1-weighted MR image shows a parotid mass  centred in the deep lobe which displaces the parapharyngeal  fat medially (arrow).    extension, to identify  additional lesions and for  staging of malignancy  CT guided biopsy may be  required for deep face  and skull base lesions    Figure 1.14 Oblique sagittal proton density-weighted MR  images in (a) closed and (b) open mouth positions demon-  strate a distorted anteriorly displaced and distorted meniscus  (arrows) which does not reduce on mouth opening.   The utility of radiography (generally OPG) is limited although it  may be used to demonstrate gross bony changes associated  with the arthritides   MRI (Figure 1.14) is non-invasive so has gained greater  acceptance than arthrography   Scanning position and basic technique  Indications for head and neck ultrasound  Acknowledgment    Ultrasound imaging does not require ionizing radiation  and is a relatively inexpensive, non-invasive and readily  available technique which is well tolerated by patients. It  is particularly useful in examining superficial structures  (less than 5 cm deep to the skin surface), where the use of a  high-frequency linear probe (7.5-12 MHz) produces high  definition images in multiple imaging planes. The spatial  resolution achieved by ultrasound surpasses that of either  computerized tomography (CT) or magnetic resonance  imaging (MRI), and when combined with tissue sampling  techniques (percutaneous fine needle aspiration [FNA] for  cytology or core biopsy for histopathology), ultrasound is  a highly specific diagnostic tool.   Clinicians who have detailed knowledge of the anatomy  of the head and neck region may choose to learn how to  use ultrasound as an adjunct to clinical examination and  as an aid to biopsy techniques. This chapter aims to give  an overview of the use of ultrasound in the neck with  relevance to clinicians who either want to gain a greater  understanding of the technique or who wish to begin to  use ultrasound in their practice.    An ultrasound image represents the reflection and scat-  tering of ultrasound waves caused by variation in acous-  tic impedance by the various tissues being scanned. A  detailed discussion of the physics involved is beyond the    scope of this text but essentially the ultrasound probe acts  as both transmitter and receiver for sound waves. Images  are generated by computerized analysis of the sound waves  reflected back to the probe. The higher the frequency of the  sound wave generated the greater the resolution obtained,  but there is a resultant fall off in penetration with higher  frequencies. Typically 8-12 MHz probes are used in assess-  ment of the neck, giving improved resolution for superfi-  cial structures but with reduced penetration, i.e. a failure  to generate images of deeper structures. This trade-off is  not usually a problem in the neck.   Air causes marked scattering of the ultrasound wave;  hence, gel is used as the interface between skin and probe  to optimize the throughput of the sound wave signal. Gas  and bone represent a problem as far as ultrasound is con-  cerned; gas will cause scatter which results in a ‘white out’,  while bone and other calcified structures transmit little  sound causing acoustic shadowing (black hole). In gen-  eral, highly reflective tissues appear echogenic (white) on  an ultrasound image whereas structures with poor reflec-  tivity (e.g. blood within the internal jugular vein [IJV])  will be hypo-echoic (black) on an ultrasound image. The  high reflectivity of some tissues may be desirable (e.g.  identification of a core biopsy needle with ultrasound) or  undesirable (e.g. a calcified thyroid lamina which prevents  assessment of the larynx).   Sadly for the uninitiated, not all hypo-echoic structures  are cystic or fluid in composition. Solid structures in the  neck that may appear typically hypo-echoic or ‘pseudo-  cystic’ (i.e. black) include lymphoma, salivary pleomor-  phic adenomata, nerve sheath tumours and parathyroid    adenomata. Conversely, some cysts do not abide by the  rules of physics - a ‘true’ cyst should be hypo-echoic or  black on ultrasound but commonly the congenital cysts of  the neck (e.g. branchial and thyro-glossal duct cysts) often  appear echogenic, i.e. pseudo-solid in appearance.   Colour and power Doppler may be used to assess flow  in normal vascular structures (e.g. assessment of carotid  arteriopathy and venous thrombosis) and abnormal flow  in pathological processes (e.g. hilar vessels in metastatic  nodal disease). Colour flow Doppler is standard on most  modern machines and can help the beginner to find vas-  cular structures. A power Doppler function is useful for  assessing flow patterns, such as the vascularity in lymph  nodes (Figures 2.1 and 2.2).    The operator will normally be positioned to the left of the  patient, but for biopsies of the left cervical region recom-  mended operator position is to the right of the patient.    Figure 2.2 Exaggerated blood flow, seen on colour flow  Doppler in a lymphoma node.    There must, therefore, be adequate space to allow a range  of operator positions in relation to the patient.   The patient should be positioned with the neck extended,  using a pillow behind the shoulders. This is sometimes  difficult to achieve in patients with cervical spondylosis,  in which case the procedure can be performed with the  patient sitting or at 45°. Comfort, both of the patient and  operator, is essential.   The choice of where to start scanning will depend on the  clinical scenario. For example, for a patient with a lipoma  of the posterior triangle, a detailed assessment of both  sides of the neck is not required, whereas a patient with a  squamous cell carcinoma (SCC) primary who is undergo-  ing a staging scan of the neck needs a bilateral assessment  of all the major lymph node territories in the neck.    Sonographic criteria for lymph node assessment have  been extensively described in the literature. Normal nodes  have a well-defined ellipsoid or fusiform shape, with an  intermediate to low reflectivity homogeneous cortex and  highly reflective central hilus. Overall length is irrelevant,  with normal cervical nodes frequently measuring 3 or  4 cm in maximum longitudinal (L) dimension. However,  short-axis (S) measurements should not normally exceed  10 mm. An S/L ratio greater than 0.5 implies a round node:  the more rounded a node, the more likely it is to contain  metastatic disease (Figure 2.3). However, in the subman-  dibular and submental regions, normal nodes tend to be  more rounded or reniform, and here shape alone should  not be used as a predictor of malignancy. Intra-nodal ves-  sels are visible with colour imaging, and in benign nodes  are typically central or hilar in distribution.   Abnormal nodes display reduced reflectivity (i.e. tend to  be hypo-echoic or ‘black’) with a tendency to lose the cen-  tral echogenic hilus. Short-axis measurements increase,  giving a rounder rather than elongated shape. Vascularity  may increase and have a disordered pattern. Peripheral  or subcapsular vessels, in particular, are a strong sign of  malignancy.   Lymphomatous lymph nodes characteristically appear  rounded, often retaining a central echogenic hilus and pos-  sess a homogenous, hypo-echoic (pseudo-cystic) cortex  (Figure 2.4). Colour flow imaging often reveals plethoric    hilar vascularity (ie. an exaggerated benign flow pattern)  (Figure 2.2). Identification of these characteristics should  prompt the operator into carrying out a core biopsy or  recommending excision biopsy depending on local prefer-  ence to allow rapid diagnosis.    The most common problems encountered include sialoli-  thiasis, inflammatory conditions and tumours.    The normal submandibular glands are homogeneous  echogenic (bright) structures lying infero-lateral to the  mylohyoid muscle in the submandibular space. Intra-  glandular ducts are visible as short defined hyper-echoic  lines but Wharton’s duct is only usually visualized when  it is dilated. Lymph nodes in the submandibular space are  exclusively extra-glandular.    The parotid gland lies in the parotid space which is the  most lateral space in the nasopharyngeal area, extending  from the external auditory canal superiorly to the level of  the angle of the mandible inferiorly. The gland is arbitrarily  divided into superficial and deep lobes by the facial nerve,  but this structure cannot be identified with ultrasound.  The retromandibular vein passes superiorly through the  parotid and can be used as a landmark for dividing the  parotid into superficial and deep lobes, i.e. as a predictor of  likely proximity of a mass to and involvement of the facial  nerve. The external carotid artery passes through the  gland deep to the retromandibular vein. Intra- and extra-  glandular nodes are seen in the parotid space. Stenson’s  duct may be visualized as bright parallel echogenic lines,  3 mm in diameter within the superficial lobe.    Intra-glandular calculi are easier to identify than ductal  stones. Frank duct dilatation (Figure 2.5) or sialectasis  may be seen, and ultrasound will also demonstrate the  complications of calculi; abscess formation and sialocele.   Ultrasound cannot definitively exclude calculi, if there  is a strong clinical suggestion of salivary duct obstruction  and ultrasound examination is negative, sialography will  be required in order to exclude a stone/stricture.    Acute salivary gland inflammation occurs in response to  suppurative sialadenitis and viral infection. Inflammation  causes gland hypertrophy and hypo-echogenicity, i.e.  the salivary glands lose their normal bright echotexture.  Ultrasound can be used to exclude abscess formation and  may demonstrate hyper-reflective microbubbles of gas  in suppurative sialadenitis, which usually affects a single  gland, along with reactive nodes. In the case of abscess  formation in acute suppurative sialadenitis, ultrasound-  guided percutaneous drainage combined with antibiotic  therapy may avoid surgical intervention.    Therearetwochronicconditions which causea distinctive  ‘leopardskir’ or ‘currant cake’ appearance, namely juvenile  chronic sialadenitis and Sjogren’s syndrome. The distribu-  tion of the changes allows a distinction between the two  conditions. In Sjogren’s disease, the changes are classically  bilateral, affecting parotid and submandibular glands,  whereas in juvenile chronic sialadenitis there is unilateral  change. The classical findings of Sjogren’s disease on ultra-  sound obviate the need for sialography.   The association of Sjogren’s disease with lymphoma  needs to be recognized and if a hypo-echoic mass is seen  within an affected salivary gland, lymphoma must be  considered.    Approximately 80% of salivary tumours are benign, 80%  occurring within the parotid with 80% of these being pleo-  morphic adenomata. The vast majority of parotid tumours  lie within the superficial portion of the gland, allowing  easy assessment with ultrasound. However, in the case of  large or deep masses, the deep extent of a lesion can be  difficult to assess (necessitating CT or MRI). Ultrasound  cannot always predict whether salivary gland lesions are  benign or malignant (although irregularity, abnormal vas-  cularity and the presence of enlarged or suspicious nodes  aids accuracy), and is usually used in conjunction with  fine-needle sampling. The smaller the salivary gland the  more likely that any tumour detected will be malignant,  ie. a tumour in the sublingual gland has a far higher like-  lihood of malignancy compared to a mass in the parotid  gland.    This accounts for 80% of parotid tumours, arising in the  superficial gland in 90% of cases and typically occurs in  females over 40 years of age. On ultrasound, pleomorphic  adenoma has the appearance of a well-defined, hypo-  echoic homogeneous solid mass (pseudo-cystic) with a  lobulated border and internal vascularity and may display  posterior acoustic enhancement. Smaller adjacent daugh-  ter tumours are often identified. Cervical lymphadenopa-  thy is not usually seen.    Warthin’s tumour commonly occurs in the elderly male  (>50 years) as a lump in the parotid tail, sometimes bilater-  ally (15%) and is rarely seen in the submandibular gland.  It arises from heterotopic salivary gland tissue in parotid  lymph nodes. On ultrasound, a Warthin’s tumour is usu-  ally well-circumscribed and measures less than 3 cm in  size. It typically contains heterogeneous cystic and solid  areas, or appears pseudo-cystic with through the trans-  mission of sound (posterior acoustic enhancement)  (Figure 2.6).   Other malignant salivary gland tumours (muco-epi-  dermoid, adenoid cystic and acinic cell carcinomas) occur  more frequently in the sublingual and submandibular  glands than in the parotid glands. Features suggestive of    malignancy include poor definition with heterogeneous  echotexture, disorganized colour flow and the presence of  associated nodes. Using these criteria, malignancy can be  predicted in around 80% of cases using ultrasound alone.    A detailed description of thyroid ultrasound is beyond the  scope of this text; however, thyroid disorders, including  generalized gland enlargement and focal nodules, are rela-  tively commonly encountered in clinical practice. In the  one-stop clinic environment, thyroid nodules are likely to  represent the second most common presenting mass, after  lymph nodes. The increasing use of ultrasound means that  the incidentally detected thyroid nodule is an increasing  problem; ultrasound will detect nodules in between 50%  and 70% of females over the age of 50. Although thyroid  nodules are very common, thyroid cancer is extremely  rare. As the thyroid gland is situated in a superficial  location in the anterior neck, it is readily imaged with  ultrasound, although retrosternal extension may require  cross-sectional techniques (CT or MRI) for adequate visu-  alization of caudal extent.   The normal thyroid is a vascular gland with a homoge-  neous hyper-echoic texture. Adjacent structures, in partic-  ular, the common carotid artery and IJV and deep cervical  lymph nodes are clearly seen and are routinely examined,  and tracheal deviation and retrosternal extension can be  appreciated. In some centres, vocal cord mobility prior to  surgery is also routinely assessed with ultrasound.   While some thyroid lesions have typical imaging fea-  tures (e.g. papillary carcinoma), thyroid ultrasound is  frequently combined with FNA to improve diagnostic  accuracy.    Papillary carcinoma accounts for 70%-80% of cases of  thyroid malignancy. While papillary carcinoma may    be multifocal at presentation, its typical appearance on  ultrasound is as a solid hypo-echoic mass. Punctate cal-  cification is a variable finding, but when present is highly  specific (Figure 2.7). Invasion of regional lymph nodes  is common, and foci of micro-calcification may also be  detected in involved nodes.    The typical benign thyroid nodule is usually heterogenous  in echotexture, with a hypo-echoic halo or peri-nodular  rim. Cystic change is very common and may display the  typical ‘ring down’ or ‘comet tail’ sign indicating colloid.  Calcification is common; either peripheral eggshell or  large globular-type calcification. Unfortunately, whether  the nodule is solitary or part of a multi-nodular thyroid  is not a predictor of malignancy. This myth is often per-  petuated but multiple large series have shown that the  incidence of malignancy in solitary and multiple nodules  is comparable.   A follicular lesion is a predominantly solid, hyper-  echoic, homogeneous nodule. Between 80% and 90% of  these lesions will turn out to be benign. However, differ-  entiation between an invasive follicular carcinoma and a  benign adenoma is not possible without histopathological  examination of the entire lesion.    We will consider just one diffuse thyroid disease as this  may masquerade as a solitary nodule occasionally, namely  Hashimoto’s thyroiditis which is the most common form  of thyroiditis. This condition causes an enlargement of the  gland in the acute phase with diffuse hypo-echogenicity  which is typically patchy starting in the anterior portion  of the gland. In time the whole of the gland is enlarged,  hypo-echoic, contains echogenic striae and is typically  hyper-vascular in the acute phase. With time the gland  atrophies, loses its hypo-echoic appearance and its vascu-  larity diminishes.    Figure 2.7 Punctate calcification, which when present is  typical of papillary carcinoma.   Lipomas are benign encapsulated subcutaneous lesions  which are frequently encountered in the neck. Typical  sonographic features include hyper-echogenicity, linear  internal echoes perpendicular to the ultrasound beam  (Figure 2.8), compressibility and a lack of internal vascu-  larity on colour flow or colour Doppler imaging. Intra-  muscular lipomas can mimic muscle and be difficult to  define with ultrasound.   The head and neck is a relatively uncommon site for hae-  mangiomas. They are frequently seen in the masseter,  trapezius and sternomastoid muscles. Haemangiomata  may have large cavernous spaces, and possess capillary  and/or lymphatic elements. Phleboliths may be dem-  onstrated within the lesion in 70% of cases. In large or  intra-muscular haemangiomas, MRI is better at depicting  the extent of the lesion.   Most branchial cysts arise from the second branchial arch  remnants, and present as a mass at the angle of the man-  dible, often following an infection. The typical location is  abutting the posterior aspect of the submandibular gland,  lying lateral to the carotid vessels and immediately ante-  rior to the anterior border of the sternomastoid. On ultra-  sound, these lesions may be cystic, but more commonly  the presence of debris, haemorrhage or infection gives rise  to a pseudo-solid appearance and the cyst wall thickens in  the presence of infection. It may be impossible to distin-  guish between a second branchial cleft cyst and a necrotic  lymph node metastasis due to SCC. Branchial cysts may  extend between the carotid artery and lateral pharyngeal  wall or have associated sinuses and these features are bet-  ter demonstrated on MRI or CT than ultrasound.    Figure 2.8 Linear internal echoes perpendicular to the  ultrasound beam, characteristic of lipoma.    Thyroglossal duct cysts can arise at any position along the  course of the thyroglossal duct remnant but the majority  are related to the hyoid bone, with most occurring at the  level of or inferior to the hyoid.   On ultrasound, thyroglossal duct cysts may appear cys-  tic, heterogeneous or pseudo-solid due to varying content  of debris, haemorrhage or infection. Classically, they are  embedded in the strap muscles, often ‘splitting’ the strap  muscles. Malignant degeneration of the epithelial lining  occurs rarely and any solid component which appears to  contain micro-calcification (ie. suggestive of papillary  carcinoma) should undergo sampling.   Dermoids can be identified by their site, i.e. either mid-  line or peri-orbital. In the peri-orbital region, they are  typically (60%) found in the upper outer quadrant of  the orbit. These lesions arise from sequestration of the  ectoderm from adjacent sutures - most commonly the  fronto - zygomatic suture. Dermoid cysts arise from  more than one germ cell layer and therefore will con-  tain one or more dermal adnexal structures. Sebaceous  glands, hair and fat are commonly found in dermoids but  they may also be purely cystic. They may therefore have a  heterogenous appearance with the presence of fat mani-  festing as a fluid/fluid level or often as rounded echogenic  masses within the cyst (representing sebaceous rests  within the dermoid). The typical location for these mid-  line cysts is in the submental region either superficial or  deep to mylohyoid.    Infection in the submandibular region frequently arises  from dental disease. Ultrasound can differentiate between  infection with a fluid component (abscess) and cellulitis,  and identify associated lymphadenopathy and venous  thrombosis.    Ultrasound is a very useful adjunct in percutaneous sam-  pling procedures, allowing direct visualization of the  needle and structures to be avoided (such as vessels). A  metallic needle is a reflective surface and if placed paral-  lel or slightly oblique to the transducer surface, the needle  will be imaged as a very reflective or echogenic structure  (Figure 2.9). Thus, the needle must be in the plane of the  ultrasound beam and as parallel to the probe surface as  possible in order to optimally visualize it.   It is essential that the patient and operator are comfort-  able, when carrying out either FNA or core biopsy in the  neck. Keeping the probe, needle, ultrasound monitor and  patient in a tight arc, in front of the operator is essential.    If biopsy in a lesion in the left neck of a patient, the opera-  tor should move to the patient’s left, allowing the probe,  needle and monitor to lie in a comfortable parallel field of  view. If necessary, for example for a lesion in the posterior  triangle ask the patient to lie on their side in order to allow  easy access for a shallow approach.   Percutaneous biopsy is an outpatient procedure but it is  prudent to ask the patient to wait for 5-10 minutes post-  biopsy to check for possible haematoma.   Ultrasound guidance should allow a variety of sampling  techniques to be performed but if there is a good local  cytology service, FNA under ultrasound control may be  all that is required. However, where lymphoma is consid-  ered as a possible diagnosis, core biopsy undoubtedly has  a superior role. Many centres are now able to diagnose and  type lymphoma on core biopsy, using flow cytometry tech-  niques, significantly reducing referral to treatment time  and avoiding open biopsy.   For many conditions, e.g. SCC lymph node metastases,  FNA will be the initial sampling technique. Core biopsy  may be reserved as a second-line test when cytology is  unable to provide the answer. Some authors advocate  the use of core biopsy as a universal first-line investiga-  tion, pointing out the fallibility of cytology for certain  conditions. However, many others believe that SCC can  be seeded during percutaneous wide-bore needle biopsy  in the neck. The decision as to which technique to use for  sampling neck masses will be influenced by local practice.   A skilled operator should be able to carry out FNA  using aspiration and non-aspiration techniques, and if  core biopsy can additionally be mastered then there will be  few conditions in the head and neck that cannot be sam-  pled under ultrasound control - allowing rapid diagnosis  in patients who present with neck masses.    We would like to acknowledge Dr. Elisabeth Tilley,  Consultant Radiologist, Portsmouth Hospitals NHS Trust.    Echogenic or reflective structures are white (for exam-  ple bone, needle, calculi).   Calcification causes complete reflection of ultrasound  and an acoustic shadow beyond it.   Congenital cysts are typically echogenic, but branchial  cleft cysts, thyroglossal duct cyst, dermoid cysts are  pseudo-cystic with some having solid elements.   Some solid lesions may appear hypo-echoic (have cys-  tic components). These include salivary pleomorphic  adenoma, parathyroid adenoma, nerve sheath tumours  and lymphoma.   When assessing nodes, the shape of nodes and blood  flow is important.    Ahuja AT and Evans RM (eds.). Practical Head and Neck  Ultrasound. New York, NY: Greenwich Medical  Media Limited; 2000.   Bruneton JN, Roux P, Caramella E, Demard F, Vallicioni  J and Chauvel P Ear, nose and throat cancer:  Ultrasound diagnosis of metastasis to cervical lymph  nodes. Radiology. 1987; 152: 771-773.   Van den Brekel M, Castelijns JA, Stel HV, Luth WJ, Valk J,  Waal I et al. Occult metastatic neck disease: Detection  with US and US guided fine needle aspiration cytol-  ogy. Radiology. 1991; 180: 457-461.    In many conditions, the formulation of a definitive treat-  ment plan is based on accurate tissue diagnosis and, hence,  biopsy and histopathology are fundamental to patient  management. This chapter deals with practical aspects  that are of direct concern to surgeons. In addition, practi-  cal aspects of other types of investigations such as micro-  biology will be outlined.    Surgical biopsy is removal and _histopathological  examination of a part (incisional biopsy) or the whole of  a lesion (excisional biopsy) for diagnosis and treatment.  Techniques/tools that may be used include the following:    The choice of incisional versus excisional and technique  depends on the indication for biopsy; the clinical diagno-  sis; the site, size and appearance of the lesion and the abil-  ity to close the defect.    A punch biopsy is a simple, convenient method of  obtaining a disc of mucosa of around 5 mm diameter  and this is generally sufficient for histological confir-  mation of mucosal lesions in conditions such as lichen  planus.    This provides a core of tissue up to 2 mm diameter and 10  mm in length, which is placed in fixative and processed  as for a surgical biopsy. It is an alternative to fine needle  aspiration cytology (FNAC) and could be used in situa-  tions where FNAC has failed to provide a definitive diag-  nosis. As with any small tissue sample, the core may not be  representative of the lesion as a whole or may fail to show  specific pathognomonic features.   Core biopsy of a suspected parotid neoplasm in  cases with an unhelpful FNAC is generally consid-  ered safe especially if narrow-bore needles - less than  0.9 mm - are used. For example, reports show the risk  of tumour seeding is extremely low and diagnostic accu-  racy in distinguishing non-neoplastic lesions, benign  and malignant neoplasms is consistently greater than  97%. Conventional incisional biopsy of parotid neo-  plasms should be avoided because of the risk of seed-  ing in the incision wound (even in benign pleomorphic  adenomas), facial nerve damage, facial scar and fistula  development.   FNAC is perhaps the first choice technique for analy-  sis of neck and salivary gland lumps. A meta-analysis by  Tandon et al. (2008) looking at almost 3500 cases showed  sensitivity, specificity, positive predictive value and nega-  tive predictive value of 89.6%, 96.5%, 93.1%, 96.2% and  90.3%, respectively. There have been significant advances  in liquid-based cytology (LBC) systems, with ability to  produce cell blocks from remnants of LBC samples to  allow for immunohistochemistry (IHC). Given that the  data above will largely derive from the pre-LBC era, it is  likely that accuracy and usefulness of this technique have  only grown.   © Simple mucosal and soft tissue lesions - clinically diag-  nosed as fibroepithelial polyps, inflammatory epulides  and mucoceles and so on - where excisional biopsy  achieves diagnosis and cure simultaneously   @ Where the complete lesion can be removed without risk  to important adjacent structures   ® Infiltration of local anaesthetic should be into perile-  sional tissue, taking care to avoid distortion of the lesion.   e A traction suture through the lesion may help in stabi-  lising the surrounding tissue area.   ® Care is needed to avoid crushing the tissue with  tweezers.   e Any sutures used to control the specimen should be left  in place to avoid possible misinterpretation of displaced  surface epithelium.   © Following removal, mucosal specimens should be sup-  ported by placing the deep aspect on a piece of card in  order to prevent distortion during fixation.   © Depending on the specimen, it may be necessary to label  specific margins by using marker sutures or labelling a  photograph or diagrammatic representation.   @ Marker sutures should be tied securely but not pulled  tight and should avoid areas of critical interest.   © Colour change following fixation may mask clinically  obvious lesions, and, hence, the Pathology Request  Form should include details on clinical appearance  and size as well as details on site and extent (including  depth) of the biopsy.   © Diathermy damages the tissue periphery and may pre-  clude histological assessment of the peripheral 1 mm  of tissue, a factor that needs to be considered in biopsy  of mucosal malignancies and premalignancies, both  proven and potential.    © To determine the diagnosis before treatment — for  larger lesions, lesions that are potentially malignant and  lesions of uncertain nature    ®@ Removal of an ellipse of tissue including both lesional  and perilesional tissue   © Superficial biopsies often fragment and are unlikely to  include vessels of sufficient thickness/calibre for assess-  ment of possible vasculitis.    ® The roof of a flaccid bulla is easily detached and manip-  ulation of tissues before and after biopsy should be  minimal.   ® Tissue that may require direct immunofluorescent  staining (such as demonstration of autoantibodies  in pemphigus and pemphigoid) must not be placed  in routine fixative solution. Special instructions  should be sought from the pathologist before book-  ing the biopsy procedure. Michel's medium is the  most commonly used transport medium for such  specimens.    In the investigation of xerostomia, after incising the  mucosa, at least six glands should be removed. It is not  usually necessary to include the surface mucosa overlying  the glands.    In investigation of suspected orofacial granulomatosis  (OFG) and related conditions, it is important to remove  a good depth of tissue since granulomata are often more  numerous within labial muscle rather than the lamina  propria and superficial submucosa.    Biopsy for histological assessment of leukoplakias,  erythroplakias and erythroleukoplakias (speckled leu-  koplakias) requires careful planning. In many cases,  the lesion is too large for excisional biopsy. In general,  incisional biopsy should include areas of induration,  erosion, erythroplakia and exophytic/papillary growth  (Figure 3.1). It is helpful to include adjacent ‘normal’  mucosa if possible and several geographic biopsies  (accompanied by a topographical diagram depicting  their site) may be necessary in large lesions especially  when non-homogeneous.   Any biopsy for suspected mucosal squamous cell car-  cinoma must be sufficiently deep to include submucosal  muscle - ideally, at least 4 mm in thickness and 10 mm x 6  mm in surface area. Particular care is needed in lesions  with an exophytic growth component and the Request  Form should give accurate clinical details including the  suspected clinical diagnosis. Superficial biopsies can be  misleading since the architecture of the rete processes and  interface between the epithelium and connective may not  be accurately depicted and atypical cytological features  may be confined to basal keratinocytes or even focal in  distribution.   Assessment of proliferative verrucous leukoplakia, par-  ticularly the distinction between verrucous hyperplasia  and verrucous carcinoma is notoriously difficult to assess    on incisional biopsy, and the definitive diagnosis may be  deferred or amended on assessment of the excision biopsy.   Inclusion of the deep advancing front in the diagnostic  biopsy in conventional squamous cell carcinoma allows  invasive front histological multifactorial malignancy  grading (IFG). The system proposed by Bryne et al. (1998)  assesses five features on a four-point scale (Table 3.1) lead-  ing to a maximum of 20 points. The first three features  relate to characteristics of the tumour keratinocytes while  the fourth and fifth relate to the epithelial-connective  tissue interface (Figure 3.2). Several independent stud-  ies have shown that the total grading score is associated  with overall survival (>16 indicating poor survival) and    Figure 3.1 Extensive non-homogeneous leukoplakia of  the floor of mouth/ventral tongue requires multiple incisional  biopsies - selecting areas of erosion (bottom arrow), exophytic  nodules (middle arrow) and thickening/induration (upper  arrow). When possible, the biopsy ellipse should include the  macroscopic edge of the lesion including a narrow rim of mac-  roscopically normal mucosa.    the pattern of tumour invasion (grades 3/4) is predictive of  lymph node metastasis.   The Risk Model is a newer validated outcome predictor  for head and neck squamous cell carcinoma. In brief, it  utilizes a scoring system based on worst pattern of inva-  sion, lymphocytic host response and perineural invasion.  It is intended for use on excision specimens of low-stage  (pT1, pT2) oral cavity squamous cell carcinoma where  the whole tumour is available for histological examina-  tion. The intention is to assist with treatment planning for  patients who might otherwise only receive primary sur-  gery and to guide decisions on elective neck dissection and  post-operative radiotherapy. Studies have shown the Risk  Model to be significantly predictive of locoregional recur-  rence and disease-specific survival. At the time of writing,  there are suggestions to incorporate this into future WHO  Classification texts and if this is the case, the Risk Model  scoring will likely become a standard item on pathology  reports.   Reproducibility of any scoring system is, of course, sub-  ject to inter- and intra-observer variation.   The reliability of incisional biopsy of a clinically suspi-  cious, potentially malignant or dysplastic lesion is question-  able. A retrospective study comparing degree of dysplasia  in biopsies and 101 definitive excision specimens found  concordance in only 49% of lesions rising to 79% when  one degree up or down the scale of dysplasia was included.  Under-diagnosis of the biopsy was made in 35% of the  lesions and over-diagnosis in 17%. Eight percent of lesions  that on biopsy (taken on average 10 months previously)  showed no, slight or moderate dysplasia harboured carci-  nomas and 50% of these were clinically homogeneous. Poor  reliability of incisional biopsy, possibly due to sampling  errors; variation in reading degree of dysplasia; progres-  sion (or regression) between biopsy and excision and unim-  portance of histological appearances suggest that even  ‘non-dysplastic’ lesions should be observed at 3-6 monthly  intervals. Unimportance of histology seems, at least, partly  responsible since the course of premalignant lesions after    (>50% of cells) (20%-50% of cells) (5%-20% of cells) of cells)   Nuclear pleomorphism _Little (75% mature cells) Moderate (50%-70% Abundant (25%-50% Extreme (<25% mature    Figure 3.2 Invasive front histological multifactorial malig-  nancy grading, pattern of invasion and host lymphocytic  response. (a) Well-delineated advancing front composed of  broad bands of tumour keratinocytes - score 1 point. The  host lymphocyte response is moderate - score 2 points. (b) Ill-  defined advancing front with tiny tumours islands and individ-  ual cells widely dispersed within muscle - score 4 points. The  host lymphocytic response is slight - score 3 points.    surgical removal is reportedly independent of their histo-  logical diagnosis. Studies looking at variability of grading  of oral dysplasia and have suggested a binary system of  low-grade and high-grade dysplasia only, eliminating the  ‘moderate’ dysplasia category, and suggest that this leads to  improved agreement and predictive value. A binary system  may also have merit in helping clinicians to make manage-  ment decisions. Grading of oral epithelial dysplasia is also  subjected to considerable inter-observer variability.    Vital staining with aqueous solution of 1% aqueous tolo-  nium chloride (toluidine blue) is widely advocated as an  aid in clinical detection of oral epithelial dysplasia/early  carcinoma. The dye binds to nucleic acids and is not a spe-  cific test. When applied to clinically suspicious lesions,  the sensitivity was 77% and the specificity 67% in one    study and 65.5% and 73.3%, respectively, in a more recent  study. This more recent study reported positive and nega-  tive predictive values of 35.2% and 90.6%, respectively.  The technique is said to be less reliable when used indis-  criminately on white lesions and ulcers with a high false-  positive rate. In addition, the dye is mutagenic leading to  concerns about its safety particularly when advocated as  a general screening test. Nevertheless, the technique can  be of value in deciding the site of biopsy in an extensive  lesion, identification of synchronous/metachronous carci-  nomas, localization of superficial tumour borders during  pre-surgical planning and in deciding whether to inter-  vene with surgery or chemoprevention. In addition, tolu-  idine blue staining can identify those high-risk primary  oral premalignant lesions with poor outcome even in  lesions with low-grade or no dysplasia. The stain is pref-  erentially retained by premalignant lesions with clinical  features associated with risk (site, size and appearance);  histologically, severe dysplasia and high-risk molecular  patterns as assessed by microsatellite analysis. Although  there has been a resurgence of interest in toluidine blue in  recent years, it should be regarded as an adjunct to clinical  diagnosis rather than an accurate test.    Curettage is generally used for the biopsy of tissue within  an anatomical or pathological cavity or fistula, and in  some conditions, the procedure constitutes treatment. The  soft tissues are scraped out with an appropriately shaped  curette. All the tissue fragments must be submitted for  pathology, including any bone spicules.   The precise diagnosis of odontogenic cysts depends on  their relationship to teeth and radiographic details should  be submitted on the Request Form. When feasible, teeth  should be submitted with the soft tissue in situ. In order  for thin sections to be cut, specimens containing teeth  and bone need to be softened by immersion in acid follow-  ing their macroscopic assessment in the laboratory. This  delays the diagnosis by days or weeks depending on speci-  men size and composition.    IHC refers to the process of detecting antigens (e.g. pro-  teins) in cells of a tissue section by exploiting the principle  of antibodies binding specifically to antigens in biologi-  cal tissues. It is a commonly used technique in diagnos-  tic pathology and is routinely employed in the sub-typing  of lymphomas and classification of sarcomas. Specific to  head and neck pathology, there are IHC stains available  that prove squamous differentiation in a poorly differenti-  ated squamous cell carcinoma, where morphologically this  diagnosis may not be obvious. Furthermore, stains can be  utilized to inform of likely primary site(s) when a patient    presents with metastatic carcinoma of unknown origin,  particularly when dealing with an adenocarcinoma.   pl6 is an IHC stain which in the setting of oropha-  ryngeal squamous cell carcinoma, and is an excellent  surrogate marker for a high-risk human papillomavirus  (HPV)-related tumour.   Molecular testing is becoming increasingly important  and more widely used in diagnostic pathology. It has been  used in the sub-typing of a wide range of tumours for  some time, largely sarcomas and lymphomas. Fluorescent  in situ hybridization (FISH) analysis can be employed to  detect single tumour-specific chromosomal transloca-  tions which define some of these tumours, Ewing's sar-  coma being a good example of this. Other examples of  current use are in determining likely response of a tumour  to a targeted therapy. For example, in widely metastatic  melanoma, DNA extracted from biopsy material can be  assessed for a mutation in the BRAF gene which if pres-  ent, predicts for response to tyrosine kinase-inhibiting  drugs including vemurafenib. The good news is that FISH  and mutational analysis can almost always be performed  on formalin-fixed paraffin-embedded tissue and there is  rarely a requirement to submit additional fresh tissue at  the time of biopsy.   As tumours are increasingly studied at the molecular  level, the list of identified tumour-specific and defining  translocations grows by the year. Study of salivary gland  tumours at the genetic level is one example where in recent  times; new information gained from these studies has led  to addition of a new entity to the classification, namely  mammary analogue secretory carcinoma. Rather than  this being a newly occurring tumour, it is most likely that  these have previously been designated as acinic cell carci-  noma. Information gained from molecular investigation  may in future be used to provide prognostic information  or guide treatment.   A summary of some of the recently identified salivary  gland tumour genetic changes is shown in Table 3.2.    ® Patient identification including surname, forename(s),  address, sex, date of birth and unit number. Always  check accuracy, legibility and completeness of pre-  printed stickers.    © Name, address and contact details of requesting consul-  tant/surgeon in charge.   @ The nature of the specimen (skin lesion, mucosal biopsy,  bony sequestra, etc.)   ® History of current condition (date of onset, duration,  location, associated local factors, investigations so far,  treatment already received).   ® Clinical description of the lesion (site, size, colour, sur-  face ulceration, texture, mobility, induration, etc.).   @ If applicable/relevant, state that the patient has con-  sented for surplus material to be used for research/  teaching.   © Type of request: urgent/non-urgent and date of follow-  up appointment.    High-quality histological sections are dependent on  adequate fixation of tissue samples. Depending on speci-  men size, 6-8 hours of immersion in a formaldehyde-  based fixative is the minimum, with 24 hours considered  ideal. The volume of fixative solution should be at least  10 times the volume of tissue. Specimens placed in saline  and alcohols are often useless for histological assess-  ment and biopsy should be delayed if adequate fixative is  unavailable. When special investigations such as electron  microscopy are required, the pathologist should advice  on the special fixatives that are needed.   Laboratory processing involves dehydration of the fixed  specimen by immersion in a series of solvents followed by  impregnation with paraffin wax. The wax block supports  the tissue which is mounted on a microtome for section  cutting. Four microns thick sections are floated onto glass  slides and after removal of the wax by solvents, stained.   Mucoepidermoid t(11,19) Presence of translocation more commonly seen in low to intermediate grade  carcinoma tumours and associated with more favourable prognosis.   Adenoid cystic t(6,9) Further research required to identify possible targeted therapies.  carcinoma   Mammary analogue _ t(12,15) Most cases previously diagnosed as acinic cell carcinoma. Awaiting longer-term    outcome studies to assess whether behaviour is similar, less or more aggressive.    The routine process from placing the specimen in fixative  to pathological assessment takes around 24 hours.    The aim is to provide accurate diagnostic information that  will determine or alter the course of surgical treatment.  The major indications are the following:    © Diagnosis and assessment of the extent of malignant dis-  ease/status of surgical resection margins (see Section 6).   @ Fresh material is necessary for special procedures  including cultures and some molecular studies and it is  helpful if the pathologist can check adequacy of tissue  sample intra-operatively.    This allows histological assessment of a stained slide  within 15 minutes of biopsy taking.    ® Care is needed in planning the site and size of the speci-  men — generally, only small tissue pieces (<10 mm)  freeze and cut well.   © Specimens should be delivered to the pathologist as  quickly as possible, fresh (that is, not placed in fixative  solution) but kept moist by a saline-soaked gauze.   ® If possible, there should be face-to-face discussion of the  correct specimen orientation and identification of spe-  cific areas of interest or concern.   ® The fresh tissue is quickly frozen (to —70°C), tradition-  ally by immersion in liquid nitrogen but more usu-  ally now by placing on a chuck, coating in embedding  medium such as OCT, TBS or cryogel and then placing  into the cryostat.   © Sampling errors can be reduced by thorough examina-  tion of the most critical areas of the specimen. After  discussion of the case, the pathologist should ensure  that multiple levels (ribbons) are mounted and also,  that all remaining frozen tissue is fixed and processed  routinely. This allows the routine slides to be checked to  confirm or refute the frozen section report.    The appearances in frozen sections differ from those  in fixed material - for example, the sections are usually  thicker - and freezing artefacts due to poor technique can  distort the cellular image further. Hence, a definite diag-  nosis may not be possible on the frozen sections but the    pathological process can be correctly determined in most  cases. The overall accuracy of frozen section diagnosis  depends on the tissue, pathological process and precision  of diagnostic category. The diagnosis of malignant versus  benign/reactive can be achieved with 98% accuracy in  most tissue types.    Histological assessment of surgical biopsies remains the  mainstay of diagnosis in oral and maxillofacial condi-  tions. Even in conditions such as aphthous ulceration in  which biopsy is generally unhelpful, it can exclude other  possible causes. Inaccuracies can arise in both clinic and  laboratory and include    @ Errors in specimen labelling and submission of inac-  curate clinical details on the Pathology Request  Form.   © Sampling errors at all stages from selection of biopsy  site to laboratory trimming of the specimen to inad-  equate histological sectioning.   ® Technical errors resulting in suboptimal stained slides.  It is the pathologist's responsibility to correct technical  problems as they arise.    Exfoliative cytology, examination of cells scraped from  the surface of a lesion, is a quick, simple method of sam-  pling surface cells without need for local anaesthetic. It is  widely used for detecting candidal hyphae, virally dam-  aged keratinocytes and acantholytic keratinocytes of pem-  phigus (Figure 3.3). The area is scraped with a flat plastic  instrument or dry tongue spatula and exfoliated cells are  transferred to clean labelled microscope slides. Air-dried  slides are used for Giemsa staining and alcohol-fixed slides  for Papanicolaou staining. Special staining techniques  including IHC can be applied to the cellular smears to  improve diagnostic specificity. The surface scrape provides  no information on deeper tissues, and, hence, is unreliable  for diagnosing cancer by simple cytology.   The brush biopsy, vigorous abrasion with a stiff bristle  brush, collects cells from the surface and subsurface layers    Figure 3.3 Exfoliative cytology. (a) Candidal hyphae are  readily detected in a smear stained with periodic acid Schiff  (PAS). (b) Virally damaged cells are evident in the fluid and cells  of vesicles and ulcers in herpetitic stomatitis.    of a lesion and is a simple, convenient way of obtaining  DNA samples. To ensure sample is sufficiently deep, the  brush should be rotated in one spot until bleeding occurs.  The cells are transferred from brush to a microscope slide.  For optimum accuracy, cellular assessment involves a  range of techniques such as scanning by an image analy-  ser, measurement of nuclear DNA content and molecular  analyses such as loss of heterozygosity and microsatel-  lite instability. Overall, the literature suggests the brush  biopsy may provide a reliable diagnostic sample once the  assessment techniques have been more fully evaluated and  one potential future use could be in monitoring molecular  changes in pre- or potentially malignant oral lesions.    A wide range of techniques can be used to aid diagnosis:    @ Exfoliate cytology and smears (see above) for rapid  confirmation of acute pseudomembraneous candido-  sis (thrush), acute ulcerative gingivitis and herpetic  stomatitis.    ® Culture and sensitivity of pus organisms. The sample  should be taken before giving an antibiotic.   ® Molecular biological tests such as polymerase chain  reaction (PCR) and fluorescent FISH for rapid  identification of bacteria and viruses. PCR identification  of mycobacterium, for example, takes around 48 hours  and is more sensitive and specific at differentiating dif-  ferent types of mycobacteria that traditional culture and  sensitivity tests.    Fresh samples are necessary, or at least preferable, for most  microbiological and molecular tests and the microbiologist  or pathologist should provide guidance on the exact nature  and preservation of the sample.    Blood investigations are essential for the diagno-  sis of blood dyscrasias and defects of haemostasis,  and helpful in investigations of other oral conditions  such as chronic candidosis, sore tongue and aphthous  ulceration. Blood must be placed in the appropriate  tube since some anticoagulants are incompatible with  certain tests and the request form should include suf-  ficient clinical detail to permit the haematologist or  clinical chemist to check that appropriate tests have  been ordered and to interpret the results. In difficult  cases, advice should be sought prior to taking the blood  sample.    e Plan the biopsy type and the tools/techniques used,  the precise site(s) with due consideration of the pur-  pose of the biopsy, the clinical features of the lesion and  the clinical differential diagnosis.   ¢ Small, superficial and crushed tissue samples may be  non-diagnostic. Consider both the surface area and  depth of the biopsy specimen. Tissue shrinks (on aver-  age 30%) during fixation and processing for routine his-  tological assessment.   e For routine histological assessment, the biopsy speci-  men should be placed immediately in a formaldehyde-  based fixative (at least 10x the volume of tissue).   ¢ Consult the pathologist before taking the biopsy  when special investigations are required. Fresh tis-  sue samples are necessary for immunofluorescent  staining, microbiological testing and some molecular  techniques.   e Always check the accuracy and completeness of the  information on the pathology request form and the  specimen pot label.    Bankfalvi A and Piftko J. Prognostic and predictive factors  in oral cancer: The role of the invasive front. J Oral  Pathol Med. 2000; 29: 291-298.   Batsakis JG, Suarez P and El Naggar EK. Proliferative ver-  rucous leukoplakia and its related lesions. Oral Oncol.  1999; 35: 354-359.   Brandwein-Gensler M and Wei S. Envisioning the next  WHO head and neck classification. Head Neck Pathol.  2014; 8(1): 1-15.   Bryne M, Boysen M, Alfsen CG, Abeler VM, Sudbo J,  Nesland JM et al. The invasive front of carcinomas.  The most important area for tumour prognostication?  Anticancer Res. 1998; 18: 4757-4764.   Cancela-Rodriguez P, Cerero-Lapiedra R, Esparza-Gomez  G, Llamas-Martinez S and Warnakulasuriya S. The  use of toluidine blue in the detection of pre-malig-  nant and malignant oral lesions. J Oral Path Med.  2000; 40(4): 300-304.   El-Nagger AK and Westra WH. p16 expression as a sur-  rogate marker for HPV-related oropharyngeal car-  cinoma: A guide for interpretative relevance and  consistency. Head and Neck. 2012; 34(4): 459-461.   Holmstrup P, Vedtofke P, Reibel J and Stoltze K. Oral pre-  malignant lesions: Is a biopsy reliable? J Oral Pathol  Med. 2007; 36: 262-266.   Hunt J. An update on molecular diagnostics of squamous  and salivary gland tumours of the head and neck.  Arch Pathol Lab Med. 2011; 135: 602-609.   Hunt J. An update on molecular diagnostics of squamous  and salivary gland tumours of the head and neck.  Arch Pathol Lab Med. 2011; 135: 602-609.   Kesse KW, Manjaly G, Violaris N and Howlett DC. Ultra-  sound guided biopsy in the evaluation of focal lesions  and diffuse swelling of the parotid gland. Brit J Oral  and Max Surg. 2002; 40: 384-388.   Kujan O, Khattab A, Oliver RJ, Roberts SA, Thakker N  and Sloan P. Why oral histopathology suffers inter-  observer variability on grading oral epithelial dyspla-  sia: An attempt to understand the sources of variation.  Oral Oncol. 2007; 43(3): 224-231.   Kujan O, Oliver RJ, Khattab A, Roberts SA, Roberts SA,  Thakker N and Sloan P. Evaluation of a new binary  system for grading oral epithelial dysplasia for predic-  tion of malignant transformation. Oral Oncol. 2006;  42(10): 987-993.    Li Y, Bai S, Carroll W, Dayan D, Dort JC, Heller K et al.  Validation of the risk model: High-risk classifica-  tion and tumor pattern of invasion predict outcome  for patients with low-stage oral cavity squamous cell  carcinoma. Head Neck Pathol. 2013; 7(3): 211-223.   Mehrotra R, Gupta A, Singh M and Ibrahim R. Application  of cytology and molecular biology in diagnosing  premalignant or malignant oral lesions. Mol Cancer.  2006; 5: 11-20.   Mehrotra R. The role of cytology in oral lesions: A review  of recent improvements. Diag Cytopath. 2012; 40(1):  73-83.   Missmann M, Jank S, Laimer K, and Gassner R. A reason  for the use of toluidine blue staining in the presurgi-  cal management of patients with oral squamous cell  carcinomas. Oral Surg Oral Med Oral Pathol Oral  Radiol Endod. 2006; 102: 741-743.   Odell EW, Jani P, Sherriff M, Ahluwalia SM, Hibbert J,  Levison DA et al. The prognostic value of individual  histologic grading parameters in small lingual squa-  mous cell carcinomas. The importance of pattern of  invasion. Cancer. 1994; 74: 789-794.   Onofre MA, Sposto MR and Navarro CM. Reliability of  toluidine blue application in the detection of oral epi-  thelial dysplasia and in situ and invasive squamous  cell carcinomas. Oral Surg Oral Med Oral Pathol Oral  Radiol Endod. 2001; 91: 535-540.   Sawair FA, Irwin CR and Gordon Dj. Invasive front grad-  ing: Reliability and usefulness in the management  of oral squamous cell carcinoma. J Oral Pathol Med.  2003; 32: 1-9.   Tandon S, Shahab R, Benton JI, Ghosh SK, Sheard J and  Jones TM. Fine needle aspiration cytology in a  regional head and neck cancer centre: Comparison  with a systematic review and meta-analysis. Head  Neck. 2008; 30(9): 1246-1252.   Zhang L, Williams M, Poh C, Laronde D, Epstein JB,  Durham § et al. Toluidine blue staining identifies  high-risk primary oral premalignant lesions with  poor outcome. Cancer Res. 2005; 65: 8017-8021.   The mandible 25  Specific challenges of reconstructing different mandibular regions 35  Choice of graft for mandibular reconstruction 36  Hardware issues 36  The maxilla 37  Dental implants oo  Distraction osteogenesis as an option for reconstruction and virtual planning 39  Conclusion 40  References 41  Suggested readings 41    Three-dimensional (3D) stereolithic modelling has  evolved to be the gold standard for planning complicated  reconstruction of ablative and traumatic defects of the  head and neck (Figure 4.1). The advent of new computer  software has enabled the surgeon and biomedical engi-  neers to create and use virtual surgical planning. From the  virtual plans, surgical guides from the data collected and  analysed are produced and used in the operating room.  The power of this innovative software has enabled the sur-  geons to precisely evaluate the complex 3D anatomy of the  defect or deformity and then plan for the alignment of the  grafts for the newly constructed functional and aesthetic  skeleton of the jaws, orbits or cranium.   Before computer planning is utilized, the doctor must  first determine what type of graft the patient will require  to fill the defect. This includes both hard and soft tissue  transplants. Vascularized grafts, free autogenous grafts,  allogeneic bone cribs filled with marrow or titanium-  milled prosthesis are all choices available to the surgeon.  There are multiple anatomic challenges of a 3D nature  that occur when harvesting a tubular bone such as the  fibula, or a flat bone such as the ilium. These grafts require  reshaping to conform to a specific anatomic location and  become a functional mandibular or maxillary skeletal  unit. When using vascularized grafts, the position and  orientation of the graft will also be dictated by the posi-  tion of the pedicle relative to the location of recipient ves-  sels that are being anastomosed.    Once the location of the donor graft is chosen, the bone  must then be reshaped and inset within the defect. The  alignment must support the soft tissue, maintain bone  contact and be aligned in a way that will allow the dental  unit to be ultimately constructed for optimum function  and aesthetics.   The computer planning technology permits 3D  assessments of the defect. The construction requires  information from several sources. First, the clinical  examination, including dental casts, if appropriate, is  used to determine the occlusal relationship. Currently,    Figure 4.1 Example of the use of 3D stereolithic models in  mandibular reconstruction.    scanning of the occlusal surfaces of the teeth by com-  puted tomography (CT) or cone beam scan along with  the use of dental models is the most widely used tech-  nique. The scans of the dental models are then super-  imposed over the CT scan dentition and a composite  model is then created. However, the current occlusal  scanning orthodontic software available allows the  incorporation of direct surface scanning of the patient’s  dentition. This may become available to integrate into  our reconstructive treatment planning protocol. This  product may obviate the need for dental casts. It may  be difficult to take dental impressions at times on  patients that have undergone resection surgery because  of decreased range of motion. Next, the Digital Imaging  and Communications in Medicine (DICOM) data from  CT scanning or cone beam scanning are utilized to  obtain the necessary image data to allow for precise  planning. Specific protocols have been established for  the different machines available (Figure 4.2). The scans  delineate the defect location of the recipient bone and  also of the donor site bone if possible.   Virtual planning begins with determining the margins  of the resection if ablative surgery is going to be part of  the reconstruction. Otherwise, the post-ablative defect  is defined with the radiographic analysis of the scans.  If necessary, anatomic stereolithic models can be con-  structed from the data to aid in treatment planning and  hardware positioning. Next, the donor bone is evaluated  and the length and shape of the bone to fill in the defect  are identified. A virtual donor bone is then brought  into alignment with the defect (Figure 4.3). If osteoto-  mies are required to create the correct alignment of the  donor graft, then this should be accomplished at this time  (Figure 4.4). When the position of the donor graft is satis-  factory, the engineers will then create virtual ‘mitre box’    cutting jigs/guides for precise translation of the virtual  surgical plan to the donor bone for execution of the vir-  tual plan in the operating room (Figure 4.5).   The power of computer planning allows for precise posi-  tioning of these osteotomies. The orientation and position  of the osteotomy sites may be easily repositioned at this  stage in order to obtain the ideal orientation of the graft  relative to the recipient site. One other powerful feature  of computer planning is that alternative sites such as the  ‘jlium vs. fibula’ can be evaluated on the screen (Figure 4.6).   Timing is also an important factor when it comes to  virtual planning. The computer information must be  ‘cleaned’ of any data that will interfere with the planning.  This process takes several hours of the engineer’s time at  the modelling company once they receive the DICOM  data sets. The medical grade CT scanners data sets have  less to ‘clean’ than the cone beam machines. Thus, one  must realize that the planning sessions cannot happen  instantly at this time. It will take several days before a  planning session appointment can be made.   An appointment must be made by the surgeon to have  a virtual planning session with the engineers. These ses-  sions typically take about 30 minutes. Once the plan has  been accepted, then the modelling company will produce  the needed cutting jigs, plate/screw hole drill guides, 3D  stereolithic model if needed and occlusal splints. The ship-  ping location must be predetermined and enough time  needs to be allocated so that the material will arrive prior  to the surgical date. The materials are usually received  within 14 days following the treatment planning session.  Ifa custom prosthesis or custom plate is required, then the  processing time could take 2 months or more.   In addition to planning the position of the grafted bone,  the possibility of dental implant placement into these grafts  may also be assessed with the virtual planning software. If    Field of View: 20.0 - 25.0 cm  Algorithm: GE: Standard (not bone or detail)  (examples) Siemens: H30s  Toshiba: FC20  Philips: B  Gantry Tilt: 0°  Archive Media: | CD or DVD  File Type: DICOM (uncompressed)  Series: Original/Primary/Axial    Less than 1.25 mm (equal to slice thickness)  Less than 1.25 mm (equal to scan spacing)    Scanner Scan Time Voxel Size Field of View  Classic i-CAT* 40 sec 0.4mm to em fd) x 13.cm th)  (Preferred) Extended FOV: 16 cm (d) x 22 cm (h)  eet 16 cm (d) x 13 cm (h)  is ‘%  ye eneleye andi ills (Preferred) Extended FOV: 23 cm (d) x17 cm (h)  14 cm (d) x 8 cm (h)  Gendex* CB-500 40 sec 0.4mm (Preferred 14cm (d) x8 cm (h)  [Portrait] 14 cm (w) x 18 cm (h)  lluma™ Cone Beam CT 40 sec 0.3 mm    (Preferred) [Portrait] Extended FOV: 16.4 cm (w) x 18 cm (h)    Figure 4.3 An example of the donor bone scan being  superimposed on the area to be reconstructed.    Figure 4.4 The images can be manipulated to demon-  strate the position of osteotomies.    Figure 4.5 Cutting jigs can then be planned on the 3D  images and then surgical jigs are constructed in the laboratory.    Figure 4.6 3D planning can also be used to compare dif-  ferent donor sites such as fibular (left image) and iliac bone  (right image).    the alignment is precise and the bone volume is adequate,  then placement of implant analogues into the virtual plan at  the time of the planning session can be accomplished easily.  From this dental rehabilitative plan, the engineers can also  create drilling guides for the surgeon to use to place implants  either at the time of reconstructive surgery or in a delayed  fashion if dictated by the circumstances (Figures 4.6 and 4.11).    The work horse for mandibular reconstruction of segmental  defects is the fibula free flap. However, the iliac crest graft  may also be considered. Both types of grafts offer suffi-  cient bone stock to accommodate dental implant placement  either at the time of the graft placement or after graft heal-  ing. The limitations of these grafting techniques are dis-  cussed at length elsewhere. The customization of these bone  graft units for mandibular defects is most accurately accom-  plished with the use of computer planning. To prepare for  this technique, the native mandible and the native fibula  should be scanned. The DICOM data are then uploaded into  the treatment planning software. The ablative portion of the  procedure can be planned as well as the orientation of the  fibula segment within the defect. When designing the fibula  osteotomies, it is important not to compromise the vascu-  larity of the donor bone by creating segments that are too  small. If that is done, the perforator vessels may be violated  and the segment may lose its viability. Generally, the seg-  ments should be no less than 2 cm in length.    This region of the mandible is anatomically challenged by  the relationship of the graft to the remaining mandibular  segment after resection. Typically, if the ramus is resected  the coronoid process is also removed to prevent the con-  dylar segment from rotating up. This leaves the recipient  site with a very thin piece of bone to graft, diminishing  the surface area of contact and the ability to get stability  and good bone healing. If the amount of condylar segment  remaining will be very small, consideration should be  given to replacing the entire unit, both ramus and condyle.    The temporomandibular joint (TMJ) is able to be replaced  by multiple types of osseous vascularized and non-  vascularized grafts as well as custom-made titanium pros-  theses. The fibula is the work horse for a very long span  with vascularized tissues. However, the use of custom-  made joint prostheses may also be considered. This would    decrease the length of the grafts needed. It is also avail-  able if a patient is not a candidate for a vascularized graft.  There have even been total joint replacements that include  the ramus and part of the body of the mandible for this  reason.    The body of the mandible articulates with the ramus pos-  teriorly and the parasymphyseal and symphyseal areas  anteriorly. This portion of the mandible requires planning  to include the possibility of replacing the missing denti-  tion that will be removed along with the resection. Once  the choice of graft is determined, the 3D planning should  account for the need to place the vertical position of these  grafts to allow for support of implant dentistry or pros-  thetic reconstruction. Although the graft may be able to  receive dental implants, the vertical position of the graft  will dictate the size/height of the superstructure that is  created to support the prosthesis. The longer the distance/  height, the more likely the prosthesis will come under  stresses that may possibly lead to failure of the hardware.    Considerations for the midline region are similar to the  body of the mandible in terms of the dentition; however,  this area is not as long as the other regions of the mandible  and care must be taken while planning not to create a small  segment that will lose its vascularity. The osteotomies cre-  ated must support this important biologic principal for  good healing. This area of the mandible when reconstructed  with the fibula will be challenged by the height of bone  available to fill the defect. Solutions here for the use of the  fibula would be to consider placing the graft about 10-15  mm below the occlusal plane, using the ‘double barrel’  technique of folding the fibula in half or vertical distraction  once the bone is healed. All of these techniques should pro-  vide enough bone for dental implant rehabilitation.    Which to choose? Fibula or ilium? It is all about location,  location, location! Tissue, tissue, tissue! There is no bone  that specifically matches the anatomy of the mandible, or  the maxilla for that matter. The 3D modelling, both vir-  tual and stereolithic, can be created to determine the need  for either bone or muscle or skin, the ability to see the sur-  gery virtually (practice!) and create templates and guides  to use in the operating room to increase precision for a  functional reconstruction.   Use of the Jewer classification is helpful to reflect the  complex nature of the reconstructive defect and guide the  decision-making in planning surgery. The mandible is  divided into the anterior mandible, the lateral mandible  and the ramus/condyle.   There can be eight possible combinations of these let-  ters. That would be L, C, H, LC, HC, LCL, HCL and HH.    The complexity of the reconstruction becomes more diffi-  cult as the number of modifiers is added to the defect iden-  tification. For instance, if a patient has a defect classified  as ‘HLmt’, it would require replacement of a great deal of  bone and soft tissue as well as the TMJ.   Fibula grafts provide up to 25 cm of length of bone. The  soft tissue pedicle can be up to 15 cm. The vascularity of  this graft is amenable to multiple osteotomies and is good  to use for H, L and C defects. There is enough bone stock  for placement of dental implants.   The ilium is large and can be harvested from 6 to 16 cm.  The bone is also curved which may be good for the type L  and C defects. The length of the pedicle is only 5-7 cm. A  single osteotomy can be created to reconstruct the C type  of defects with care to keep the periosteum and iliacus  muscle intact to maintain the blood supply. The bone is  thick enough to receive dental implants. The best defects  for the ilium are H, L, C or combination defects.   The scapular osteocutaneous free flap is good for a  large quantity of soft tissue replacement. The bone can  be up to 14 cm with a pedicle of 6-9 cm. Multiple oste-  otomies are difficult for this graft, however, it can be split  into two bone segments. This flap also comes with a large  amount of skin and soft tissue. It can also receive den-  tal implants. The radial forearm osteocutaneous free flap  provides a large amount of soft tissue. But, bone posi-  tion of the flap is only a short segment of monocorti-  cal bone up to 14 cm. This cannot have osteotomies or  dental implants. Thus, this should be reserved for short  segments of L defects that require large amounts of soft  tissue replacement.    3D planning can also help with the alignment of the recon-  struction bone plates that will be needed to stabilize these  bone grafts.! They can be made two different ways. First, a  stereolithic model can be fabricated and mailed to the sur-  geon with the resection defect set. The surgeon can then pre-  bend the plate to the defect. The plate is then sterilized to    use in the operating room. Although the plate is bent to fit  the anatomically correct patient specific model, the surgeon  cannot precisely free hand this alignment in the operating  room. The surgical cutting jigs are used to resect the man-  dible; the bone plate is then aligned based on its relationship  with the model. Marks on the plate can be made to help with  the alignment as well as distance from the inferior border  of the stereolithic model to transfer to the patient’s mandible  in the operating room. This may increase accuracy and needs  to be validated with appropriate studies. The stereolithic    model can also be sterilized to use at this time as well. The  accuracy of this technique, however, is not as great as when  a custom plate is bent or milled by the plating company and  used with drill hole guides to place the place more precisely.    The anatomic challenges of stabilizing a graft to reconstruct  the maxilla not only require a bone that will support the  alveolus but also the nose and possibly the orbital region.    Brown et al.,” in 2000, described and classified the type  of defects created by ablative surgery to help identify the    possible function and aesthetic demands on the recon- Class 1: Maxillectomy without an oro-antral fistula  struction. The classification is divided into vertical and Class 2: Low maxillectomy (not including orbital floor  horizontal components (Figure 4.8). or contents)    Classification of maxillary defects according to the Brown et al. classification (a) Class |, (b) Class 2, (c) Class 3, (d) Class 4,  (e) Class 1, (f) 'a’, (g) 'b' (h) 'c’.    Distraction osteogenesis as an option for reconstruction and virtual planning 39   ® Classes 2-4: They are qualified by adding the letter a,  bore    ® Unilateral alveolar maxillectomy  ©® Bilateral alveolar maxillectomy  @ Total alveolar maxillary resection    Based on these defect descriptions, the choice of graft  material can be determined. The need for bone recon-  struction typically falls in the Classes 2-4 regions. The  small Class 2 defect may have a number of bone recon-  struction choices including the fibula, iliac crest, scap-  ula or radial free flap. However, with increased size the  choices go down. Once the defect is located in the Class  3 region, the iliac crest or scapula can be used and in  the Class 4 defect the iliac crest and a large soft tissue  free flap from the rectus, latissimus dorsi or anterolat-  eral thigh flap are necessary to fill this large defect and  support the nose.    The dentoalveolar unit is the most difficult to reconstruct  with bone grafting for segmental defects of the jaws. If the  alveolus and soft tissues can be replaced, a truly functional  reconstruction can be achieved. The prosthetic demands  for replacing missing dentition need to be kept in mind  with the final reconstruction. There must be enough room  for components of the implant abutments and superstruc-  tures for fabrication of the dentition (Figure 4.9a and b).  The minimum height of bone required to place standard  implants predictably is 10 mm. However, the width of  the graft also needs to be taken into consideration. Since  implants range from 3 to 6 mm in width a cuff of bone no  less than 1 mm is necessary for integration. The advent  of thinner and shorter implants may give us the ability  to place them in smaller pieces of bones; however, they  need to withstand the functional demands of chewing  once the prosthesis is in place. Taking into consideration,  that many of these patient may be irradiated, one must  not increase the risks of osteoradionecrosis due to hard-  ware failure and possible infection due to poorly planned  prosthesis design.   With this concept in mind and knowing that the par-  ticular anatomy of the fibula, ilium, scapula or radius  may lack ‘wiggle room’, virtual planning and fabrica-  tion of drilling guides will help the surgeon place these  fixtures whether primarily or delayed in a more precise  fashion.    Figure 4.9 There must be sufficient bone to accommodate  the implants.    Distraction osteogenesis in reconstructive surgery has  two purposes. First, the distraction hardware can be used  to increase the height of the bone grafts after they have  healed. This technique is used to create the dentoalveolar  bone needed for implant placement at the correct verti-  cal position for rehabilitation. This technique will require  a single vector to distract. Virtual or stereolithic model  planning here will allow for cutting jigs and drill guides  to be made as well as alignment of the distractors for the  correct vector.   The second area where distraction can be used is in rec-  reating the alveolus and soft tissues with L and C defects  of the mandible as well as maxilla (Figure 4.10a through c).  This technique is able to ‘grow’ the whole length of the  mandible if needed and there is enough bone stock avail-  able. This, however, may not be very practical as only 1 mm  per day of bone can be grown. However, if a small unit  of bone needs to be made such as from the canine to the  second molar region, the alveolar bone can be predictably  recreated to the areas where the dental implants need to    Figure 4.10 Distraction osteogenesis can be utilized to  close maxillary alveolar defects.    be placed then the remainder of the defect can be grafted  with non-vascularized bone.   Once again virtual planning will allow the surgeon  to visualize the vector or path of the transport segment,  plan for the alignment of the plate needed to stabilize  the proximal and distal segments of the reconstruc-  tion, and align the distractor itself with drill guides and  osteotomy jigs.    Virtual planning is quickly becoming the standard of  care for planning complicated surgical procedures across  many specialties.> Computer-assisted surgery supports    *The modelling company has stock osseous virtual models of the fib-  ula, ilium and scapula if these patient-specific scans cannot be done.  They have both male- and female-sized bones. The virtual bones can be  used and a ‘best fit’ scenario created then translated with the cutting  jig/mitre box created off these stock bones into the operating room.    Figure 4.11 Work flow for use of the fibula and ilium, scap-  ula or radial forearm flaps.    the surgeon while making difficult decisions with diag-  nosis, operational planning and even intra-operative  navigation. Surgery requiring movement of skeletal com-  ponents in three dimensions for many different types of  surgical problems requires sophisticated planning tools  to precisely navigate through the surgery planning and  the operation itself. The combination of this virtual plan-  ning technology, along with the fabrication of stereolithic  models, splints and custom hardware, as well as the trans-  lation of this data into computer navigation systems will  increase safety and accuracy. Virtual reality is the new  frontier of surgery.    1. Patel A, Otterburn D, Saadeh P, Levine J and Hirsch  DL. 3D volume assessment techniques and com-  puter-aided design and manufacturing for preop-  erative fabrication of implants in head and neck  reconstruction. Facial Plast Surg Clin North Am.  2011; 19(4): 683-709.   2. Brown JS, Rogers SN, McNally DN and Boyle MA.  Modified classification for the maxillary defect. Head  Neck. 2000; 22(1): 17-26.   3. Sharaf B, Levine JP, Hirsch DL, Bastidas JA, Schiff  BA and Garfein ES. Importance of computer-aided  design and manufacturing technology in the multi-  disciplinary approach to head and neck reconstruc-  tion. J Craniofac Surg. 2010; 21(4): 1277-1280.    Ayoub N, Ghassemi A, Rana M, Gerressen M, Riediger  D, Holzle F, et al. Evaluation of computer-assisted  mandibular reconstruction with vascularized iliac  crest bone graft compared to conventional surgery:  A randomized prospective clinical trial. Trials. 2014;  15: 114.   Brown JS. Maxillary reconstruction. Indian J Plast Surg.  2007; 40(Suppl S1): s35-s43.   Ciocca L, Mazzoni S, fantini M, Persiani F, Marchetti C  and Scotti R. CAD/CAM guided secondary man-  dibular reconstruction of a discontinuity defect after   Coppen C, Weijs W, Berge SJ and Maal TJJ. Oromadibular  reconstruction using 3D planned triple template  method. J Oral Maxillofac Surg. 2013; 71(8): e243-e247.   Eckardt A and Swennnen GR. Virtual planning of com-  posite mandibular reconstruction with free fibula  bone graft. J Craniofac Surg. 2005; 16(6): 1137-1140.   Hou JS, Chen M, Pan CB, Wang M, Wang JG, Zhang  B, et al. Application of CAD/CAM-assisted tech-  nique with surgical treatment I reconstruction of  the mandible. J Craniomaxillofac Surg. 2012; 40(8):  e432-e437.   Jewer DD, Boyd JB, Manktelow RT, Zuker RM, Rosen IB,  Gullane PJ, et al. Orofacial and mandibular recon-  struction with the iliac crest free flap: A review of  60 cases and a new method of classification. Plast  Reconstr Surg. 1989; 84(3): 301-403.   Li A, Zhao Y, Yao S, Zhao J, Yu S and Zhang W. Immediate  reconstruction of mandibular defects: A retrospec-  tive report of 242 cases. J Oral Maxillofac Surg. 2007;  65: 883-890.   Modabber A, Gerressen M, Stiller MB, Noroozi N, Fuglein  A, Holzle F, et al. Computer assisted mandibular  reconstruction with vascularized iliac rest bone  graft. Aesthetic Plast Surg. 2012; 36(3): 653-659.   Roser SM, Ramachandra §, Blair H, Grist W, Carlson GW,  Christensen AM, et al. The accuracy of virtual surgi-  cal planning in free fibula mandibular reconstruc-  tion: Comparison of planned and final results. J Oral  Maxillofac Surg. 2010; 68(11): 2824-2832.   Shen Y, Sun J, Li J, Li MM, Huang W and Ow A. spe-  cial considerations in virtual surgical planning of  secondary accurate maxillary reconstruction with  vascularized fibula osteomyocutaneous flap. J Plast  Reconstr Aesthet Surg. 2012; 65(7): 893-902.   Wang Wh, Zhu J, Deng JY, Xia B and Xu B. Three-  dimensional virtual technology in reconstruction of  mandibular defect including condyle using double-  barrel vascularized fibula flap. J Craniomaxillofac  Surg. 2013; 41(5): 417-422.   Zheng GS, Su YX, Liao GQ, Chen ZF, want L, Jiao PF, Liu  HC, et al. Mandible reconstruction assisted by pre-  operative virtual surgical simulation. Oral Surg Oral  Med Oral Pathol Oral Radiol. 2012; 113(5): 604-611.   Pre-operative evaluation and preparation for a dental extraction  Instruments and techniques used to extract teeth  Non-surgical removal of roots    The extraction or removal of a tooth from the alveolus  is a very commonly performed procedure, despite the  increasing trend for the preservation and retention of  teeth throughout life. Dental extractions can usually  be performed in a controlled, atraumatic manner fol-  lowing careful evaluation of the patient and the tooth  to be removed. All patients benefit from the increased  comfort and reduced recovery time afforded by limiting  the extent of surgical trauma. The avoidance or mini-  mization of bone removal during dental extractions  and the use of luxators and periotomes facilitates this  to a greater degree than is possible with conventional  techniques.   There are many indications for tooth extraction  including caries, periodontal disease, pulpal necro-  sis, pericoronitis and traumatic injury. In addition,  extractions may be indicated prior to orthodontic or  prosthodontic treatment and before radiotherapy or  treatment with bisphosphonates and other antiresorp-  tive medications which may complicate subsequent  extractions.   An intra-alveolar or ‘forceps’ extraction is one in  which a tooth is removed from the alveolus without the  surgical creation of a pathway for its delivery. A transal-  veolar or ‘surgical’ extraction is one which requires a    mucoperiosteal flap to be raised, allowing visualization  of the tooth and invariably bone removal to facilitate its  removal. This technique may be used electively where fac-  tors precluding forceps extraction are appreciated from  the outset or when a tooth proves resistant to, or fractures  during attempts to deliver it with forceps.    Most of the difficulties, unpleasantness and complica-  tions associated with dental extractions can be avoided  with proper pre-operative assessment and planning.  Assessment of a patient’s general health, their level of  anxiety about the procedure, the condition of the tooth for  extraction and its radiographic appearance all contribute  to this evaluation. Patients requiring special measures to  be taken before or after the extraction can therefore be  identified so that the associated risks may be minimized  and the surgical outcome is optimal. All patients should  therefore undergo well-planned procedures with appro-  priate pain and anxiety control.   Given a cooperative patient, the vast majority of den-  tal extractions can be completed successfully under  local anaesthetic. For those patients who are anxious    or undergoing prolonged or unpleasant procedures,  intravenous sedation with midazolam offers a safe and  reliable adjunct, producing around 40 minutes of anx-  iolysis, sedation and amnesia. Since local anaesthetic  techniques provide a similar window of pulpal anaes-  thesia, it is widely accepted that procedures predicted to  take longer than this should be done in stages or under  general anaesthesia. General anaesthesia is therefore  rarely indicated for dental extractions. Its use should be  restricted for patients unable to cooperate with treat-  ment in any other way or where there is a degree of  urgency to complete treatment but the presence of acute  infection precludes the achievement of effective local  anaesthesia.   The preparation of a patient for a dental extraction  must include an explanation of the proposed treatment  and appropriate warnings about the associated sequelae.  Administration of a pre-operative analgesic, to utilize its  pre-emptive effect and reduce pain experience post-oper-  atively, and mouth rinsing with chlorhexidine should also  be considered.   The operator usually stands to extract teeth, although  technique and positioning can be modified to allow  patients to be treated supine. Patients undergoing extrac-  tion of maxillary teeth should be positioned with their  mouth level with the operator’s elbow and the dental chair  reclined so that the upper arch lies at an angle of 60° to the  floor (Figure 5.1).    For the extraction of mandibular teeth, the chair should  be lower and reclined slightly less so that the lower arch is  parallel to the floor (Figure 5.2).   During routine extractions, the surgeon stands in front  of the patient on the same side as his own dominant hand,  except for mandibular extractions in the quadrant on the  same side as his dominant hand. For these the surgeon  should stand behind the patient. When a surgical extrac-  tion is performed, the operator usually stands adjacent to  the quadrant being treated to allow the best possible view  and access.    An extraction may be successfully completed with the use  of extraction forceps alone. Dental elevators are, however,  often used to assist with the luxation of a tooth and the  dilation of its socket prior to extraction with forceps, in  addition to being essential to the removal of teeth and roots  during surgical procedures. A range of new instruments,  designed to remove teeth atraumatically prior to implant  placement have recently been introduced. These ‘extrac-  tion systems’ work by screwing a post into a retained root  and pulling it out, as a cork from a bottle, by turning a  screw connected to the root.    Positioning of a patient for the extraction of a  maxillary tooth.    Positioning of a patient for the extraction of a  mandibular tooth.    Figure 5.3 (a) Even distribution of force to tooth with closely adapted forceps. (b) Blades which are too narrow distribute force  unevenly. Molar forceps have beaks to engage the radicular maxillary (c) or mandibular (d) bifurcations.    A wide variety of forceps is available with operator prefer-  ence and the anatomy of the tooth being removed deter-  mining those selected for use. The pattern of mandibular  extraction forceps in general use differs between the United  Kingdom and the United States. In the United States, the  blades of such forceps run in line with the handles, curv-  ing downwards to engage the buccal and lingual surfaces  of a tooth. When in use, the handles enter the mouth from  the front, are in line with the dental arch and are usually  held with the palm of the hand facing upwards, the ‘under-  hand technique’. In contrast, the mandibular forceps used  in the United Kingdom have blades which run “fore and  aft’ perpendicular to the handles, which cross the dental  arch at right angles during an extraction. The principles of  use are common to both. The operator must find the for-  ceps comfortable to grip and the blades should fit closely  around the tooth with the beaks engaging the radicular  bifurcations (Figure 5.3).   When using forceps to extract a tooth, two move-  ments are involved. The first severs the gingival and  periodontal ligament attachment to the tooth. The  blades should be positioned beneath the gingival mar-  gin on the buccal and lingual aspects of the tooth and  then driven with increasing force in an apical direction.  Thus, they slide along the length of the root surface to  their final position rather than gripping it from the out-  set. The placement of the forceps in the most possible  apical position possible ensures that the mechanical  efficiency of subsequent movements to extract the tooth  is maximal and the risk of root fracture is minimized.  The wedge shape of the blades also dilates the socket  (Figure 5.4).   The second movement of forceps extraction removes  the tooth from the alveolus. Whilst the apical position  achieved in the first movement is maintained, the tooth  should then be gripped firmly by the blades of the forceps  and the tooth luxated in its bony socket. This allows the    Figure 5.4 (a) and (b) Failure to seat forceps apically results  in a more coronal centre of rotation during the movements of  the extraction. This increases the degree of movement of the  root apex and predisposes to its fracture.    socket to dilate and the tooth to be lifted out. The move-  ments involved should be slow and deliberate, allow-  ing time for the alveolus to expand; their direction will  be determined by the anatomy and position of the tooth  being removed. Resistance to such forces should prompt  consideration of a surgical approach.    © Incisors, canines and premolars: Figure 5.8  @ Molars: Figures 5.9 and 5.10    A wide variety of elevators is available. Although appar-  ently very different in design, their common feature is  their curved blades. The blades transmit forces, gener-  ated by rotating the handles around their long axis, to the    surface of the tooth or root. This produces luxation and  movement of the tooth away from the point of application,  where the elevator contacts the tooth.   Forces may be applied perpendicular to the tooth  with an elevator in the interdental space or along its  long axis buccally. Since considerable force is applied  to the tooth, the elevator must be prevented from slip-  ping. Whilst it is being used, the operator’s index fin-  ger should therefore be extended along the length of  the blade to act as a finger rest on adjacent hard tissues  (Figure 5.11).    Figure 5.5. (a) Upper straight or universal forceps are seated as apically as possible. (b) Slow, steady labial movement followed  by release then palatal movement is repeated with gradually increasing force. (c) Rotational movements may be introduced to com-  pletely sever the periodontal ligament fibres. (d) The tooth is delivered labially.    Figure 5.6 Prior to the application of forceps, the first premolar should be luxated to prevent fracture as this tooth is often two  rooted. (a) Upper premolar or universal forceps engage the tooth firmly and apically. (b) Buccal pressure is applied to the tooth.  (c) Gentle palatal movements are introduced. (d) The tooth is delivered in a buccal direction, with additional tractional force to  remove the tooth from its socket.    Figure 5.7 (a) Upper molar or anatomical forceps should be seated with their beaks engaging the buccal bifurcation. (b) The  predominant movement is buccal and significant force may be required. (c) Palatal forces can be applied, although the palatal  cortical plate is thick and unyielding. (d) Firm steady buccal pressure allows the socket to expand and the tooth is delivered in    Figure 5.8 (a) These teeth with similar, single conical root morphology are removed with lower premolar or universal forceps  which are positioned as far down the root surface as possible. (b) Force is applied labially and then lingually (c). Rotational move-  ments are introduced until the tooth is finally delivered in a buccal—occlusal direction (d).    The curved blade of the elevator is placed on the root  surface, thus lying between the tooth and the alveolar  bone which acts as a fulcrum around which the elevator  is turned.   Rotation of an elevator used in this way will produce a  force which luxates the tooth and tends to displace it out of  its socket (Figure 5.12a).   An equal force will also be applied to the fulcrum, so it  is important to ensure that this is alveolar bone capable of  resisting such a force and not an adjacent tooth which may  as a result become inadvertently loosened or displaced  (Figure 5.12b).    Elevators must be used with caution when luxating  teeth to avoid generating excessive and potentially dam-  aging forces. Should a tooth resist attempts to luxate it,  another solution should be sought.    Luxators are sharp, fine, slightly flexible single-bladed  instruments, not unlike Coupland’s elevators in appear-  ance. They are used to incise the soft-tissue attachment of  a tooth whilst sliding down the periodontal space to an    Figure 5.9 (a) Lower molar forceps are positioned with beaks engaging the bifurcation buccally and lingually. (b) Buccal and  lingual (c) excursions are made, with increasing force as the tooth begins to become mobile. (d) A figure of eight movement inde-  pendently dilates the mesial and distal sockets. (e) Tooth is delivered in a bucco-occlusal direction.    Figure 5.10 Where the crown of a mandibular molar is  extensively destroyed, the use of Cow Horn forceps may allow  an extraction to be completed routinely, thus a surgical pro-  cedure can be avoided. The sharp, curved buccal and lingual  beaks are positioned between the mesial and distal roots. As  the handles of the forceps are closed, the beaks are squeezed  further into the bifurcation and produce a tractional force  which expels the tooth from its socket. Subsequent bucco-  lingual movements allow the tooth to be lifted from its socket.    apical position. Their subsequent rotation then luxates and  promotes the displacement of the tooth, with a minimum  of force and alveolar destruction.    Periotomes are instruments that are used to sever the soft-  tissue attachment of a tooth. They resemble fine straight  elevators, but have sharp, narrow blades for cutting.  Straight periotomes are used for single-rooted teeth whilst  angled ones are appropriate for multi-rooted teeth. They    Figure 5.11 Operator's index finger is extended along the  length of the elevator.    are inserted into the periodontal space and with apical  pressure are moved from the distal to the mesial aspect of  a tooth or root; first buccally and then palatally. By sever-  ing the soft-tissue attachment in this way, there is less need  for vigorous manipulation of the tooth within its socket  during the extraction. Alveolar expansion and damage are  therefore minimized. Patients who have received treat-  ment with bisphosphonate or other antiresorptive medi-  cation and those for who implant treatment is planned will  benefit from the use of periotomes prior to an atraumatic  forceps extraction.    Where the crown of a tooth is largely absent, attempts can  be made to remove it without a surgical procedure which  will minimize unpleasant post-operative sequelae such as  pain and swelling. Using alveolar bone to act as a fulcrum  to apply forces to the root, luxators or elevators may be  used to displace roots from their sockets. Luxators are par-  ticularly effective in this situation.   Single-rooted teeth: The instrument should be inserted  between the mesial and distal aspects of the root surface  and alveolar bone. By rotating it, the root becomes mobi-  lized ready for delivery by forceps or displaced out of the  socket (Figure 5.13).   Multi-rooted teeth: Where a multi-rooted molar with a  destroyed crown must be removed, elevation alone may  be fruitless and not result in delivery of the tooth. In this  situation, the roots may be divided with the use of a water-  cooled bur (Figure 5.14) or by rotating a straight elevator  in the bifurcation (Figure 5.15). The separated roots are  subsequently elevated or removed with forceps.    The surgical removal of teeth using a traditional transal-  veolar approach utilizes the benefits of improved access  and visibility afforded by raising a mucoperiosteal flap.  The removal of alveolar bone and tooth division may also  be necessary. Extensive coronal destruction, unusual root  morphology, unfavourable root pattern, ankylosed or  dilacerated roots are predictive of the need for a surgical  extraction.   The aim of the surgical approach is to deliver a tooth or  its remnants along a surgically created pathway. The first  step involves the raising of a mucoperiosteal flap. An inci-  sion is made through the mucoperiosteum, allowing the  site of surgery to be exposed. The incision defining the flap  should be full thickness, placed over bone not planned  for removal and distant from adjacent vital structures.  A horizontal element around the gingival margin and ver-  tical relieving incision buccally are usually indicated, with  inclusion of the gingival papilla within the flap. Ensuring  that the base of the flap is wider than the gingival aspect,    Figure 5.12. (a) The elevator produces a force which luxates the tooth, displacing it out of its socket. (b) An equal force will also    careful manipulation and effective closure of the soft tis-  sues optimizes the vitality and healing of the flap. Where  visualization of the surgical site is still difficult, the provi-  sion of a further relieving incision to create a three-sided  flap improves both this and surgical access (Figure 5.16).    Having exposed a tooth, the improved access and direct  vision may allow it to be elevated or removed with forceps  with no need for bone removal (Figure 5.17).   The removal of bone from around the tooth is, however,  often necessary. Tungsten carbide tipped round or fis-  sure burs with water coolant are usually used. Creation of  a bony gutter on the buccal aspect of a tooth reduces its  support making it easier to displace, provides a point of  application for elevators and exposes it sufficiently to facil-  itate its surgical division. Bone removal along the tooth’s  mesial-distal length should expose the root surface and  produce a deep but narrow cut which may be engaged  effectively by elevators (Figure 5.18).   A multi-rooted tooth may resist being elevated intact  from the alveolus even after bone removal. It may have  roots with no common path of withdrawal and surgi-  cal division is then indicated. This procedure allows the  tooth to be removed in smaller constituent parts, bone  is therefore preserved and the forces needed to complete  the extraction are reduced. Maxillary molars have buccal  roots which may be divided from the palatal root and each  other if necessary (Figure 5.19).   Mandibular molars may be divided with one bucco-  lingual cut (Figure 5.20).   Bone removal to expose the bifurcation of a tooth and  subsequent use of a bur to cut from the bifurcation in an  occlusal direction allows a greater degree of certainty that  the roots will be effectively separated than when a cut is  made blind from the occlusal surface towards the bifur-  cation. Decoronation prior to surgically dividing a tooth  may further maximize the chance of successful section. It  is often desirable to avoid cutting right through the root  mass, instead the bur can be used to divide two thirds of  the way through the tooth and then the remainder split by  rotating a narrow, straight elevator within the cut. Such  surgical division is usually sufficient to allow the tooth to  be removed; however, in other cases, the separated roots  may still resist removal. Bone removal around each of  them will then be necessary.   Following bone removal and tooth division, straight  dental elevators of increasing size can be used to luxate  and remove the tooth or its separated root fragments.    Figure 5.16 (a) Three-sided flap produced by a gingival and one relieving incision. (b) Further relieving incision creates a four-    Figure 5.17 Removal of a root with forceps following the  reflection of a mucoperiosteal flap.    Figure 5.18 (a) Bone removal to expose the root surface  and produce a gutter buccally. (b) Use of elevators at the point  of application to displace a tooth.    Figure 5.19 (a-d) Division and elevation of the roots of a maxillary molar.    Force should be applied mesially and buccally in the long  axis of the tooth. Clinical experience brings with it the  ability to generate, identify and use a point of application  to its full advantage. An effective technique when applying  a force to elevate a tooth is also essential.   The use of a sharp-ended Cryer’s (East-West) elevator to  remove a root of a multi-rooted tooth following extraction  of an adjacent one is valuable. The sharp end is introduced    to the depth of the socket generated by the removal of the  first root and is used to engage the inter-radicular bone  and remaining root. A rotational movement is produced  as the handle is rotated, allowing the root to be removed  (Figure 5.21).   Following the removal of a tooth or its constituent frag-  ments thorough debridement and closure of the surgical  defect complete the procedure.    Figure 5.20 (ad) Division and elevation of the roots of a mandibular molar.    In recent years, an increased appreciation of the bene-  fits of preserving both bone and soft tissue at extraction  sites where implant placement is planned has resulted in  a greater general awareness of the benefits of optimizing  alveolar and mucosal contour for all patients following  dental extraction. Therefore, there has been shift away    from the traditional surgical exodontia of multi-rooted  teeth involving mucoperiosteal flaps and buccal bone  removal towards a more conservative approach. When  there is resistance to a forceps extraction (often attribut-  able to unfavourable root morphology) rather than pro-  gressing to a conventional transalveolar approach, the  sectioning or surgical division of the tooth will usually  facilitate its removal without the need to raise a flap. This  technique can be used to extract maxillary and mandibu-  lar molars or multi-rooted premolar teeth. Although the  outcome is not as predictable as when a flap is raised, in  experienced hands this technique may, however, offer the  benefits of tissue preservation.   The removal of the coronal portion of the tooth prior to  root division is not essential although this does provide an  axial view of the root anatomy which permits the surgeon  to divide the remaining roots at the correct location and  angulation. Decoronation and the sectioning of roots in  their long axis is best achieved with a narrow fissure bur,  a straight elevator or luxator can then be inserted into the  cut made and rotated to deliver the component parts.    Where a small portion of a root is retained and resistant  to removal with an elevator, curette, probe or root pick, an  assessment of whether it may be left in situ should be made.    If its removal is indicated then a surgical procedure must  be undertaken. The conventional technique of raising a  buccal flap, removing bone to expose the root and deliver  it may be utilized; however, this is a relatively destructive  procedure. Alternatively, a more minimal technique where  a soft-tissue flap is raised but the bulk of the buccal plate is  preserved may be preferred. This involves creating only a  small fenestration in the buccal plate at the anticipated site  of the retained root allowing an instrument to be inserted  through it to displace the root coronally (Figure 5.22).    The number of extractions that can be performed on one  occasion is determined by the patient’s cooperation, local  anaesthetic dose and surgical difficulty. Maxillary extrac-  tions should be performed prior to those in the mandible  to avoid debris from the former contaminating mandib-  ular sockets. Posterior teeth should be removed prior to  anterior ones in the same arch so that there is no obscur-  ing of the view of the former by bleeding anteriorly. The  use of papillary sutures to re-appose mucosal tissue allows  better soft-tissue healing and contour post-operatively,  since the mucosa may gape even without the creation of  surgical flaps.    The principles of extracting deciduous teeth are essentially  the same as those for permanent teeth; however, there are  some differences to consider. First, the unerupted per-  manent successor of the deciduous tooth being removed  is likely to be in close proximity and as this erupts, the  roots of the deciduous tooth become resorbed. Thus, the  risk of inadvertently removing the developing permanent    tooth with the deciduous tooth increases as the permanent  tooth moves occlusally. It is therefore particularly impor-  tant that smaller, deciduous, extraction forceps are applied  to deciduous molar teeth either mesial or distal to but not  within its bifurcation (Figure 5.23).   A second modification of technique is needed to reflect  the fact that the roots of deciduous molars are divergent,  relatively long and fragile. They are therefore prone to  fracture during extraction resulting in retained fragments  close to the developing crown of the successor. When this  occurs, the remnants should be removed very carefully  with the application of elevators to the mesial aspect of the  mesial root and the distal aspect of the distal root only,  thus avoiding the region of the bifurcation (Figure 5.24).    On completion of a dental extraction, the surgeon assumes  responsibility for the patient’s aftercare. Both verbal and  written instructions should be given, explaining how the  extraction site should be cared for, how to avoid precipitat-  ing bleeding and what to do should this occur. Responsible  surgical practice requires the operator to prescribe suit-  able and effective post-operative analgesia for the patient  as it is almost inevitable that pain will ensue.   The nonsteroidal anti-inflammatory drugs (NSAIDs)  have been shown to be highly effective in controlling acute  pain following oral surgery. Of this group of drugs, ibupro-  fen is associated with the lowest incidence of side effects  and 400 mg controls this type of pain more effectively than  10 mg morphine intramuscular or 1 g paracetamol taken  orally, although emerging evidence suggests that com-  bined drugs containing both ibuprofen and paracetamol  are superior to either single drug. Patients for whom the  prescription of ibuprofen is contraindicated will benefit  from a paracetamol containing analgesic.    Figure 5.22 (a) and (b) Retrieval of a retained root tip using a bone preserving technique.    Figure 5.24 Elevation of the roots of a deciduous man-  dibular molar away from the bifurcation.    Careful pre-operative planning, an atraumatic surgical  technique and attention to post-operative instructions  will minimize the occurrence of complications following  dental extraction. A patient must, however, be warned pre-  operatively of those occurring commonly and sequelae  such as pain, swelling and limited mouth opening should  be expected. More significant complications are unusual  but include post-extraction haemorrhage and alveolar  osteitis.   Under normal circumstances, following a dental extrac-  tion, a socket should stop bleeding in less than 10 minutes.  When a patient presents with post-extraction haemor-  rhage contributory systemic factors should be excluded.  The mouth should then be cleaned thoroughly and the  bleeding point identified (good illumination and suction  will be required). Local pressure will usually control the  bleeding; this can be aided by the insertion of a haemo-  static agent such as oxidized cellulose. Control of persis-  tent haemorrhage may require the administration of local  anaesthesia, placement of sutures, diathermy or ligation of    vessels. Packing ribbon gauze, pre-soaked in Whitehead’s  varnish into a socket usually achieves haemostasis when  other means fail.   Alveolar osteitis (dry socket) is an acutely painful  condition which can complicate dental extractions. It is  characterized by the onset of pain 24-72 hours post-oper-  atively. Examination reveals halitosis, erythema of sur-  rounding soft tissues and an exposed bony socket from  which the clot has been lost and which has often become  filled with debris. Treatment involves debridement of  the socket into which an antiseptic, obtundant dressing  should be placed and the prescription of analgesia. Recent  systematic reviews have examined the efficacy of thera-  peutic interventions undertaken to reduce the incidence  of alveolar osteitis after oral surgery. These demonstrated  that mouth washing with chlorhexidine pre-operatively  and then for 7 days post-operatively and the placement  of chlorhexidine gel into sockets immediately following  extraction are both effective in reducing the occurrence  of alveolar osteitis, although clinicians should be aware  of the possibility of anaphylaxis as a result of such topical  use of chlorhexidine products. There is no evidence to  support the prescription of antibiotics to prevent alveo-  lar osteitis or post-operative infection following dental  extraction in healthy patients.    e During an extraction, the proper positioning of the  patient and operator ensures that both are comfortable  and that the forces applied to the tooth are mechani-  cally efficient.   e Attempts to remove a tooth by using elevators and  forceps when pre-operative evaluation suggests that a  surgical procedure should be undertaken will be exces-  sively traumatic and will prolong the procedure.   e The use of periotomes and luxators and the minimiza-  tion of bone removal will preserve vital tissue and opti-  mize outcome.   e When using an elevator, the blade must be positioned  correctly between the root and alveolar bone and not  between two teeth as this will mobilize and displace  both.   e The generation of excessive force whilst using elevators  or forceps should be avoided as this predisposes to the  fracture of the tooth or alveolus.   e The surgical division of a tooth without raising a muco-  periosteal flap minimizes post-operative discomfort  and preserves both bone and keratinized soft tissue at  the extraction site.   e Mucoperiosteal flap design should provide optimal  access and visualization of the surgical site whilst limit-  ing the extent of surgical trauma.   e Buccal bone removal to create a narrow gutter adjacent  to a tooth reduces its bony support whilst preserving  a ridge of buccal cortex which then provides a fulcrum  for the subsequent elevation of the tooth.   e Most complications result from inadequate pre-opera-  tive evaluation and poor surgical technique.   Gillbe GV and Moore JR. Extraction of erupted teeth and  their roots. In Moore JR (ed.), Surgery of the Mouth  and Jaws. Oxford: Blackwell Scientific Publications;  1985. pp. 315-338.   Hedstrém L and Sjégren P. Effect estimates and method-  ological quality of randomised controlled trials about  prevention of alveolar osteitis following tooth extrac-  tion: A systematic review. Oral Surge Oral Med Oral  Pathol Oral Endod. 2007; 103(1): 8-15.    Meechan JG (ed.), Minor Oral Surgery in Dental Practice.  London: Quintessence; 2006.   Moore UJ (ed.), Principles of Oral and Maxillofacial Surgery,  Fifth Edition. Oxford: Blackwell Science; 2001.   Pedlar J. Extraction of teeth. In Pedlar J and Frame JW  (eds.), Oral and Maxillofacial Surgery. An Objective-  Based Textbook. London: Churchill Livingstone;  2001. pp. 27-47.   Peterson LJ, Ellis E IN, Hupp JR and Tucker MR (eds.),  Contemporary Oral and Maxillofacial Surgery, Fourth  Edition. St Louis, Mo: Mosby; 2003.    An unerupted tooth is one that has not emerged through  the oral mucosa into the oral cavity at a developmental  stage when this would usually have been expected. In  most cases, such failure of eruption is the result of impac-  tion where ectopia or an identifiable barrier (e.g. lack of  space, a supernumerary tooth, odontome or cyst) pre-  vents the normal eruption of a tooth. Less commonly,  eruption ceases before the tooth emerges through the  oral mucosa with no identifiable barrier to eruption, a  situation referred to as primary retention. After third  molars, the maxillary canines and mandibular premo-  lars are the teeth that most frequently remain unerupted.  Supernumerary teeth, most commonly seen in the ante-  rior maxilla or mandibular premolar region, also tend to  remain unerupted.   The surgical removal of an unerupted tooth may be  indicated if its retention will interfere with the orthodontic  alignment of adjacent teeth, if there is associated pathol-  ogy or if the presence of the unerupted tooth is adversely  affecting adjacent teeth. If there is no indication to remove  an unerupted tooth then this can be left in situ, provided  that it is monitored clinically and radiographically (at  appropriate intervals) to ensure that pathological change  does not develop.   The principles of completing an extraction with mini-  mal loss of vital tissue whilst avoiding iatrogenic damage  to adjacent structures have been discussed in Chapter 5  and are as relevant, perhaps more so, during the surgical  removal of unerupted teeth.    The presence of an unerupted tooth should be suspected  when a permanent tooth fails to erupt within 6 months of  its contralateral counterpart, if there is prolonged reten-  tion of primary teeth or where a localized malocclusion  is accompanied by a ‘missing tooth’. Clinical examina-  tion will confirm which teeth of the normal series are  unerupted and may suggest the reason for this if crowding,  abnormally fibrous soft tissue or a dental anomaly are con-  tributory. Palpation of the alveolus may allow the surgeon  to determine the bucco-palatal position of the unerupted  tooth, particularly if it is in a superficial position, but may  be unproductive or unreliable. Radiographic assessment  is essential prior to the surgical removal of an unerupted  tooth to ensure that the surgeon has a clear understand-  ing of its position, relationship to adjacent teeth and other  vital structures such as the maxillary sinus or mental and  inferior alveolar nerves (IANs). Panoramic radiography  provides a useful overview of the dentition and position  of teeth. It can be used in a parallax technique with intra-  oral radiographs such as periapical and occlusal views to  establish the bucco-palatal position of an unerupted tooth.  This is essential when considering the design of the muco-  periosteal flap which will provide the most effective access  to the tooth during its removal.   Cone beam computerized tomography (CBCT) pro-  vides highly accurate localization of an unerupted tooth  in three dimensions and demonstrates resorption, dilac-  eration, morphology, malformation and proximity to  anatomical structures very clearly allowing accurate    pre-operative surgical planning. The surgeon should,  however, be aware that the effective radiation dose of  CBCT is considerably greater than plain radiography and  its use particularly in the younger patients often present-  ing with unerupted teeth should be considered carefully.  UK Ionizing Radiation (Medical Exposure) Regulations  (IR(ME)R) and European Commission radiation protec-  tion guidance recommends that the use of CBCT in chil-  dren should be restricted to complex cases in which the  benefit of additional diagnostic information obtained out-  weighs the additional radiation risk. The dose received by  the patient should be further minimized by scanning the  smallest possible volume size (Figure 6.1).   The importance ofidentifying that an unerupted tooth is  closely related to a sensory nerve which could be damaged    Figure 6.1 Cone beam computerized tomography (CBCT)  views of a right maxillary canine tooth that has been prevented  from erupting by a compound odontome. The benefits of  detailed, three dimensional imaging which this scanning tech-  nique provides is clearly demonstrated.    during its extraction cannot be understated. A failure to  appreciate this and the spacial relationship between tooth  and nerve may result in a patient suffering an avoidable  permanent post-operative sensory deficit, possibly accom-  panied by neuropathic pain, which can be functionally  disabling in some individuals. Unerupted mandibular  canine, premolar and molar teeth present the greatest risk  of neuropathy within the distribution of the IAN but the  removal of high, unerupted maxillary teeth and the inju-  dicious use of flap retractors high in the buccal sulcus dur-  ing extractions in the maxillary arch can also disrupt the  infraorbital branch of the maxillary nerve. In cases where  surgical intervention is unavoidable but CBCT scanning  demonstrates an intimate relationship between the root  of an unerupted tooth and the inferior dental canal (IDC)  suggesting that the surgical removal of the entire tooth  would present an increased risk of post-operative neurop-  athy, coronectomy may be considered. Coronectomy, or  partial odontectomy is a conservative surgical technique  in which the crown of a tooth is removed but its roots  or (root) are deliberately left in situ. In carefully selected  cases, this alternative to the complete removal of a tooth  may represent the treatment of choice to reduce the risk of  post-operative neuropathy (Figure 6.2).    The surgical removal of a maxillary incisor may be indi-  cated when its eruption has been prevented by an obstruc-  tion such as a supernumerary tooth or odontome or when  trauma to the primary dentition has resulted in dilacera-  tion of the permanent incisor which cannot be aligned.  These teeth are usually accessed using a two-sided buc-  cal flap, the distal relieving incision usually being neces-  sary to expose the incisor which may occupy a very high  position in the alveolus. The buccal bone overlying the  crowns of these teeth is often very thin and its removal  may be achieved with hand instrumentation. If this is  not the case, a water-cooled rosehead bur can be used  to expose the tooth with care being taken to avoid dam-  age to the roots of the adjacent teeth. Once its crown is  exposed, the incisor tooth can usually be elevated from  the alveolus without difficulty; however, if there is a sig-  nificant dilaceration of the root of the tooth, the section-  ing and removal of the crown may be required to allow  the elevation of the root along a different path of with-  drawal (Figure 6.3).    Maxillary canines may remain unerupted as a result  of crowding, ectopia, impaction or an inherited dental    Parasagittal (a), coronal (b) and axial (c) CBCT images of an unerupted mandibular left first molar tooth which dem-  onstrates the inferior dental canal (IDC) running between its two buccal and two lingual roots and the surgical procedure to expose    Red line indicates the line along which this  severely dilacerated central incisor will need to be sectioned to  allow its root to be elevated.    anomaly. If the orthodontic alignment of an unerupted  canine is not indicated, surgical removal is often requested  to prevent later development of cystic change or resorption    of adjacent teeth. Buccally placed unerupted canines are  usually accessed via a two-sided mucoperiosteal flap  comprising a gingival sulcus and distal relieving incision  (Figure 6.4).   If, however, the canine occupies a superficial position  high in the buccal sulcus where it is easy to locate, a linear  incision within the moveable soft tissues just inferior to  the tooth can also be used to access the tooth whilst avoid-  ing unnecessary gingival recession around the adjacent  teeth (Figure 6.5).   An unerupted palatal canine should be accessed with  the use of a palatal flap created by a gingival sulcus inci-  sion on the palatal aspect of at least two teeth either  side of its anticipated position. Once the soft-tissue flap  is retracted, the position of the crown of the unerupted  canine will often be revealed by a bulge in or a thinning  of the bone overlying it. If this is not the case, a water-  cooled rosehead bur can be used to expose the tooth  with superficial, sweeping strokes at the indicated site  as suggested by imaging to be its most likely location.  The sight a soft-tissue dental follicle within the alveolar  bone is often the first indication of the position of the  underlying tooth. The surgical exposure of the tooth    Figure 6.4 Technique for the surgical removal of an unerupted maxillary buccal canine. (a) Two-Sided buccal flap raised. (b) Bone  removed to expose crown of unerupted canine. (c) Luxator used to elevate tooth.    should continue until the bone overlying the crown and  just beyond the cemento-enamel junction (CEJ) has been  removed and an application point for elevators created.  Care should be taken not to damage the roots of the  adjacent teeth which often lie in close proximity. At this  point, the use of a luxator or small elevator on the mesial  and distal aspects of the unerupted tooth will often com-  plete the extraction. Care must be taken to ensure that  adjacent teeth are not used to provide a fulcrum or these  will become mobilized or even displaced. Excessive force  should not, therefore, be used and if the tooth resists rea-  sonable force applied, the removal of the crown of the  tooth allowing it to be disimpacted from the roots of  adjacent teeth will usually allow the root to be delivered  successfully (Figure 6.6).    Maxillary second premolar teeth may fail to erupt as a  consequence of crowding or space loss following the early  extraction of primary teeth. These almost always occupy a  palatal position, often becoming ‘trapped’ above the con-  tact point between the first premolar and molar which have  become approximated. A palatal flap created by a gingival  sulcus incision extended to include at least two teeth either  side of the unerupted premolar is used to provide access for  the extraction. Once the flap is raised, the premolar is often  accessible for the use of a luxator to elevate it. If this is not  the case, bone removal to expose the crown usually facili-  tates its delivery. If resistance to movement is encountered    Figure 6.5 Technique for the surgical removal of an unerupted high buccal maxillary canine. (a) Pre-operative appearance.  (b) Incision made in mobile tissue of buccal sulcus. (c) Crown of unerupted canine exposed. (d) Luxator used to elevate tooth.    or the position of adjacent teeth makes them vulnerable to  becoming mobilized when reasonable force is applied, the  crown of the premolar should be sectioned from the root to  complete the extraction without complication (Figure 6.7).    The primary retention of maxillary molars or their fail-  ure to erupt due to an obstruction (often adjacent teeth)    may necessitate their surgical removal. This will usually  involve a buccal approach via a two-sided flap to expose  the crown of the unerupted tooth. It may then be possible  for the tooth to be elevated intact; however, decoronation  and the division of roots may be necessary to deliver the  tooth and avoid disruption to the adjacent dentition. The  surgical removal of a primarily retained first molar which  has limited the development of the adjacent alveolus and  occupies a superior position close to the floor of the max-  illary sinus often creates a communication between the  socket and the sinus and care should be taken to achieve    Figure 6.6 Technique for the surgical removal of an unerupted palatal maxillary canine. (a) Pre-operative appearance.  (b) Localized palatal flap reflected. (c) Luxator used to elevate tooth. (d) Canine removed.    Mandibular canine teeth may remain unerupted because  they are ectopic or because of a lack of space for their rela-  tively late eruption. Surgical removal is achieved by a buc-  cal approach, usually with a two-sided flap. The relieving  incision of this flap should be sufficiently mesial to avoid  damage the mental nerve as it exits the mandible and to  allow subsequent closure of the incision to be supported  by intact bone (away from the site of bone and tooth  removal). If the crown of the unerupted canine is not vis-  ible after a flap has been reflected, a water-cooled rosehead  bur should be used to expose the tooth with superficial  strokes at the site revealed by available imaging to repre-  sent its most likely location in order to minimize damage  to adjacent teeth. Once the crown and upper portion of  the root have been exposed, it is often possible to deliver  the canine tooth with the use of elevators at its mesial and    distal aspects. If this is not the case, the tooth should be  decoronated to allow the crown and root to be elevated  separately. The operator must ensure that the mental  nerve which is frequently closely related to the crown  of the unerupted canine is protected from compression  during the elevation of the tooth or from the use of a flap  retractor as both can produce post-operative neuropathy  (Figure 6.9).    Space loss, obstruction to eruption, over-retained and  ankylosed primary teeth or ectopia may cause mandibular  premolars to remain unerupted and the removal of these  teeth may be indicated. To ensure that an unerupted man-  dibular premolar is removed as effectively as possible it is  essential that the surgeon carefully interprets their clinical  findings and the available imaging to ensure that they have  a clear understanding of the position of both the crown and  the root of the tooth. Not infrequently, unerupted mandib-  ular premolars lie transversely across the alveolar arch with    Figure 6.7 Technique for the surgical removal of an  unerupted, palatally displaced maxillary premolar. (a) Localized  palatal flap reflected. (b) Bone removed to expose crown of  premolar. (c) Luxator used to elevate tooth.    the root apex being located buccally whilst the crown lies  lingual to the adjacent teeth. The removal of an unerupted  mandibular premolar which lies entirely lingual to the den-  tal arch should be facilitated by raising a lingual flap, cre-  ated with a single incision in the gingival crevices of the  lingual aspect of the teeth adjacent to that being removed.  Those unerupted premolars which lie entirely buccal to the  arch or transversely across the arch but with the root in a  buccal position should be removed with a buccal approach.  A two-sided buccal flap is usually required to expose the  tooth adequately so care must be taken to ensure that the  relieving incision is made well away from the mental nerve.  The crown of the premolar is often found to have become  ‘trapped’ within the line of the arch beneath the contact    Figure 6.8 Diagram to show the lines along which an  unerupted maxillary first molar should be sectioned to effect  an atraumatic extraction with minimal disruption to adjacent  teeth and the floor of the maxillary sinus.    point of the adjacent tooth which necessitates decorona-  tion in order to allow removal of the crown and then the  separated root of the tooth. Occasionally the decoronated  crown is too large to be delivered through the limited buc-  cal bony window which can be created between adjacent  teeth without being further sectioned itself. Once the  crown is delivered, the root of the tooth can usually be  elevated without difficulty (Figure 6.10).    Primary retention or obstructed eruption with subse-  quent mesial tipping of the tooth distal to it may neces-  sitate the surgical removal of a mandibular first or second  molar. Not infrequently, the roots of these teeth have  a close relationship to the IAN because of their inferior  position within the mandible. Good quality radiographs  or ideally CBCT enhance the planning of the surgical pro-  cedure to remove such teeth and this is invaluable when  circumstances (caries or cystic change) dictate that the  unerupted molar has to be completely removed despite  a known intimate relationship to the IAN. A two-sided  buccal flap will be necessary to adequately expose the  crown of the tooth and once again, care must be taken  to ensure that the relieving incision is distant from the  mental nerve. The tooth should then be decoronated to  allow accurate division of its roots (which may have mul-  tiple rootlets as a result of apical root development being  deflected by the IDC) under direct vision. This atraumatic,  elective root division minimizes the risk of IAN injury by  reducing the compressive forces transmitted to the nerve  from the gentle elevation of the separated roots compared  to the heavier forces necessary to deliver the undivided  root complex (Figure 6.11).    Figure 6.9 Technique for the surgical removal of an  unerupted mandibular canine. (a) Buccal flap reflected. (b) Bone  removed to expose crown. (c) Luxator used to elevate  tooth.    A supernumerary tooth in the upper labial segment is  usually located on the palatal aspect of the permanent  incisors, which may remain unerupted because of its pres-  ence. These supernumerary teeth in the anterior maxilla  can be identified and removed via a flap created by mak-  ing a gingival crevice incision on the palatal aspect of one  or two teeth to each side. It is often possible to raise the  flap without disruption to the nasopalatine neurovascular  bundle as it emerges from the incisive canal, but if this  obstructs the removal of the supernumerary it can be  divided to improve access with little consequence. The  removal of a high, inverted, often conical supernumer-  ary tooth (a ‘mesiodens’ above and between the roots of  the central incisor teeth warrants high-quality imaging,  perhaps CBCT, to ensure that this is achieved without  excessive bone removal and damage of the adjacent inci-  sor roots, which could result in them becoming non-vital.  Although the roots of such supernumerary teeth may lie  on the palatal aspect of the incisor roots, their crowns (the  widest part) are often superior to the incisor apices and  most easily removed with a high buccal approach. It may  be possible to elevate the supernumerary tooth intact from  the buccal aspect after the overlying bone is removed or if  resistance is encountered it can be decoronated and then  the root elevated and delivered superiorly (Figure 6.12).   The supernumerary teeth which develop in the man-  dibular premolar region, occasionally bilaterally, can often  be left in situ without problem. Where, however, their  removal is indicated, accurate imaging (true occlusal view  or CBCT) to establish their bucco-lingual position relative  to the adjacent teeth is essential to ensure that the most  appropriate flap is raised. This is particularly important  if the teeth are in the early stages of development and still  small as at this time they can be very difficult to locate  clinically without significant bone removal and risk of  damage to neighbouring teeth.    The most common indications for the removal of man-  dibular third molars (M3Ms) are caries and recurrent  episodes of pericoronitis (inflammation of the sur-  rounding operculum) due to incomplete eruption.  Unerupted M3Ms may also become associated with  cysts or tumours and require removal. In addition to  thorough clinical examination, detailed radiographic  assessment is essential when treatment planning M3M  surgery because of the potential risk of inferior alveolar  nerve injury ([ANI).   The surgeon should examine the dental panoramic  tomogram (DPT) in a stepwise manner to establish the  following (Figure 6.13):    Figure 6.10 Technique for the surgical removal of an unerupted mandibular premolar. (a) Two-Sided buccal flap reflected and  premolar exposed. (b) Crown and root divided and elevator used to separate them. (c) Decoronated premolar. (d) Luxator used to    1. Angulation of the tooth: Whether mesial, distal, hori-  zontal, vertical or transverse.   2. Depth of impaction: Indicated by the distance from the  alveolar crest to the potential application point of an  elevator. This provides an appreciation of the amount  of bone that will need to be removed during the extrac-  tion. The quality or density and quantity of surrounding  bone are also important factors to consider. The posi-  tion of the tooth in relation to the ascending ramus is a  further indicator of the extent of bone removal required  to facilitate delivery.   3. Coronal morphology and associated pathology: Atten-  tion should be paid to the presence of caries or increase  in follicular width suggestive of cystic change associ-  ated with the M3M. The restorative condition of the  adjacent tooth should also be noted as extensive caries  or large restorations can pre-dispose to intra-operative  damage.   4. Root number, morphology, length and the presence of  hypercementosis or ankylosis.    5. Proximity to the IAN: Radiographic signs suggestive of  an intimate relationship with the IAN include darken-  ing of the root, loss of the corticated margin of the canal  and both deviation and narrowing of the canal. In these  situations further investigation with CBCT should be  considered (Figure 6.14).    The presence of the high-risk features listed above are  not the only indicators for CBCT. It is also important  to consider such imaging in cases where plain radiogra-  phy demonstrates that there are sharp apical curvatures  at risk of fracture, long root/IDC contact surface area  or where the IAN is likely to be in close proximity to a  planned surgical cut. In these circumstances, positional  awareness of the IAN is vital in reducing iatrogenic  nerve injury.   The proximity of a M3M to the IAN is a very significant  factor in the selection of the M3M removal or coronec-  tomy as the surgical intervention of choice for a patient  who presents for treatment (Figure 6.15).    Technique for the surgical removal of an unerupted mandibular first molar. (a) Pre-operative appearance, note  absence of permanent first molar. (b) Buccal flap reflected and bone removed to expose crown of tooth. (c) First molar decoronated  and mesial/distal roots divided. (d) First molar removed, inferior alveolar nerve (IAN) seen within socket.    CBCT images demonstrating that although the root of this high inverted midline supernumerary tooth lies palatal  to the roots of the adjacent incisors, its removal is most effectively achieved via a buccal approach.    Figure 6.13 Radiographic assessment of an unerupted mandibular third molar (M3M) from a dental panoramic tomogram    A buccal approach is most commonly used with access  being dictated by the angulation of impaction and the vol-  ume of overlying bone. A vertically soft tissue impacted  M3M can be extracted through a minimally invasive single  distal relieving incision. When bone removal and sectioning  are required, a two-sided full thickness mucoperiosteal  ‘triangular’ flap or envelope flap with distal relief will pro-  vide optimal access to the surgical site (Figure 6.16).    In all cases, the posterior or distal relieving incisions  should be positioned buccal to the crest of the ridge to  avoid transection of lingual nerve which can be superficial.  The use of a suitable retractor such as a rake or Minnesota  enables atraumatic handling of buccal soft tissues. The use  of lingual retraction is not advised unless there is a risk of  perforation of the lingual plate or lingual displacement of  the tooth.   Bone removal using a water-cooled, sterile rosehead bur  should be undertaken to remove sufficient overlying bone    DPT displaying darkening  of the mesial and distal  roots and narrowing of  the IDC. The corresponding  axial CBCT section shows  the IDC weaving through  grooving the roots.    DPT displaying  superimposition of the IDC  over the root mass with  corresponding coronal  Superimposition CBCT section showing  the IDC positioned buccal  to the root mass, with  apparent loss of cortication  medially.    DPT displaying darkening  of root apex and narrowing  of the IDC with  corresponding CBCT    Figure 6.14 DPT with corresponding CBCT sections of M3Ms noted to be closely related to the IDC.    Figure 6.15 Algorithm for the treatment planning of Figure 6.16 Flap design for access to unerupted M3M.  M3Ms. (a) Triangular flap. (b) Envelope flap with distal relief.    (a) Sectioning pattern for a mesioangular M3M, extraction achieved through decoronation and subsequent root  division. (b) Sectioning pattern for a horizonal M3M. Care must be taken to ensure the decoronating cut (1) does not undercut the  crown which makes it difficult to deliver. Crown removal may require multiple sections. (c) Sectioning pattern for a distoangular  M3M. Initial oblique decoronating cut with retrieval of distal portion of impacted crown (1) leaving mesial application point intact.  The remaining mesial portion may elevate intact or require root division prior to delivery.    to expose the crown and create an application point. As  with all exodontia, every effort should be made to retain  as much vital tissue as possible. Decoronation (possibly  requiring multiple sections) of the tooth using a fissure  bur allows assessment of the pulp morphology and sub-  sequent accurate division of the roots under direct vision  (Figure 6.17).   Elective surgical sectioning and elevation of individual  roots with light pressure minimizes the transmission of  potentially damaging forces to the IAN. Careful reference  to pre-operative imaging prior to the sectioning of the  M3M will ensure that the cuts are optimally planned and  executed, minimizing the risk of iatrogenic IAN injury.    The use of the technique of coronectomy may be indicated  to treat a symptomatic, disease free M3M which is inti-  mately related to the IDC when the complete removal of  the tooth would pose risk of iatrogenic [ANI (Figure 6.18).    Access to the M3M is achieved by raising a full thickness  mucoperiosteal triangular flap which provides sufficient  visual and surgical access. Bone removal using a rosehead  bur may be required to expose sufficient crown to facilitate  sectioning. Bone removal should be limited to the coronal  portion of the tooth only and not extended down the root  surface. Exposure of the crown allows the decoronating  cut to be placed correctly at this level, and minimizes the  need for additional enamel removal later. The decoronat-  ing cut should be made using a fissure bur perpendicular  to the long axis of the tooth. The cut should extend three-  fourths of the way across the crown to enable the use of  light or fingertip pressure to rotate a couplands chisel or  straight Warwick James elevator to displace the crown but  avoid transmission of elevating forces to the root mass.  The crowns of horizontally impacted teeth may need to  be delivered in multiple sections. The retained root should  be inspected for signs of mobility and presence of enamel.  If enamel is observed this must be removed using a rose-  head bur. Finally, the root mass should then be reduced to  so that it lies 2-3 mm below bone level and remnants of    (a) Retraction of a triangular mucoperiosteal flap to expose an unerupted right M3M. (b) Bone removal to expose  the cement-enamel (CEJ) junction. (c) Decoronation cut is made at the level of the CEJ and perpendicular to the long axis of the  tooth. (d) Decoronation is completed with the insertion and rotation of an elevator. (e) Finished root surface which has been reduced  2-3mm below surrounding bone level complete with removal of coronal pulp remnants.    coronal pulp removed using a rose head bur. Care must be  taken (especially with distoangularly impacted M3M) not  to damage the adjacent root. Any roots which are noted    to have become mobile during the coronectomy proce- Surgical removal of unerupted maxillary third molars is  dure should be removed using the sectioning technique, indicated when there is infection, resorption or an associated  which is previously discussed. Primary wound closure is cyst or tumour. Pre-operative assessment should include the    required. identification of the proximity of the tooth to the maxillary    Figure 6.19 Flap design for the surgical removal of an  unerupted maxillary third molar which is located: (a) In the  tuberosity region, (b) More anteriorly.    sinus and adjacent second molar. Access to the unerupted  tooth is achieved using a buccal approach with flap design  being influenced by the position of the tooth. A full thickness  triangular flap may be sufficient in cases where the tooth lies  in the tuberosity region; however, if the tooth is more anteri-  orly placed then a two-sided flap with mesial relief anterior  to the second molar provides better access (Figure 6.19).  Careful placement of a Howarth, Laster or Minnesota  retractor during the surgical removal of unerupted max-  illary third molars is important to prevent displacement  of the tooth into the infratemporal fossa. The crowns of  unerupted maxillary third molars are often buccally  positioned and minimal, if any, bone removal is usu-  ally required to facilitate effective elevation. Where an  impacted maxillary third molar is palatally inclined    decoronation followed by sectioning of the root mass  may be necessary. Prior to closure, the socket should be  assessed for communication with the maxillary antrum as  this would influence the post-operative regimen.    Following the surgical removal of an unerupted tooth, the  extraction site must be thoroughly debrided and particu-  larly when the tooth has been surgically divided, inspected  carefully to ensure that no tooth fragments remain. If  closely related to the extracted tooth, the adjacent teeth  should be examined for signs of iatrogenic damage or exces-  sive mobility which if identified should be addressed. After  irrigation beneath the flap retractor where bone and tooth  debris tends to accumulate, the soft-tissue flap should be  closed and ensuring that the gingival tissue of adjacent teeth  is replaced in its pre-extraction anatomical position to min-  imize recession. Verbal and written aftercare instructions  should be given and appropriate analgesics is prescribed.    e Careful clinical and radiographic assessment of the posi-  tion and the relationships of an unerupted tooth to adja-  cent structures optimizes the planning of its removal.   e Wherever possible, the removal of an unerupted tooth  should be facilitated by sectioning of the tooth rather  than bone removal.   e By ensuring that the cuts made to section a tooth  remain within the tooth being extracted, damage to  adjacent teeth may be minimized.   e Adequate access to and the visibility of an unerupted  tooth during its removal are very important and should  be clinically assessed pre-operatively. It should be rec-  ognized that any degree of limited opening or inelas-  ticity of peri-oral tissues will complicate an extraction.    European Commission. Radiation Protection 172: Evidence  Based Guidelines on Cone Beam CT for Dental and  Maxillofacial Radiology. Luxembourg: Office for  Official Publications of the European Communities;  2012. Available at http://ec.europa.eu/energy/nuclear/  radiation_protection/doc/publication/172.pdf.   Gleeson CF, Patel V, Kwok J and Sproat C. Coronectomy  practice. Paper 1. Technique and trouble-shooting. Br  J Oral Maxillofac Surg. 2012; 50(8): 739-744.   Patel V, Gleeson CF, Kwok J and Sproat C. Coronectomy prac-  tice. Paper 2: Complications and long term manage-  ment. Br J Oral Maxillofac Surg. 2013; 51(4): 347-452.    Trigeminal nerve injuries may occur from third molar  surgery, local anaesthetic injections, orthognathic sur-  gery, maxillofacial trauma, implant surgery or pathology  surgery, and most often involve the inferior alveolar nerve,  the lingual nerve (LN) and the infraorbital nerve. Nerve  repair is indicated where the nerve injury is significant  (Sunderland IV or V degree injury), demonstrated either  by direct visual inspection or by clinical neurosensory  testing or adjunctive testing (i.e. magnetic resonance neu-  rography, trigeminal nerve conduction and chemosensory  testing). Repair should be carried out at the earliest oppor-  tunity under microscopic magnification by a trained  microsurgeon. (Although no standard exists for training  in microneurosurgery of the trigeminal nerve, suggested  standards for training in microsurgery exist and include  a minimum 40+ hours of didactic courses and labora-  tory experience including the successful anastomoses of  10 arteries, 10 veins and 10 neural repairs. A trained  microneurosurgeon should serve as first assistant to an  experienced microneurosurgeon in at least three cases and  then serve as primary surgeon in six cases.)    ® Witnessed nerve injury from third molar surgery,  orthognathic surgery (e.g. sagittal split osteotomy),  implant surgery or mandibular or maxillary trauma    © Non-witnessed nerve injury with persistent severe or  complete sensory impairment for approximately 3-6  months from third molar surgery, orthognathic surgery  (e.g. sagittal split osteotomy), implant surgery or man-  dibular or maxillary trauma    The operation is performed under general anaesthesia  with nasoendotracheal intubation. The throat is packed  with moist ribbon gauze and the endotracheal tube  secured. Microneurosurgery is difficult to perform under  local anaesthesia owing to movements of the awake patient  being magnified under the microscope, and requires a lon-  ger operating time than can be afforded by deep sedation.    The patient is laid supine on the operating table and turned  to keep the anaesthetic machine at about the waist level  of the patient. The patient should be positioned in a way  to allow two surgeons to sit on either side of the patient’s  head with an operating microscope over the patient’s head.    The microsurgeons must be seated comfortably during  the microsurgical phase of the procedure. Therefore, if  the motor base of the operating table does not rotate free  from the table, the patient should be positioned with the  head at the foot end of the operating table. This affords  the microsurgeons freedom to sit with their legs under  the operating table. The face around the mouth and the  oral cavity is cleansed. A head drape is used. If a nerve  graft site has been identified prior to surgery, the selected  location is prepared and draped for access. An operat-  ing microscope with two operator eyepieces should be  available; the microscope focal distance is set at 250 mm  with the zoom at mid-range. The operator eyepieces  should be adjusted to suit the surgeons and draped. If  available, video camera feed from the operating micro-  scope is useful for recording and allowing other team  members to see the procedure. Microsurgery in the oral  cavity requires longer microsurgical instruments, usu-  ally around 18 cm length and preferably of the bayonet  design. Bipolar diathermy and two separate suction tub-  ings should be available.   For LN surgery, the operating surgeon sits on the same  side of the operation site. For inferior alveolar nerve or  infraorbital nerve surgery, the surgeon sits on the opposite  side of the operation. Local anaesthetic with epinephrine  (adrenaline) is given as an inferior alveolar nerve block  and infiltrated around the operative site.    The patient’s head is kept central and a modified Dingman  mouthgag is inserted to position the mouth open, using  the tongue blade to keep the tongue from the operative  site. Penny towels are used to prop up the Dingman handle  (Figure 7.1). The modified Dingman should not be left in    Figure 7.1 Modified Dingman retractor for lingual nerve  (LN) microsurgical repair access.    this position but removed, if there is a need to move away  from the oral cavity for a time (e.g. to harvest a sural nerve  graft) so as to avoid prolonged pressure and ulceration of  the oral tissues.   An intra-oral mucosal incision is made with a No. 15  Bard-Parker (B-P) scalpel over the ascending ramus to the  distal of the mandibular second molar. A buccal extension  is made from the distal of the molar to the buccal sulcus,  and a lingual extension is made to the lingual sulcus curv-  ing forward up to the mandibular first molar (Figure 7.2).  The buccal and lingual mucosal flaps are raised supraperi-  osteally using a periosteal elevator and Metzenbaum curved  dissecting scissors, and secured to the modified Dingman  frame with 3/0 or 4/0 black silk sutures (Figure 7.3). Suction  of the operative site is provided using a fine Frazier suction.    Figure 7.3 Supraperiosteal flaps are reflected and secured  to the Dingman retractor for access to the LN.    The operating microscope is brought into the operative  field and positioned. The LN is located and exposed begin-  ning at healthy nerve proximal and distal to the injury site;  the LN is often found in a pouch of fat. The exposed proxi-  mal and distal nerve segments are carefully retracted with  vessel loops, one proximal and one distal to the injury site  (Figure 7.4). The injury site is often adherent to the lingual  aspect of the mandible, and is released with careful micro-  dissection using curved microscissors.   A modified background is placed beneath the released  nerve. The background is made by sharply cutting the  luerlock end of the small gauge butterfly venipuncture  system and then advancing this cut end through a tunnel  created in a 1- x 1-inch neuropatty and then securing the  tubing within the neuropatty with silk suture. The neu-  ropatty is then placed beneath the nerve at the injury site,  and the needle end of the modified butterfly venipuncture  system is inserted into the lumen of an active suction tub-  ing. The nerve is examined under microscopic magnifica-  tion (25x). The injury may be a complete transection with  a neuroma at the end of each nerve segment, or a partial  transection with a neuroma in continuity. The neuroma is  carefully excised with straight microscissors and the nerve  ends trimmed to expose the fascicular surfaces with peri-  odic irrigation with heparin saline (Figure 7.5). A 6/0 or  7/0 monofilament suture is passed into the epineurium of  each segment to the adjacent muscle and used to approxi-  mate the nerve segments together to facilitate repair  without undue tension. If the nerve segments cannot be  coapted without tension (approximately 1 cm or more of  nerve gap), a nerve graft will be necessary.    The trimmed nerve endings are coapted, using the  vasa nervorum as a guide aligning the nerve segments.    Using an 8/0 or 9/0 monofilament on a cutting needle,  the first suture is placed at the 12 o'clock position; a  longer strand is left. Further sutures are placed in similar  manner at the 4 and 8 o'clock positions (Figure 7.6).   The nerve may be ‘flipped over’ holding the suture  strands with microforceps. The intervening gaps in the  coaptation site are closed with circumferential sutures  placed at regular intervals around the nerve; usually six to  eight sutures may be required.   The repaired nerve is examined and any excess suture  is trimmed. The approximating suture and then the back-  ground are carefully removed.    Figure 7.6 Microsuture sequence of neurorrhaphy. (a) The  first suture is placed at the 12 o'clock position, followed by the  second suture at the 4 o'clock position. These sutures are left  long to provide a holding point. (b) The nerve is rotated to  expose the underside surface, where the third suture is placed  at the 8 o'clock position. (c, right) The nerve repair is completed  by placing other sutures in between the first three sutures.    The microscope is moved out of the operative field. The  black silk sutures retracting the buccal and lingual muco-  sal flaps are released and removed. The operative site is  irrigated with saline. The mucosal flaps are replaced and  closed with 4/0 Vicryl interrupted sutures.   The modified Dingman mouth gag and then the throat  pack are removed. The patient is reversed and extubated  by the anaesthetist.    The patient’s head may be turned to the side opposite the  operation site. An incision is made just above the mandib-  ular buccal sulcus from the midline of the lower lip poste-  riorly to the ascending ramus, using a No. 15 B-P scalpel.  A sub-periosteal flap is raised exposing the mandible from  the alveolus to the inferior border, including the mental  foramen, taking care to preserve the mental nerve.   A small round bur is used to create grooves radiating  outwards from the mental foramen, then joined to form  windows in the buccal cortical bone. The bone win-  dows are carefully fractured with either a Coupland or  Warwick-James elevator, taking care to avoid the men-  tal nerve. Windows are created in a similar manner over  the course of the inferior alveolar nerve from anterior to  posterior, bearing in mind the downward and backward  turn made by the nerve before it exits the mental foramen  (Figure 7.7). The inferior alveolar nerve is exposed to 1 cm  beyond the site of injury; the incisive branch is sharply  divided with a scalpel and the inferior alveolar nerve is  carefully dissected free from its bed (Figure 7.8).    The operating microscope is brought into the operative field  and positioned. The proximal and distal nerve segments are  lifted from the mandibular bone with a nerve hook, and    Figure 7.8 Incisive nerve division with a scalpel, lateraliza-  tion of the inferior alveolar nerve and preparation of the nerve  injury (nerve hook).    a modified neuropatty background is placed beneath the  nerve segments. The nerve is examined under microscopic  magnification. The injury may be a complete transection or  a partial transection with a neuroma in continuity.   The neuroma is carefully excised with straight micro-  scissors and the nerve ends trimmed to expose the fascicu-  lar surfaces with periodic irrigation with heparinsaline. If  necessary, a 6/0 or 7/0 monofilament suture passed through  the epineurium of each segment and used to approximate  the nerve segments together to facilitate repair without  undue tension. As the distal nerve is transposed towards  the proximal, a nerve graft will usually not be necessary.    The trimmed nerve endings are coapted, using the vasa ner-  vorum as a guide aligning the nerve segments. Using an 8/0  or 9/0 monofilament on a cutting needle, the first suture is  placed at the 12, 4 and 8 oclock positions; a longer strand is  left at each suture to facilitate further placement of sutures  (Figure 7.6). The intervening gaps in the coaptation site are  closed with circumferential sutures placed at regular inter-  vals around the nerve; usually six to eight sutures may be  required. The result is repositioning of the distal nerve seg-  ment so that the mental nerve is positioned posteriorly to  the original foramen to avoid a nerve graft (Figure 7.9).  The repaired nerve is examined and any excess suture  is trimmed. The approximating suture and then the back-  ground are carefully removed. Gelfoam is sometimes  placed around the nerve and the nerve is replaced in its bed.    The microscope is moved out of the operative field. The  operative site is irrigated with saline. The mucosal flap is  replaced and closed with 4/0 Vicryl interrupted sutures.   The throat pack is removed and the patient is reversed  and extubated by the anaesthetist.    Figure 7.9. Transposition of the mental nerve posteriorly  for completion of the inferior alveolar nerve repair.    Two approaches are used for microneurosurgical repair of  the infraorbital nerve. A cutaneous approach is used when  the site of injury is proximal to the infraorbital foramen.  An intra-oral approach is used when the site of the injury  is close to or distal to the infraorbital foramen.    1. The globe is protected with a temporary tarsorrhaphy  using 4/0 silk suture or a scleral shell. The subciliary  incision line is drawn with a skin marker approximately  2 mm inferior to the eyelashes along the length of the  lower eyelid. The incision may be extended laterally to  2 cm beyond the lateral canthus, curving inferiolater-  ally following a natural skin crease. The incision line is  infiltrated with local anaesthetic with epinephrine. The  subciliary incision is made with a No. 15 B-P scalpel to  the subcutaneous layer, until the underlying orbicularis  oculi muscle is visible. Sharp curved scissors are used for  subcutaneous dissection for a few millimetres inferiorly  towards the inferior orbital rim. Scissors are used to dis-  sect through the orbicularis oculi muscle to the perios-  teum overlying the inferior orbital rim, reaching the plane  between the muscle and septum orbitale. The skin—muscle  flap of tissue is elevated from the lower eyelid and retracted  inferiorly. The periosteum over the inferior orbital rim is  incised with a No. 15 B-P scalpel a few millimetres below  the edge of the rim. The periosteum is elevated with a peri-  osteal elevator until the infraorbital foramen is reached,  usually located 7-9 mm inferior to the inferior orbital rim.   2. An intra-oral vestibular incision is made in the unat-  tached mucosa of the maxillary vertibule from the mid-  line to the zygomatic process. The nerve is exposed via a  sub-periosteal dissection. The infraorbital nerve imme-  diately branches into up to 10 branches at the foramen.    A small round bur is used to create a groove around  the infraorbital foramen. The bone around the foramen  is carefully removed with Rongeur forceps. The infraor-  bital canal is carefully unroofed exposing the infraorbital  nerve until 1 cm beyond the injury site, and may reach the  orbital floor (Figure 7.10).    The operating microscope is brought into the operative  field and positioned. The proximal and distal nerve seg-  ments are lifted from the bone with a nerve hook, and a  modified neuropatty background is placed beneath the  nerve segments. The nerve is examined under microscopic  magnification. The injury may be a complete transection  or a partial transection with a neuroma in continuity.   The neuroma is carefully excised with straight micro-  scissors and the nerve ends trimmed to expose the fascic-  ular surfaces with periodic irrigation with heparinsaline.  An approximating suture using 6/0 or 7/0 monofilament is  passed through the epineurium of each segment and used  to approximate the nerve segments together to facilitate  repair without undue tension.    The trimmed nerve endings are coapted, using the vasa ner-  vorum as a guide aligning the nerve segments. Using an 8/0  or 9/0 monofilament on a cutting needle, sutures are placed at  the 12, 4 and 8 oclock positions (Figure 7.6). Circumferential  sutures are placed at regular intervals around the nerve; usu-  ally six to eight sutures may be required.   The repaired nerve is examined and any excess  suture is trimmed. The approximating suture and then  the background are carefully removed (Figure 7.11).    Figure 7.10 Transcutaneous approach to access injury of  the infraorbital nerve.    Gelfoam may be placed around the nerve and the nerve  is replaced in its bed.    The microscope is moved out of the operative field. The  operative site is irrigated with saline. The periosteum is  closed with 4/0 silk sutures, and the skin-muscle flap is  replaced and closed with 4/0 silk interrupted sutures or a  running 6/0 non-resorbable suture. The patient is reversed  and extubated by the anaesthetist.    The sural nerve remains the ‘workhorse’ of autogenous nerve  graft applications in trigeminal nerve repair. Alternative  autogenous nerve graft locations are the greater auricular  and medial antebrachial cutaneous nerves. The sural nerve  is easily harvested by a 2-cm curvilinear incision one finger  breadth distal and superior to the lateral malleolus of the  ankle. The sural nerve, the small saphenous vein and artery  are within the subcutaneous tissues of the lateral leg and  are superior to the fascia of the posterior tibialis muscle.  The nerve is isolated from the vein and artery using vessel  loops and dissected as far distally and proximally as pos-  sible (Figure 7.12). The most distal end is transected sharply  and the sural nerve exteriorized to determine the length  required for adequate grafting of the lingual or inferior  alveolar nerve (Figure 7.13). If greater length is required,  a second incision above and parallel to the first is made  until the adequate length of nerve is obtained. At least  1 cm of proximal nerve is spared so that after harvesting,  the proximal stump can be repositioned into the muscle    to avoid painful neuroma formation. This is accomplished  by creating a small ‘trap door’ access through the posterior  tibialis fascia to expose the muscle and then suturing the  proximal stump of the sural nerve against muscle using  resorbable suture, closing the fascia over the stump and  completing the skin closure (Figure 7.14). The wound is  then dressed and supported with an elastic gauze bandage  (Ace bandage). Non-weight bearing crutches are provided.  The patient is instructed to change the bandage daily to  avoid compression for 1 week. Non-weight bearing activity  is enforced for 2 weeks after which sutures are removed.    A gauze pack may be placed over the operative site intra-  orally. The patient is transferred to the post-operative anaes-  thesia care unit and may either be allowed home or admitted    to the ward overnight. Analgesia and chlorhexidine mouth  rinse is prescribed; post-operative wound care instructions  are provided. Adjunctive medication for neuropathic  pain should be continued if these have been in use pre-  operatively. The patient is followed up 7-10 days later and  may be given instructions for sensory retraining which  can begin immediately and continued for up to 1 year after  surgery. Mandibular range of motion should be normal by  1 month. Clinical neurosensory testing can begin 3 months  after surgery since the first statistical indicator of regen-  eration occurs no sooner than 6-8 weeks post-operatively  in half the patients. Sensory regeneration should be com-  plete by 1 year in the majority of patients so that discharge  should occur after the 1-year follow-up time. Exceptions to  this rule occur due to age, location of injury and degree of  injury. Older patients, more distal injuries (mental nerve  versus inferior alveolar nerve), complete transection inju-  ries requiring nerve grafts are expected to reach maximum  regeneration over longer times (beyond 1 year).    e Position the patient appropriately before commenc-  ing surgery so that the microsurgeons are comfortable  throughout the procedure.   e Use an operating microscope that has two viewing  ports and a video feed.   e Irrigate the nerve repair site with heparin saline during  neurorrhaphy.    Epker BN and Gregg JM. Surgical management of maxil-  lary nerve injuries. Oral Maxillofac Surg Clin North  Am. 1992; 2: 439-445.   Gregg JM. Surgical management of lingual nerve inju-  ries. Oral Maxillofac Surg Clin North Am. 1992; 4:  417-424.   LaBanc JP and Van Boven RW. Surgical management of  inferior alveolar nerve injuries. Oral Maxillofac Surg  Clin North Am. 1992; 4: 425-437.   Wolford LM. Autogenous nerve graft repairs of the trigemi-  nal nerve. Oral Maxillofac Surg Clin North Am. 1992;  4: 459-463.   Zuniga JR and Essick GK. A contemporary approach to the  clinical evaluation of trigeminal nerve injuries. Oral  Maxillofac Surg Clin North Am. 1992; 4: 353-367.    Surgical endodontics aims to treat microbial infection  of the root canal and peri-radicular tissues which persist  following conventional orthograde treatment. Surgical  procedures include apicectomy (root-end resection) usu-  ally in association with retrograde root filling, lateral  perforation repair, root resection and hemisection. Root  resection and hemisection will not be considered in detail,  but the surgical principles are broadly similar. The most  frequently performed procedure is apicectomy with ret-  rograde root filling usually following unsuccessful ortho-  grade treatment.   It must be remembered that reroot treatment is the gold  standard treatment in most cases and surgery should be  considered only when more conservative treatment is not  possible or appropriate (Table 8.1).   Presurgical assessment must ensure that retention of  a surgically treated tooth is appropriate to the long-term  dental health of the patient. The teeth listed for surgery  should be restored with a successful coronal seal. Any  extracoronal restorations should not have a history of  cementation failure. The vitality of adjacent non-end-  odontically treated teeth and mobility and periodontal  pocketing of teeth in the surgical area may influence  the outcome of surgery. Peri-apical radiographs must  be available for teeth involved in surgery; they should    be taken using a paralleling technique to enable root-  length determination. Panoral films may be necessary  to demonstrate the extent of larger lesions. The advent  of CBCT imaging has made more specific diagnosis  possible.   The microbial invasion of most peri-radicular lesions  can alter the clinical picture ina short time and these signs  should be reassessed just prior to surgery.    Success rates have been shown to increase with recent  advances in technique, including root-end resection  without a bevel, the use of ultrasonics for root-end cav-  ity preparation and the move away from amalgam as the  restorative material of choice. Previously, success rates of  between 50% and 80% were quoted, with highest success  rates for upper anterior teeth. Full radiographic healing is  now being reported in more than 90% of cases, with most  studies suggesting over 80% with full healing at one year.  This improvement in initial outcome is likely to reduce the  need for repeat surgery.   Unsuccessful apical surgery will reduce the volume of  bone available for osseointegration. Repeat surgery may  compromise or complicate future implant placement in  the area.    Failed conventional orthograde treatment where repeat treatment is either not possible,    Canals unable to be instrumented fully by orthograde approach, for developmental or    Provide chlorhexidene 0.2% mouthwash to reduce the  oral bacterial load. A pre-operative dose of non-steroidal  analgesics can be provided for suitable patients. Some cli-  nicians commence this regime 24 hours prior to surgery.  Magnification must be used, ideally a microscope, to  improve visualization of the lesion and root apex.    Whilst extensive lesions may require general anaesthe-  sia, the majority of patients will be treated under local  anaesthesia leaving the surgery following a short recovery  period. Regional local anaesthetic blocks, where possible,  are to be recommended. The vasoconstriction provided by  local infiltration in addition to either a regional block or  general anaesthesia is advised for all patients.    All the flaps described should be full thickness mucoperi-  osteal, with the incision perpendicular to the mucosal sur-  face in all areas other than the gingival sulcus where the  scalpel is placed within the gingival crevice incising from  the base of the pocket to the crest of the alveolar bone.  Relieving incisions should not cross an eminence or divide  a fraenal attachment as this will increase tension on the  replaced flap (Figure 8.1).   The need to avoid the mental foramen and nerve will  influence the position of any relieving incision in the lower  premolar and first molar region.    Post-operative gingival recession is most relevant in the  anterior region. An alteration to the emergence profile,    especially in the presence of crown or bridge margins, may  lead to failure of the apicectomy for aesthetic reasons.   For this reason, flaps which do not involve the gingival  margin or gingival papilla are increasingly utilized.    These include Luebke-Oschenbein (Figure 8.1), horizon-  tal, vertical, semilunar and flaps utilizing microsurgical  techniques, such as the papilla base incision.   Papilla base incisions and other microsurgical tech-  niques are described in the recommended texts.   The Luebke-Oschenbein removes the risk of post-oper-  ative gingival recession, provides adequate access to the  apex of the tooth and is easily repositioned. The horizon-  tal incision lies within the attached mucosa and follows the  scalloped contour of the gingival margin. The literature  suggests a minimum of 2 mm of attached mucosa coronally  to the horizontal incision to minimize the risk of papillary  necrosis, 4 mm is often more practical. Healing is compro-  mised if periodontal bone loss extends apically or the lesion  coronally beyond the horizontal incision. Placement of the  vertical incision is as for gingival margin flaps. This flap was  described as three sided, but may not require the second  relieving incision. When treating a purely apical lesion and  there is adequate height of unattached mucosa overlying the  apex of the tooth, a similar flap may be raised wholly within  the unattached mucosa. The slight increase in bleeding is  minimized by infiltrating a vasoconstrictor containing  local anaesthetic pre-operatively (Table 8.2).    Single horizontal and vertical incisions have been used. The  absence of a relieving incision reduces access. Advances in  imaging demonstrate that very few lesions are appropriate  for this approach. The semilunar flap has the disadvantages    Figure 8.1 Two-sided or triangular flap. No distal relieving incision. Provides adequate access posteriorly and often sufficient ante-  riorly, especially if access to the apex is not required, e.g. lateral perforation repair. Can be extended to three-sided if greater access  is found to be necessary. Again the fraenum or eminence should not be crossed with a relieving incision. Luebke-Oschenbein flap.   Advantageous where lesion does not  originate apically, or extends coronally  beyond the area exposed by other  designs of flap   Horizontal element does not divide  labial vessels, possibly improving  visibility and reducing post-operative  swelling    of flaps without relieving incisions and its curvature can  make retraction difficult and closure unpredictable. These  single incision flaps are not to be recommended.    Flaps are raised with fine periosteal elevators. In areas  where the soft tissue of the lesion has fenestrated the  bone, careful dissection is necessary to elevate the over-  lying mucosal flap without perforation. Tissues should be  retracted with an instrument such as a Cawood Minnesota  retractor. This non-toothed retractor is wide enough  to provide access and protect the labial soft tissues. If a  lengthy procedure is expected, ensure that the flap does  not desiccate. The author achieves this by placing saline-  soaked gauze between the flap and retractor.   If there is no bone fenestration, the apex of the tooth  is exposed by removal of bone using an irrigated round  bur. The starting point may be identified by probing the    bone surface with a sharp instrument to identify an area  of thinning, and by estimating the length and alignment  of the tooth from the pre-operative peri-apical radio-  graph. The true long axis may be disguised in a crowned  tooth. From the initial point of entry, the bone window is  increased to give sufficient access to perform the root-end  resection and curette the soft tissue from the entirety of  the defect. The position of the inferior alveolar canal and  its upward curve to the mental foramen should be kept in  mind during bone removal for apical surgery involving  lower molar and premolar teeth.    The granulation tissue is removed using curettes, dental  excavators and gauze pellets. Gauze pellets may also be  useful in removing the lesion from palatal mucosa where  bony fenestration has occurred. It is not possible to deter-  mine clinically whether granulation tissue present is part  of the destructive or reparative process, and it may be  appropriate to retain tenacious granulation tissue rather  than instrument the root surface of an adjacent tooth. The  soft tissue removed should be preserved for histological  evaluation.   Some clinicians advocate the use of ribbon gauze with  or without a vasoconstrictor placed within the bony defect  prior to placement of the retrograde filling to aid haemo-  stasis, better visualize the root end and facilitate removal  of excess filling material from the cavity.    The apex of the tooth is resected, perpendicular to the  long axis of the tooth to minimize the number of exposed  dentinal tubules. Dentinal tubules allow communication  between untreated contaminated areas of the root canal  system and the peri-apical tissues. The level of the resec-  tion should be sufficient to remove the portion of the root  canal system identified pre-operatively as potentially  harbouring micro-organisms, usually 3-4 mm. It is not  necessary to resect the root at the base of the cavity as    this will expose a larger dentinal surface and reduce the  remaining root length for restoration and stability. The  orthograde root filling will usually be exposed by the  resection. If mineral trioxide aggregate (MTA) has been  used for the orthograde filling, no root-end preparation is  necessary (Figure 8.2).   The root-end cavity is prepared using contra-angled  surgical ultrasonic tips (Figure 8.3). These are preferred  over rotary instruments as correctly angled cavity prep-  aration is easier and there is a reduced risk of fractures  forming within the retained root tissue. The preparation  must encompass the width of the root canal system and  have a minimum depth of 3 mm for adequate restoration.   The retrograde filling material of choice is MTA and  other options are modified zinc oxide eugenol cements  (IRM, which includes polymethacrylate, Super EBA,  which includes ethoxybenzoic acid). There is sufficient  evidence to contraindicate the use of amalgam, which has    Figure 8.2 Root-end resection. Resection perpendicular to  the long axis of the tooth.    the added disadvantage of tattooing adjacent soft tissues in  some patients. Only MTA stimulates hard-tissue deposi-  tion in direct contact with the filling material.   The prepared cavity is dried with paper points and gauze  pledgets or reduced pressure air spray. The MTA is mixed  according to the manufacturers’ instructions and placed  into the prepared cavity using specially designed carri-  ers, small pluggers and flat plastic instruments. Excess  MTA is wiped away using damp cotton wool. The resto-  ration should be adequately condensed and burnished for  best results, debris removed and the flap repositioned and  sutured. Some specialists advocate radiographic imaging  before closure. When early review is possible, 5/0 synthetic  monofilament sutures are preferred. If this is not possible,  vicryl rapide is recommended. Single interrupted sutures  are used; however, and where a gingival margin flap has  been raised, suspensory sutures may improve the aesthetic  result. Following suturing, pressure should be placed to the  flap using a moistened gauze pack. This pressure should be  maintained for 5 minutes. This improves the adaptation of  the flap and haemostasis (Figures 8.4 and 8.5).    Antibiotics are not routinely prescribed; analgesia may be  required for several post-operative days. When possible,  the patient should be reviewed 3-4 days later to remove  sutures and take a peri-apical radiograph of the apicected  tooth. Subsequent reviews should note any pain or tender-  ness to percussion, buccal swelling or sinus, unexpected or  increasing mobility, loss of vitality in adjacent teeth, pres-  ence of gingival recession.    Radiographically, the procedure is said to be successful  with bony infilling of the peri-radicular defect and appear-  ance equivalent to that of a normal periodontal ligament  and lamina dura. This imaging should be no less than 3  months post-operatively.    Once the flap is raised and the root is visualized, it may  become apparent that the tooth is non-salvageable. Likely  causes include root fracture, palatal perforation, lateral  canal inaccessible to surgery or root resorption.   Late complications are commonly due to failure to  eliminate the causative micro-organisms resulting in con-  tinuation of the inflammatory and infective processes.    The possibility of aesthetic failure will have been dis-  cussed pre-operatively, in some cases gingival creep will  improve the appearance of small defects over a period of  months, but results cannot be predicted.    e Ensure tooth has adequate coronal seal and is restor-  able post-operatively.   e Ensure best possible orthograde root filling is provided  prior to considering surgical treatment.    e Use magnification.  e Prepare root-end cavity with ultrasonic instruments.  e Use mineral trioxide aggregate (MTA).  e Apply pressure for 5 minutes on completion of surgery.  e Remove sutures at 3-4 days.  ¢ Do not compromise future implant placement.  e Avoid operating if there is a more appropriate conser-  vative option.  SUGGESTED READINGS    Bernabe P, Holland R, Morandi R, de Souza V, Nery MJ,  Otoboni Filho JA, et al. Comparative study of MTA  and other materials in retrofilling of pulpless dogs’  teeth. Braz Dent J. 2005; 16: 149-155.   Chandler N and Koshy S. The changing role of the api-  cectomy operation in dentistry. J Roy Coll Surg Edin.  2002; 47: 660-667.   Velvart P and Peters C. Royal college of surgeons of eng-  land. Guidelines for Surgical Endodontics 2012.  Soft tissue management in endodontic surgery. J  Endodont. 2005; 31: 4-16. Available at www.rcseng.  ac.uk/fds/publications-clinical-guidelines/.   von Arx T. Apical surgery: A review of current techniques  and outcomes. Saudi Dent J. 2011; 23(1); 9-15.    Key considerations  Odontogenic cysts of the jaws  Cysts of the face and neck  References    1. A multilocular radiolucent lesion of the jaws ought to be  incisionally biopsied in order to establish a microscopic  diagnosis prior to rendering definitive treatment.   2. Despite controversies in nomenclature, the kerato-  cystic odontogenic tumour (KOT) and the odonto-  genic keratocyst (OKC) are managed identically and  independently of nomenclature.   . Large, clinically diagnosed dentigerous cysts should be  pathologically processed to rule out the presence of a  unicystic ameloblastoma.   4. The glandular odontogenic cyst may microscopically  resemble a central mucoepidermoid carcinoma such  that a precise histopathologic diagnosis is paramount to  proper surgical therapy.   . A branchial cleft cyst may clinically resemble a lymphoma  of the neck such that a thorough history and physical  examination is required to preliminarily distinguish these  processes. Most commonly, the computed tomography  (CT) scans will provide the distinction as the branchial  cleft cyst contains fluid while a lymph node containing  cancer would be solid.    Cysts are common and clinically diverse lesions of the  oral/head and neck region that must be considered when  examining and creating a differential diagnosis of an  expansile process of the jaws, face or neck. The character-  istic clinical presentation, radiographic appearance and  history of these lesions result in the formation of a focused  differential diagnosis that leads to proper and expedient  surgical treatment. Most of these cysts, in fact, may be sur-  gically excised with curative intent without first perform-  ing an incisional biopsy. Under such circumstances, the    With rare exceptions, epithelial-lined cysts in bone are  seen only in the jaws.! Other than a few cysts that may  result from the inclusion of epithelium along embryonic  lines of fusion, most jaw cysts are lined by epithelium that  is derived from odontogenic epithelium, hence the term  odontogenic cysts.    Dentigerous cysts of the jaws develop in association  with impacted teeth, most commonly mandibular third  molars. Maxillary third molars, maxillary canines and  mandibular second premolars are also observed to be  associated with dentigerous cysts. They may also occur  in association with supernumerary teeth and odonto-  mas; however, they are only rarely associated with pri-  mary teeth.’? Although dentigerous cysts occur over a  wide age range, they are most commonly seen in patients  between the ages of 10 and 30 years. Many dentigerous  cysts are small asymptomatic lesions that are discovered  serendipitously on routine radiographs, although some  may enlarge to considerable size thereby causing bony  expansion.   Radiographically, the dentigerous cyst represents the  prototypical unilocular radiolucency, often with a scle-  rotic border (Figure 9.1). A large dentigerous cyst may  give the impression of a multilocular process because of    Figure 9.1 A dentigerous cyst of the left mandible associ-  ated with impacted tooth no. 17. The cyst is noted to be a uni-  locular radiolucency and is exhibiting root resorption of tooth  no.’s 18 and 19 with scalloping of the inter-radicular areas.    the presence of bony trabeculae within the radiolucency,  but dentigerous cysts are grossly and histopathologically  unilocular processes and probably are never truly multi-  locular lesions.'   One diagnostic and treatment dilemma for oral and  maxillofacial surgeons involves the clinical and radio-  graphic distinction between a dentigerous cyst and an  enlarged dental follicle. This distinction becomes clinically  significant when the surgeon considers whether to submit  tissue removed with an impacted third molar for histo-  pathologic examination as opposed to clinical designation  as a follicle that may be discarded without microscopic  analysis. The radiographic distinction becomes somewhat  arbitrary; however, any pericoronal radiolucency that is  larger than 4-5 mm is considered a cyst and should be sub-  mitted for microscopic examination. It is noteworthy that  pathologists also struggle with the distinction between  dental follicles associated with developing teeth and odon-  togenic lesions.** It seems that odontogenic cysts, odon-  togenic fibroma and odontogenic myxoma are the lesions  most often incorrectly offered as diagnoses for follicles  by surgical pathologists owing to a general unfamiliarity  with the normal process of odontogenesis.*? Of perhaps  even greater concern in terms of proper diagnosis and  treatment is the large unilocular radiolucency. Although  most commonly classified radiographically as dentigerous  cysts, it is incumbent upon the surgeon to section these  excised specimens in the operating room and to consider  frozen-section analysis. This exercise is important so as to  rule out the existence of a unicystic ameloblastoma that  would at least require an aggressive curettage with cura-  tive intent.   Most dentigerous cysts are treated with enucleation  of the cyst and removal of the associated tooth, most  commonly without a preceding incisional biopsy due to  the unilocular nature and likely diagnosis of the lesion  (Figure 9.2). The routine application of curettage of the  cyst cavity is always advisable at the time of removal of  the cyst in the event that a more aggressive cyst or an  odontogenic tumour amenable to curettage is diagnosed    Figure 9.2 The specimen from the enucleation and curet-  tage surgery for the dentigerous cyst seen in Figure 9.1. The  removal of several associated teeth was performed for com-  plete cyst removal.    histopathologically following removal in an office setting.  Such diagnoses would include the OKC and the unicystic  ameloblastoma.   Large dentigerous cysts may be treated with marsupi-  alization when enucleation and curettage might other-  wise result in neurosensory dysfunction or predispose  the patient to an increased chance of pathologic fracture  post-operatively. Some patients who are not candidates  for general anaesthesia may also be treated with a mar-  supialization procedure in an office setting under local  anaesthesia. This permits decompression of the large den-  tigerous cyst with a resultant reduction in the size of the  cyst and bony defect. At a later date, the smaller cyst can  be removed as part of a smaller scale surgery.   Histopathologic examination of all radiolucencies that  are empirically diagnosed as dentigerous cysts is para-  mount in the treatment of these cysts. This includes those  lesions that are enucleated as well as those that undergo  marsupialization, during which procedure it is impor-  tant to inspect the cyst lumen and submit a representa-  tive portion of the lesion for histopathologic examination.  Support of this statement is derived from the occasional  formation of a squamous cell carcinoma, mucoepidermoid  carcinoma or ameloblastoma from or in association with  a dentigerous cyst.*-” The prognosis for most histopatho-  logically diagnosed dentigerous cysts is excellent, with  recurrence being a rare occurrence.    The OKC is a distinct form of odontogenic cyst  that deserves special consideration because of its  controversial nomenclature and reported aggressive    clinical behaviour. Some investigators have proclaimed  the OKC as a benign cystic neoplasm rather than a cyst,  applying the nomenclature KOT of the World Health  Organization in their most recent classification of odon-  togenic tumours in 2005.° For the purposes of this chap-  ter, the terms OKC and KOT will be utilized with relative  equivalence.   Two variants of the OKC are well known; the spo-  radic cyst and the syndromic cyst associated with the  nevoid basal-cell carcinoma syndrome. Both variants  of the OKC are believed to be derived from remnants  of the dental lamina. This cyst shows a different growth  mechanism and biologic behaviour from the previ-  ously described dentigerous cyst. Most authors believe  that dentigerous cysts continue to enlarge as a result of  increased osmotic pressure within the lumen of the cyst.  This mechanism does not appear to hold true for OKCs,  and their growth may be related to unknown factors  inherent in the epithelium itself or enzymatic activity in  the fibrous wall.’   Adequate diagnosis and treatment of the OKC is  important for three reasons: this cyst is recognized as  being more aggressive than other odontogenic cysts,'°  the OKC has a higher rate of recurrence than other  odontogenic cysts!' and its association with nevoid  basal-cell carcinoma syndrome requires that the clini-  cian examine a patient with multiple cysts of the jaws for  physical findings that might permit the diagnosis of this  syndrome.!?-4   OKCs may be found in patients from infancy to old  age; however, 60% of cases are seen in people between  10 and 40 years old.'® Although it is rare for a dentiger-  ous cyst to appear multilocular on radiographs, it is most  common for OKCs to appear multilocular (Figure 9.3).  Some appear unilocular and can therefore be confused  with dentigerous cysts. It is clear, therefore, that the dif-  ferential diagnosis of a unilocular radiolucency must  include both entities and that treatment of all unilocu-  lar radiolucencies should include curettage in the event  that the diagnosis is later determined to be OKC. When  more than one multilocular radiolucent lesion is noted on  a panoramic radiograph, the clinician must consider the  possibility of the presence of nevoid basal-cell carcinoma  syndrome.   Similar to the treatment of other odontogenic cysts,  the OKC is typically treated with enucleation and curet-  tage and is ideally removed in one piece which requires  acceptable access and lighting (Figure 9.4). An OKC/  KOT that is radiographically multilocular ought to be  biopsied pre-operatively. This exercise will permit a pre-  cise microscopic diagnosis due to the differential diagno-  sis of OKC/KOT vs. ameloblastoma. Despite controversy  regarding whether the OKC/KOT represents a cyst or  tumour, this approach to treatment seems to be non-  controversial. As such, many patients are treated in an  operating room setting under general anaesthesia. Under  such circumstances, most sporadic OKCs are effectively    Figure 9.3 An odontogenic keratocyst (OKC) of the left  mandible presenting as a multilocular radiolucency.    Figure 9.4 The specimen from the enucleation and curet-  tage surgery for the OKC seen in Figure 9.3. Tooth no. 18 was  removed to ensure complete removal of the cyst.   The reported frequency of recurrence of the OKC  ranges from 2.5% to 62.5% in various studies.'' This wide  variation is likely related to the total number of cases  studied, the length of follow-up periods, and the inclu-  sion or exclusion of orthokeratinized cysts in the study  group. Several reports that include large numbers of  cases indicate a recurrence rate of approximately 30%.!  Brannon has suggested three mechanisms responsible for  recurrence: remnants of dental lamina within the jaws  not associated with the original OKC being responsible  for de novo cyst formation; incomplete removal (persis-  tence) of the original cyst secondary to a thin friable lin-  ing and cortical perforation with adherence to adjacent  soft tissue; and remaining rests of dental lamina associ-  ated with the original cyst and the presence of satellite  cysts following enucleation.!® Vedtofte and Praetorius  reviewed 72 patients with 75 OKCs and observed rem-  nants of dental lamina between the cyst membrane and  overlying mucosa.’? As such, they advocated the exci-  sion of overlying mucosa in conjunction with removal  of the cyst. Other authors have recommended a primary    enucleation and curettage surgery for OKCs, including  the use of methylene blue as a marking agent, followed  by a 3-minute application of Carnoy’s solution so as to  reduce the chance for recurrence."!   The orthokeratinized odontogenic cyst, once thought  to be a variant of the OKC, is now generally well accepted  as being a different clinicopathologic entity from the  more common parakeratinized OKC. The orthokera-  tinized odontogenic cyst should therefore be placed in a  different category. From the perspective of nomenclature,  the parakeratinized cyst is referred to as a KOT while  the orthokeratinized cyst is an OKC. These cysts usu-  ally appear as unilocular radiolucencies, but occasional  examples have been multilocular. A majority of these  cysts are encountered in a lesion that appears clinically  and radiographically to represent a dentigerous cyst,  most often involving an unerupted mandibular third  molar tooth. Histologically, the epithelium is thin and  orthokeratinized, and a prominent palisaded basal layer,  characteristic of the OKC, is not present. Enucleation and  curettage of the orthokeratinized cyst is curative in most  cases. The reported rate of recurrence of 2% is far lower  than the previously quoted statistics for recurrence of the  OKC in general.’    The nevoid basal cell carcinoma syndrome (basal cell nevus  syndrome, Gorlin syndrome) is an autosomal-dominant  inherited condition that exhibits high penetrance and vari-  able expressivity. It is caused by mutations in the PTCH  tumour suppressor gene, mapped to chromosome 9q22.3-  q3l. Observed hard and soft tissue anomalies include    Figure 9.5 A coronal CT scan demonstrating radiolucen-  cies of the right maxilla and left mandible. These were noted  in a patient with hypertelorism, frontal bossing, multiple  basal cell carcinomas and mandibular prognathism, thereby  clinically and radiographically proclaiming nevoid basal cell  carcinoma syndrome. Removal of both jaw cysts identified  keratocystic odontogenic tumours (KOTS).    multiple basal cell carcinomas, frontal bossing, hyper-  telorism, mandibular prognathism, bifid ribs, lamellar cal-  cification of the falx cerebri, palmar and plantar pitting and  multiple OKC (Figure 9.5).'* The discovery of multiple OKCs  is usually the first manifestation of the syndrome that leads  to the diagnosis. For this reason, any patient with an OKC  should be clinically evaluated for this condition. Although  the cysts in patients with nevoid basal-cell carcinoma syn-  drome microscopically resemble those not associated with  the syndrome, they often demonstrate greater epithelial  proliferation and daughter cyst formation in the cyst wall.  The treatment of the OKC in patients with nevoid basal-  cell carcinoma syndrome can be difficult owing to the large  number of ‘recurrences’ in these patients. As a matter of  point, these ‘recurrences’ probably represent new primary  cysts owing to the autosomal-dominant penetrance of the  syndrome and cyst development.”” Whatever the mecha-  nism, a resection hardly seems to be warranted when man-  aging a syndromic cyst. Marsupialization (Figure 9.6) is a    Figure 9.6 Marsupialization of a syndromic KOT will result  in shrinkage of the lesion, and ultimately requiring an enucle-  ation and curettage of the lesion. (a) The CT scan identifies a  large multilocular radiolucency that crosses the mandibular  midline. (b) Two 14-French red rubber catheters were placed in  the lesion following suturing of the lesion’s epithelium to the  oral mucosa.    more desirable procedure that has been shown to result in  at least partial resolution of the syndromic cyst. A defini-  tive enucleation and curettage should be performed once  radiographs demonstrate a significant decrease in the size  of the cyst.”    The glandular odontogenic cyst is a rare cyst of the jaws  that is capable of aggressive behaviour and recurrence.  Although it is generally accepted as being of odontogenic  origin, it shows glandular or salivary features that seem to  point to the pluripotentiality of odontogenic epithelium as  cuboidal/columnar cells, mucin production and cilia are  noted in these cysts. Glandular odontogenic cysts occur  most commonly in middle-aged adults, with a mean age  of 49 years at the time of diagnosis.’ A majority of cases  occur in the mandible, particularly the anterior mandi-  ble, with many mandibular lesions crossing the midline  (Figure 9.7).*! These cysts may appear either unilocular or  multilocular radiographically.   There is a histologic similarity between the glandular  odontogenic cyst and the predominantly cystic intraos-  seous mucoepidermoid carcinoma. However, the epithe-  lial lining of the glandular odontogenic cyst is typically  thinner and does not show evidence of the more solid or  microcystic epithelial proliferations seen in mucoepider-  moid carcinoma. Waldron and Koh reviewed the simi-  larities between the two lesions and concluded that it is  entirely possible that some cases previously diagnosed as  central mucoepidermoid tumours may be reclassified as  examples of glandular odontogenic cysts.” Most glandular  odontogenic cysts are treated with enucleation and curet-  tage. Some authors, however, point to a recurrence rate of  approximately 30% and therefore recommend resection.”*    Figure 9.7 A unilocular radiolucency is noted in the anterior  mandible on this CT scan. Biopsy indicated glandular odonto-  genic cyst. (From Carlson ER. In: Miloro M (ed.), Peterson’s Principles  of Oral and Maxillofacial Surgery, 3rd edition, Shelton, CT: People’s  Medical Publishing House-USA, Chapter 29, 625-652, 2012.)    The calcifying odontogenic cyst (COC), or Gorlin cyst,  is an uncommon lesion that demonstrates considerable  histopathologic diversity and variable clinical behav-  iour. Although designated as a cyst, some investigators  provide evidence for subclassification as a neoplasm as  well.*4”5 In addition, the COC may be associated with  other recognized odontogenic tumours, most commonly  the odontoma. Adenomatoid odontogenic tumours and  ameloblastomas have also been associated with the COC.  Ghost cell keratinization, the characteristic microscopic  feature of this cyst, is also a defining feature of the cutane-  ous lesion knownas the calcifying epithelioma of Malherbe  or pilomatrixoma. The World Health Organizational 2005  classification of odontogenic tumours groups the COC  with all its variants as an odontogenic tumour rather than  an odontogenic cyst.* Specifically, this lesion is referred  to as a calcifying cystic odontogenic tumour. The review  by Hong and colleagues designated 79 of 92 cases of COC  as cysts with the remaining 13 cases being neoplastic in  nature.**   The COC is predominantly an intraosseous lesion,  although 13%-30% of reported cases occur as peripheral  lesions.’ Both the peripheral and central lesions occur with  about equal frequency in the maxilla and mandible. There  appears to be a predilection for the incisor and canine  areas (Figure 9.8). Patients range in age from infant to  elderly, with a mean age of occurrence of about 30 years.  COCs that are associated with odontomas tend to occur in  younger patients, with a mean age of 17 years.' The more  rare neoplastic variant of the COC appears to occur in  elderly patients. Most COCs appear radiographically as  unilocular well-defined lesions. The radiopaque structures    Figure 9.8 An occlusal radiograph demonstrating a mixed  radiolucent/radio-opaque lesion of the anterior maxilla. The dif-  ferential diagnosis should include calcifying odontogenic cyst  (COC). (From Carlson ER. In: Miloro M (ed.), Peterson’s Principles of  Oral and Maxillofacial Surgery, 3rd edition, Shelton, CT: People’s  Medical Publishing House-USA, Chapter 29, 625-652, 2012.)    Figure 9.9 Enucleation and curettage of the lesion are per-  formed of the lesion noted in Figure 9.8. Final pathology iden-  tified a COC and complex odontoma.    within the lesions have been described as either irregular  calcifications or tooth-like densities (Figure 9.8).   The standard treatment for the COC is enucleation and  curettage (Figure 9.9). A limited number of recurrences  have been reported after such treatment. When a COC is  associated with another recognized odontogenic tumour  such as an ameloblastoma, the treatment and prognosis  are likely to be the same as for the associated tumour. The  rare neoplastic variant of the COC should be treated with  resection.    Several cysts occur in the soft tissues of the face and neck.  Developmental cysts of the neck are rare malformations  that develop along embryonic fusion lines or from other  embryonic remnants. Four pharyngeal clefts separating  the branchial arches are noted in the 5-week-old embryo.  The dorsal aspect of the first cleft penetrates the underlying  mesoderm and results in the development of the external  auditory meatus. Active proliferation of the mesodermal  tissue of the second arch causes it to overlap the third and  fourth arches. The second, third and fourth clefts tempo-  rarily form an ectoderm-lined sinus, the cervical sinus.  Branchial cleft anomalies are believed to develop asa result  of incomplete obliteration of the cervical sinus or from  epithelial rests of the branchial clefts. These abnormalities  include cysts, sinuses and fistulae. They typically occur in  the lateral neck region, anterior border of the sternoclei-  domastoid muscle, or in the vicinity of the parotid gland  and external ear.   The term dermoid cyst is utilized to describe three his-  tologically related developmental squamous epithelial    lined cysts including the dermoid, epidermoid and tera-  toid cysts. A distinguishing characteristic of dermoid and  epidermoid cysts is the presence of dermal appendages  such as sebaceous glands and hair follicles within the wall  of the dermoid cyst and their absence in the epidermoid  cyst. Teratoid cysts are extremely rare in the head and  neck region and contain structures from all three germi-  nal layers such as nervous, gastrointestinal and respiratory  tissues.    Epidermoid cysts are the most common cutaneous cysts.  They can be found anywhere on the body, but are most  commonly found on the trunk and face, specifically in  mid-cheek (Figure 9.10) and pre-auricular areas. They are  often incorrectly called sebaceous cysts but do not contain  any sebaceous component. The walls are lined with strati-  fied squamous epithelium and the cyst is often filled with  keratin. These cysts often arise from trauma or surgery  causing the epidermis to be implanted into the dermis.  They are subcutaneous formations that are slow growing,  firm, and rarely grow larger than 5 cm. There is no gender  predilection and can be single or multiple in the head and  neck. They are frequently found in individuals with a long  history of chronic skin irritation such as acne or irregular  skin complexions.   Epidermoid cysts are commonly diagnosed by their  clinical appearance. These cysts are intradermal forma-  tions that rarely exceed growths that require imaging.  Nonetheless, on CT scans, they are noted to be well cir-  cumscribed with fluid attenuation (Figure 9.11). These  cysts are removed with surgical excision with frequent  removal of skin with an elliptical excision (Figure 9.12).  Recurrences are rare although patients may develop simi-  lar cysts in other areas of the facial or neck skin.    Figure 9.10 Clinical appearance of an epidermoid cyst of  the left cheek.    Figure 9.11 (aand b) The CT scans of the patient in  shows signs consistent with an epidermoid cyst.    Branchial cleft anomalies account for 30% of all congeni-  tal neck masses that are commonly found in children and  young adults with equal male-to-female predilection.  They are usually asymptomatic but can become pain-  ful if secondarily infected. These anomalies can enlarge  over time and attain a very large size up to 10 cm. They  are found anywhere from the pre-auricular region down  to the supraclavicular fossa, lateral to the anterior border  of the sternocleidomastoid muscle . They are  usually firm, not easily moveable, and do not move with  swallowing.   CT scans of non-infected branchial arch cysts typically  appear as mucoid attenuation with a well-circumscribed  smooth cystic lining . On magnetic resonance  imaging (MRI), the signal intensity on T1 weighted images  are low to intermediate, on T2 images signal intensity is    Figure 9.13 A 23-year-old man with a left lateral neck  swelling. Branchial cleft cyst should be placed on the differ-  ential diagnosis primarily due to the patient’s age and the  location of the neck mass.    moid cyst of the patient in  was sacrificed with the cyst.    Figure 9.14 The CT scan of the patient in fF that  shows signs consistent with the branchial cleft cyst.    high. Infection can lead to a thickened cystic wall that may  become fibrotic which enhances with contrast.   The treatment of choice for branchial cleft cysts is com-  plete surgical excision in a non-inflamed cyst (F 15).  A cyst with an acute infection should be treated with anti-  biotics and incision and drainage if necessary. Following  resolution of the infection, complete removal is recom-  mended and recurrence is rare.    Dermoid cysts are uncommon developmental malfor-  mations in the head and neck that form when ectoderm  becomes entrapped during the fusion of the first and    Figure 9.15 (aandb) Excision of the lesion was performed  and final histopathology confirmed the diagnosis of branchial  cleft cyst.    second brachial arches during the fourth week of embry-  onic development. They are most common in the testes  and ovaries and only 6.9% of dermoid cysts are found  in the head and neck.”” The epithelial-lined cyst cavities  may contain hair follicles, sebaceous glands and other  skin derivatives. Keratin and sebum may be present.  They occur most commonly during the second and third  decades of life but can be found at any age including new-  borns.”* Clinically they are soft, encapsulated, doughy to  palpation and sinus tracts are uncommon .   In 1937, New and Erich classified the dermoid cyst as  either congenital or acquired and divided it into three  types.*° The first type is a teratoma-like congenital mass  most commonly found in the testicles or ovaries. The  second type is an acquired cyst, caused by traumatic iat-  rogenic inclusion of epidermoid tissue most commonly  found in the hand. The third type is a congenital inclu-  sion cyst which develops during embryonic development  in the head and neck. The majority of floor of mouth  dermoid cysts are slow growing, midline and asymp-  tomatic. They account for 1.6% of all dermoid cysts.’”  The position of the cyst in relation to the mylohyoid  and geniohyoid muscles affects its clinical presentation.  Hidden dermoid cysts in the floor of mouth can obtain  a large size that impairs normal speech and swallowing,  and can cause partial obstruction of the airway. These  cysts should always be removed as early as possible in  newborns and young children to prevent these potential  airway complications. The differential diagnosis should  include a plunging ranula, an odontogenic infection,  salivary gland tumour and obstruction of the subman-  dibular duct.   If located in the midline neck, dermoid cysts can be dif-  ferentiated from a thyroglossal duct cyst by its fixed nature    Figure 9.16 A submental mass is present in a 25-year-old  male. The anatomic location of the mass suggests the pres-  ence of a dermoid cyst. The cyst was excised and final  histopathology confirmed the presence of dermoid cyst. (From  Carlson ER and Kang E, Odontogenic and Non-Odontogenic  Cysts, American Association of Oral and Maxillofacial Surgeons  Knowledge Update. Rosemont, IL: American Association of  Oral and Maxillofacial Surgeons.)    during swallowing and tongue protrusion. In the neck, the  differential diagnosis should include a thyroglossal duct  cyst, cystic hygroma, lymphoma, thyroid mass or cervical  lymphadenopathy.   CT scans show a unilocular and well-defined cystic  mass with a fluid-filled lumen with low attenuation. Fatty  internal material may be present giving a mixed density of  fluid contents. On MRI, T1 weighted images will have dif-  fuse high signal intensity. On T2 weighted images, there  will be heterogeneous high signal intensity caused by fat  and calcifications.   The treatment for dermoid cysts is complete surgical  excision. Recurrence does not occur if the cyst and associ-  ated tract are completely excised. For submental cysts aris-  ing above the mylohyoid muscle, a transoral incision may  be used. For cysts arising below the mylohyoid muscle, a  transcutaneous incision is recommended to permit bet-  ter surgical access. Subcutaneous dermoid cysts may have  deep tracts that can be adherent to underlying periosteum  and other bony structures. Meticulous surgical technique  must be used during removal because of the cyst’s adher-  ence to adjacent tissue that may lead to inadequate excision.  Malignant transformation has been reported but is rare.*!    1. Neville BW, Damm DD, Allen CM and Bouquot  JE. Odontogenic cysts and tumors. In Neville BW,  Damm DD, Allen CM and Bouquot JE (eds.), Oral  and Maxillofacial Pathology. Philadelphia, PA: WB  Saunders; 2002. pp. 589-642.   2. Kusukawa J, Irie K, Morimatsu M, Koyanagi S and  Kameyama T. Dentigerous cyst associated with a  deciduous tooth. A case report. Oral Surg Oral Med  Oral Pathol. 1992; 73: 415-418.   3. Suarez PA, Batsakis JG and El-Naggar AK. Don’t  confuse dental soft tissues with odontogenic tumors.  Ann Otol Rhinol Laryngol. 1996; 105: 490-494.   4. Kim J and Ellis GL. Dental follicular tissue:  Misinterpretation as odontogenic tumors. J Oral  Maxillofac Surg. 1993; 51: 762-767.   5. Johnson LM, Sapp JP and McIntire DN. Squamous  cell carcinoma arising in a dentigerous cyst. J Oral  Maxillofac Surg. 1994; 52: 987-990.   6. Eversole LR, Sabes WRand Rovin S. Aggressive growth  and neoplastic potential of odontogenic cysts. With  special reference to central epidermoid and mucoepi-  dermoid carcinomas. Cancer. 1975; 35: 270-282.    D (eds.). Odontogenic tumours. In World Health  Organization Classification of Tumours—Pathology  and Genetics of Head and Neck Tumours. Lyon:  International Agency for Research on Cancer (IARC)  press; 2005. pp. 283-327.   E and Guralnick WC.  Collagenolytic activity in keratocysts. J Oral Surg.  1972; 30: 879-884.   Ahlfors E, Larsson A and Sjogren S. The odontogenic  keratocyst: A benign cystic tumor? J Oral Maxillofac  Surg. 1984; 42: 10-41.   Williams TP and Connor FA. Surgical management  of the odontogenic keratocyst. Aggressive approach.  J Oral Maxillofac Surg. 1994; 52: 964-966.  Mustaciuolo VW, Brahney CP and Aria AA.  Recurrent keratocysts in basal cell nevus syndrome:  Review of the literature and report of a case. J Oral  Maxillofac Surg. 1989; 47: 870-873.   Pritchard LJ, Delfino JJ, Ivey DM, Sclaroff A and  Giglio JA. Variable expressivity of the multiple nevoid  basal cell carcinoma syndrome. J Oral Maxillofac  Surg. 1982; 40: 261-269.   Gorlin FJ. Nevoid basal cell carcinoma syndrome.  Medicine. 1987; 66: 98-113.   Meara JG, Li KK, Shah SS and Cunningham MJ.  Odontogenic keratocysts in the pediatric popula-  tion. Arch Otolaryngol Head Neck Surg. 1996; 122:  725-728.   Eyre J and Zakrzewska JM. The conservative man-  agement of large odontogenic keratocysts. Br J Oral  Maxillofac Surg. 1985; 23: 195-959.   Meiselman F. Surgical management of the odon-  togenic keratocyst: Conservative approach. J Oral  Maxillofac Surg. 1994; 52: 960-963.   Brannon RB. The odontogenic keratocyst: A clini-  copathologic study of 312 cases. Part II: Histologic  features. Oral Surg Oral Med Oral Pathol. 1977; 43:  233-255.   Vedtofte P and Praetorius F. Recurrence of the  odontogenic keratocyst in relation to clinical and  histologic features. A 20 year followup study of 72  patients. Int J Oral Surg. 1979; 8: 412-420.   Carlson ER, Oreadi D and McCoy JM. Nevoid basal  cell carcinoma syndrome and the keratocystic odon-  togenic tumor. J Oral Maxillofac Surg. 2015; 73:  $77-S86.   Carlson ER. Odontogenic cysts and tumors. In Miloro  M, Ghali GE, Larsen P and Waite P (eds.), Peterson’s  Principles of Oral and Maxillofacial Surgery, Third  Edition, Chap. 29. Shelton, CT: People’s Medical  Publishing House - USA; 2012. pp. 625-652.  Waldron CA and Koh ML. Central mucoepider-  moid carcinoma of the jaws: Report of four cases  with analysis of the literature and discussion of the    relationship to mucoepidermoid, sialodontogenic  and glandular odontogenic cysts. J Oral Maxillofac  Surg. 1990; 48: 871-877.   Hussain K, Edmondson HB and Browne RM.  Glandular odontogenic cysts. Diagnosis and treat-  ment. Oral Surg Oral Med Oral Pathol Oral Radiol  Endod. 1995; 79: 593-602.   Hong SP, Ellis GL and Hartman KS. Calcifying  odontogenic cyst. A review of ninety-two cases with  reevaluation of their nature as cysts or neoplasms,  the nature of ghost cells, and subclassification. Oral  Surg Oral Med Oral Pathol. 1991; 72: 56-64.  Buchner A. The central (intraosseous) calcifying  odontogenic cyst: An analysis of 215 cases. J Oral  Maxillofac Surg. 1991; 49: 330-339.   Acierno SP and Waldhausen JH. Congenital cervical  cysts, sinuses and fistulae. Otolaryngol Clin N Am.  2007; 40: 161-176.    King RC, Smith BR and Burk JL. Dermoid cysts in  the floor of the mouth: Review of literature and case  reports. Oral Surg Oral Med Oral Pathol. 1994; 78:  567-576.   Gibson WS and Fenton NA. Congenital sublin-  gual dermoid cyst. Arch Otalaryngol. 1982; 108:  745-748.   Carlson ER and Kang E. Odontogenic and Non-  Odontogenic Cysts. American Association of Oral  and Maxillofacial Surgeons Knowledge Update.  Rosemont, IL: American Association of Oral and  Maxillofacial Surgeons.   New GB and Erich JB. Dermoid cysts of the head and  neck. Surg Gynecol and Obstetr. 1937; 65: 48-55.  Naujoks C, Handschel J, Braunstein S, Emaetig F,  Depprich R, Meyer U, et al. Dermoid cyst of the  parotid gland—A case report and brief review of lit-  erature. Int J Oral Maxillofac Surg. 2007; 36: 861-863.   Diagnosis and treatment planning  Assessment of bone quantity and quality  Anatomic considerations for dental implants  Important aspects to increase implant surgical success  Surgical procedures    The history of tooth replacement goes back to ancient  civilization. The earliest attempts at tooth replace-  ment with dental implants were in the Mayan civiliza-  tion dating back to 600 ap. Ancient skulls have been  discovered in which teeth were replaced by materials  ranging from carved stones, bamboo sticks and ivory,  to fragments of seashells. It was not until the work of  Professor Branemark in Sweden in the early 1950s,  that biocompatibility of dental implants in experimen-  tal studies in animals was demonstrated. The depth  of the scientific research, specifically in titanium  implants, was the work of the group led by Per-Ingvar  Branemark an orthopaedic surgeon. His work defined  osseointegration. Osseointegration was originally  defined as a direct structural and functional connec-  tion between ordered living bone and the surface of a  load-carrying implant. It is now said that an implant  is regarded as osseointegrated when there is no pro-  gressive relative movement between the implant and  the bone with which it has direct contact. In practice,    this means that in osseointegration there is an anchor-  age mechanism whereby non-vital components can be  reliably and predictably incorporated into living bone  and that this anchorage can persist under all normal  conditions of loading. This definition of osseointe-  gration has formed the basis for today’s implantology  science.   The clinical replacement of lost natural teeth by osseo-  integrated implants represents one of the most significant  advances in dentistry.    The key to the success of implant treatment is collat-  ing appropriate information that will result in a well  thought out, performed and successful procedure. It  is essential for the surgeon to understand the patient’s  chief complaint and why they want dental implants.  Providing the patient with detailed information includ-  ing that about possible long-term complications is  equally important.    Figure 10.1 Lekholm and Zarb, degrees of resorption. (a) Most of the alveolar bone is present. (b) Moderate residual ridge  resorption has occurred. (c) Advanced residual ridge resorption has occurred and only basal bone remains. (d) Some resorption of  the basal bone has taken place. (e) Extreme resorption of the basal bone has taken place.    ® Medical, dental and social history: Medical evalua-  tion is vital in implant surgery especially because the  treatment is often provided for an older segment of  the population. Review of the risks and benefits of the  treatment plan should be discussed with the patient.  Patients that are immunocompromised or smoke  heavily should expect a lower success rate than other  patients for example. Medications such as bisphospho-  nates and other antiresorptive drugs can also have a  significant impact.   @ Extraoral and intraoral examination: A complete  examination of the head and neck is vital. Facial sym-  metry, smile line, tooth show, midline relation and  occlusal plane should be evaluated. Intraoral exami-  nation should include the condition of the mucosal  tissues, the condition of the remaining dentition and  the quality and quantity of maxillary and mandibu-  lar bone.   © Radiographic examination: Intraoral periapical radio-  graphs are very helpful in assessing the space between  adjacent teeth and the direction of the adjacent roots.  The advantages of periapical radiographs are low radia-  tion dose, high resolution and they are inexpensive. The  limitations are distortion and magnification, minimal  site evaluation and lack of cross-sectional imaging.  Computerized tomography (CT) scans provide much  more information and allow a more detailed evaluation,  especially of structures such as the mandibular canal  and the antrum.   © Articulated study casts: The value of diagnostic  casts is critical in oral implantology as they provide  essential information about occlusal centric relation,  number of missing teeth, space between the adjacent  teeth and the inter-arch space for the implant and  restoration.   © Template for surgery: A well-made template assists the  operator in the correct placement of the dental implant. It is    important that the template fits securely, and gives appro-  priated access to the drill to prepare the implants sites.   © Signed consent form: Assures the surgeon that patients  completely understand the surgical treatment and its  complications.    Every tooth extraction leads to remodelling of the alveo-  lar bone, and bone loss, that is greater during the first 3  months. Remodelling is mostly complete after 1 year. Bone  loss occurs in both the vertical and horizontal planes.   The surgeon should be able to assess bone quality and  quantity. An elegant description is the one proposed by  Leholm and Zarb (Figures 10.1 and 10.2).   Assessment of bone quantity by Leholm and Zarb (Figure  10.1) is as follows:   3. Advanced residual ridge resorption has occurred and  only basal bone remains.    Figure 10.2 Lekholm and Zarb bone quality classification.  (1) Almost the entire jaw is comprised of homogenous com-  pact bone. (2) A thick layer of compact bone surrounds a core  of dense trabecular bone. (3) A thin layer of cortical bone sur-  rounds a core of dense trabecular bone of favourable strength.  (4) A thin layer of cortical bone surrounds a core of low-density  trabecular bone.    Assessment of bone quality by Leholm and Zarb (Figure  10.2) is as follows:   . A thick layer of compact bone surrounds a core of dense  trabecular bone.   . A thin layer of cortical bone surrounds a core of dense  trabecular bone of favourable strength.   4. A thin layer of cortical bone surrounds a core of low-    The maxillary bone is a hollow cuboid shape that houses  the teeth, forms the roof of the oral cavity, forms the floor  of and contributes to the lateral wall and roof of the nasal  cavity, houses the maxillary sinus and contributes to the  inferior rim and floor of the orbit. Two maxillary bones are  joined in the midline to form the middle third of the face.   Performing implant surgery in the maxilla requires a  detailed knowledge of the anatomical landmarks, such  as the maxillary sinus, the nasal cavity, the nasopalatine  canal, midline suture, cortical shell (especially when defi-  cient). Appreciation of diminished vertical and horizontal  dimensions is essential as well.    The operator should be familiar with the effects of the loss  of teeth, the effect and possible extent of the alveolar bone  resorption and also be familiar with the anatomical areas  of the mandible such as the body region, the exact loca-  tion of the inferior alveolar nerve, the region of the sym-  physis and of the mental nerve. The mental nerve before  exiting through the mental foramen may form a loop that  runs anterior and inferior to the foramen. This loop can  extend from 1 to 7 mm. Generally, the mandibular canal  runs from the mandibular foramen inferiorly and anteri-  orly, then runs horizontally and laterally most of the time  just below the roots apices of the molars. When placing    implants in the area close to the inferior alveolar nerve,  clearance of at least 2 mm from the most superior aspect  should be allowed to prevent surgical trauma.   Knowledge of the concavities of the mandible especially  in the lingual region is important to avoid any perforation  whilst drilling that may produce a significant bleeding  from the sublingual vessels (Figure 10.3).    After administration of local anaesthetic and sedation as  required, two different incision designs can be performed  in the anterior mandible:    ® Crestal incision is made when the mandible has ade-  quate height and the muscle fibres are inserting below  the alveolar crest. When patient has healthy attached  gingiva a crestal incision provides a good access to labial  and lingual regions (Figure 10.6).   © Vestibular incision is made for patients with poor  attached gingiva or when the insertion of the muscle is  high (Figure 10.7).    Both incisions must follow the principles of good incision  design (adequate access and visibility to allow identifica-  tion of important anatomical landmarks such as mental  foramina, incisal canal etc., and a mucoperiosteal flap that  provides good vascular supply). A careful blunt dissection  is required to identify anatomical landmarks.   After the surgical template is positioned, a sterile pencil  is used to mark the position of the implant in the bone.   After the flap is raised, with copious irrigation and a  high speed (maximum 2000 rpm), the bone preparation    can be initiated following the instructions of the different  implant manufacturers. Most implant systems provide the  surgeon with several drill sizes that will allow the gradual  enlargement of the surgical site. The drilling should be  done with the intermittent technique, always having new  sharp burs and copious irrigation.   When the osteotomy site is prepared, using a low speed  of 15-20 rpm, the implant is placed. Then the healing abut-  ment or cover screw is positioned. If there is good stability  of the implant, a healing abutment can be placed immedi-  ately. Otherwise, a cover screw must be placed so that the  implant can be buried and later uncovered during Stage I  surgery. At the end of the procedure, the surgical area is  irrigated and a primary closure is performed with 3-0 or  4-0, silk or vicryl sutures (Figures 10.8 through 10.14).    After administration of local anaesthetic and sedation as  required, an incision that is slightly palatal to the alveolar  crest is made. This incision design will allow the surgeon  to visualize the palatal bone contours. After the flap is  raised, the osteotomy of the implants sites is performed.  In the maxillary arch, sometimes it is possible to estab-  lish bicortical stability in the area of the sinus and nasal  bone, being careful that only the apical tip of the implant  engages the cortical plate. Then, the healing abutment  or cover screw is placed. If there is good stability of the  implant, a healing abutment can be placed immediately.  Otherwise, a cover screw must be placed so that the    implant can be buried and later uncovered during Stage II  surgery. At the end of the procedure, the surgical area is  irrigated and a primary closure is performed with 3-0 or  4-0 silk or vicryl sutures.    ® Antibiotics: Studies have shown similarly improved  success rates in implant placement with the use of both  pre-operative and post-operative antibiotic prophy-  laxis as compared to no antibiotics. Risks and benefits  of antibiotic therapy must be evaluated for each case to  determine whether specific indications exist for the use  of antibiotic prophylaxis. If an infection develops post-  operatively, a 1-week course of a broad-spectrum beta-  lactam antibiotic should be prescribed.    Figure 10.12 Note that abutments are parallel and ready  for prosthetic rehabilitation.    © Analgesics: Patients usually only require Ibuprofen  400 mg every six hours. If the implant procedure is  more involved, a combination of an anti-inflammatory  analgesic with codeine or paracetamol usually suffices.   © Oedema: Post-operative, mild oedema is sometimes  present and generally settles uneventfully. Use of ste-  roids intra-operatively and post-operatively can be con-  sidered for selected cases.   ® Local care: Meticulous oral care with gentle rinses of  0.2% chlorhexidine four times daily for 2 weeks, and  gently brushing with a soft tooth brush, being careful  with the operative site.   © Diet: A diet high in proteins and soft in texture that does  not cause injury to the surgical sites should be advised.    Figure 10.13 From view of integrated implants support-  ing mandibulary fixed-detachable prosthesis.    Figure 10.14 Three months after stage two implants have  integrated and ready for implant-borne and screw-retained  prosthesis, the prosthesis is removable by the dentist.    This is only performed if a two-stage technique has been  selected with the implant submerged and left to osseoin-  tegrate. During the second stage, the head of the implant  body is exposed and the transmucosal abutment is placed.  Usually, this procedure is carried out under local anaes-  thesia and the incision is made directly over the implant  head and a small flap is raised, the cover screw removed  and the appropriate healing abutment is secured on the  implant. The flap is then repositioned and sutured.    Written post-surgical instructions for oral surgery  should be given to the patient. If the patient is wearing  dentures and a crestal incision was performed, wear-  ing of dentures is acceptable during healing period. If  a vertical incision was performed, it is advisable for    the patient not to wear the denture immediately. It is  always necessary to examine the patient 1 week later  for possible suture removal, irrigation and any denture  adjustment.    Traditionally, before placing a dental implant the teeth  are removed and the extraction sockets are left to heal  for several months prior to the placement of an implant.  Patients and doctors like, where feasible, to shorten the  time between tooth extraction and implant placement.  The potential advantages of immediate or early place-  ment of an implant result in fewer surgical treatments  and shorter treatment time. Bone loss is part of the nor-  mal remodelling phase after extraction, but might be  reduced to advantage with an early implant placement,  which can enhance the aesthetic result. The potential dis-  advantages are increased risk of infection, implant fail-  ure, difficulties in achieving primary stability and gaps  can be present between the implant and the bony walls  of the socket.   Several publications and reviews have been published on  survival and success rates of implants placed immediately  into a fresh extraction socket or early placement (Slagter  2014; Lang 2011; Esposito 2010. A Cochrane review).   Esposito, in a Cochrane review identified 14 eligible ran-  domized controlled trials (RCTs) evaluating the success,  complications, aesthetics and patient satisfaction between  ‘immediate (same day)’, immediate delayed (10 days) and  delayed implants (3 months) to evaluate whether and  when augmentation procedures are necessary and which  is the most effective technique.   The authors conclude that there is insufficient evidence  to determine possible advantages or disadvantages of  immediate, immediate-delayed or delayed implants. The  authors add that these preliminary conclusions are based  on a few underpowered trials. There is a suggestion that  immediate and immediate-delayed implants may have a  higher risk of implant failure and complications than con-  ventional delayed implants. On the other hand, the aes-  thetic outcome might be improved when placing implants  just after teeth extraction. They report that there is not  enough reliable evidence supporting or refuting the need  for augmentation procedures at the time of immediate  implant placement in fresh extraction sockets or whether  any of the augmentation techniques are superior others.    Bone grafting can be performed at the time of surgery if  the defects are small. The graft in these cases is usually  taken from an intraoral site, such as    1. From the anterior mandible (chin).  2. Retromolar area of the mandible.    Figure 10.15 Bone bits trapped in the bur can be used as  autologous graft.    3. Bone can also be retrieved for the graft from the drill-  ing site by using a bone collector either from the suction  line or from the drill bits (Figure 10.15).    Autografts are the preferred source of bone material due  to the lack of antigenicity of the graft material. In addi-  tion, we can use Allografts that are obtained from a human  cadaver. The clinical success of these grafts is well proven.  The advantage of allografts is that there is not an additional  surgical procedure to obtain the bone. Xenografts are grafts  from one species to another, e.g. bovine bone; they are use-  ful when mixed with the patient’s blood. Alloplastic grafts  are synthetic bone substitute that may act as a framework  for bone formation. Bone morphogenic protein (BMP)  has recently been approved by the U.S. Food and Drug  Administration for use in bone grafting. These molecules  act to signal stem cells that migrate to the site of the graft  and differentiate into osteoblasts which lay down new bone.    1. Haemorrhage during drilling. This most often occurs  after perforation of the lingual cortex of the mandi-  ble. Sometimes, bleeding can advance into the floor  of the mouth, producing a threat to the patient’s  airway, necessitating emergency treatment.   4. Paraesthesia. Trauma to the nerves in the area of  the implant placement is the usual cause.   5. Infection is unusual in implant surgery if a sterile  technique is used.    1. Failure to integrate. Usually, presenting as a painful  and mobile implant. The reasons for this complica-  tion can be multifactorial. Poor clinical evaluation  for surgical site, poor surgical technique, infection  or a lack of experience are the usual causes. The  solution is removal of the implant.   2. Difficulties placing the abutment. Possible causes  include damage to internal features of the implant  body during placement of the implant, and bone  overgrowth during the healing process.    e Inorder to preserve the interproximal dental papilla it is  important to have at least 3 mm between implants, and  1.5 mm between natural tooth and implant.   e Implants should be placed at a minimum of 2 mm from  the inferior alveolar canal or below the maxillary sinus.   e Gentle surgical technique, light and intermittent drill-  ing pressure and copious cooling irrigation, is impor-  tant factors to increase implant surgical success.   e¢ The amount of bone needed buccal and lingual to the  implant (width) is a minimum of 1.5 mm of cortical  bone.   e A good incision design should have good access and  visibility to allow identification of important anatomical  landmarks, and have a good mucoperiosteal flap that  provides good vascular supply.   e Immediate placement of implants may result in  improved aesthetics through maintenance of soft tis-  sue architecture and contours.    Block MS. Color Atlas of Dental Implant Surgery, Second  Edition. London, UK: Hodder Arnold; 2009.   Branemark P-I, Zarb GA and Albrektsson T. Tissue-  Integrated Prostheses Osseointegration in Clinical  Dentistry. New Malden, UK: Quintessence; 1985.   Hobkirk JA, Watson RM and Lloyd JJS. Introducing Dental  Implants. London: Churchill Livingstone; 2003.   Misch CE. Contemporary Implant Dentistry, Third Edition;  St. Louis, MO: Mosby Elsevier; 2008.    Adequate bone stock is essential for successful implant  placement. Deficient bone may arise due to physiologic  resorption in edentulous areas or acquired defects sec-  ondary to trauma or ablative surgery. There are numer-  ous augmentation materials and techniques available if  the bone volume is inadequate at the planned implant  site. Many factors influence the selection of augmen-  tation material and technique; however, the volume,  location and morphology of the defect are primary  determinants.    These materials may be used individually or in combina-  tion to replace and/or regenerate deficient bone. They may  also be supplemented by biologically active materials such  as platelet-rich plasma (PRP) and bone morphogenic pro-  teins (BMPs). Autogenous bone remains the gold standard  graft material, since it possesses osteogenic, osteoinduc-  tive and osteoconductive properties, whereas allografts  have only osteoconductive and possibly inductive prop-  erties, and alloplasts are merely osteoconductive. This  chapter focuses on autogenous augmentation techniques    that can be performed in the office or outpatient clinic  environment.   Selection of the appropriate donor site is determined  by many factors including the volume and the type of  bone required (cancellous or corticocancellous). Potential  donor sites suitable for office or outpatient clinic bone  harvesting include local sites in the maxilla and mandible  or remote sites such as proximal tibia. It should be recog-  nized that mandibular and maxillary donor sites provide  only a limited source of cancellous bone. It is reported  that membranous bone grafts show less resorption than  grafts harvested from endochondral bone. Although  cancellous grafts vascularize more rapidly than cortical  grafts, cortical grafts harvested from membranous bone  vascularize more rapidly than endochondral bone grafts  with a thicker cancellous component. Figure 11.1 shows  the potential donor sites in the maxilla and mandible.  Table 11.1 outlines the potential bone stock of different  donor sites.    The osteotomies allowing harvest of the autogenous graft  from the donor site may be performed using traditional  burs, saws, discs, trephines and osteotomes or using recent  technology such as piezosurgery. Piezosurgery utilizes a  range of working tips that oscillate at ultrasonic frequen-  cies of around 10-60 Hz, thereby cutting bone while pre-  serving soft tissue (nerves, sinus lining, blood vessels and  mucosa). The reported advantages of piezosurgery over    Cortical shavings from 2-5  maxilla/mandible  Bony exostoses/tori  Suction-line bone traps  Mandibular symphysis 5    Mandibular ramus 5-10  Calvarial shavings 10-14  Proximal tibia 20-40  Anterior iliac crest 50    traditional rotary instruments are that there is no thermal  injury or adjacent bone necrosis and the osteocytes remain  viable at the osteotomy site. Therefore, healing takes place  more rapidly, with little or no inflammation and without  the need for an osteoclastic phase.    DONOR SITES  Mandibular symphysis  The mandibular symphysis presents a convenient donor site    for corticocancellous bone due to its proximity to the recipi-  ent site. There is a limited supply of cancellous bone in this    region, but there is adequate cortical bone stock to augment  up to 1.5-2 cm in length, 1 cm in height and 4-7 mm in  thickness. Some reports suggest superior bone quality at the  grafted site when the bone is harvested from the symphysis  compared to other sites including the iliac crest.    Panoramic and lateral cephalometric radiographs are  adequate to assess the volume of bone available within  the anatomic constraints described later. Tomograms and  computed tomography (CT) scans may add more infor-  mation regarding bony undercuts and deficiencies. Local  mouth preparation should include chlorhexidine mouth  rinse pre-operatively. This procedure may be performed  under intravenous sedation or local anaesthetic.   Local anaesthetic (2% lidocaine with 1:100,000 epineph-  rine may be mixed with 0.5% bupivicaine) is adminis-  tered either as bilateral inferior alveolar and lingual  nerve blocks, or as bilateral mental nerve blocks supple-  mented with labial and lingual infiltrations. Many sur-  geons use a perioperative antibiotic that is administered  either enterally or parenterally before surgery. Access  to the symphysis can be achieved either by a vestibular/  labial incision 5-7 mm below the mucogingival junction  or by a sulcular/crestal incision (Figure 11.2). A poten-  tial disadvantage of the sulcular incision is that it may  result in bone resorption at the crest if the labial bone is  thin and therefore reliant on the overlying periostium  for its blood supply. In this situation, or when there is  pre-existing marginal bone loss at the alveolar crest due  to periodontal disease, a vestibular/labial approach is  preferred.   For the vestibular/labial approach, a genioplasty inci-  sion is made in the vestibular mucosa extending from  canine to canine. The incision is carried through the  mucosa and submucosa until the bellies of the mentalis  muscle are reached. These bellies may need to be divided  depending on the level of the mentalis origin, to give  access to the underlying symphyseal and parasymphy-  seal region of the mandible. The mentalis muscle is then  detached from the anterior mandible using a periostial  elevator or bovie electrocautery, and the soft tissues are  elevated inferiorly down to the inferior border of the  mandible in the subperiosteal plane. The required length  of the bone graft dictates the lateral extension of the dis-  section. With larger corticocancellous blocks, it may be  necessary to expose and identify the mental nerves. If a  sulcular/crestal incision is made, it is necessary to create  distal releasing incisions through the mucosa to allow  adequate retraction of the flap as far inferiorly as the  lower border of the mandible.   Once the anterior mandible is fully exposed down to  the inferior border, there are some important anatomic  constraints that should be outlined prior to performing  the osteotomies (Figure 11.3). The superior horizontal    osteotomy should remain at least 5 mm inferior to the  incisor and canine apices. The inferior horizontal oste-  otomy should maintain at least 5 mm of intact cortical  bone at the inferior border. If the lateral osteotomies need  to be placed close to the mental foramina for larger grafts,  5 mm of bone should remain anterior to the foramen, as  the mental nerve may course anteriorly prior to exiting the  mental foramen.   Bone may be harvested from the anterior mandible  within these anatomic boundaries either using tre-  phines to obtain multiple cores of corticocancellous  bone (maintaining the integrity of the lingual cortex),  or using small fissure burs, saws or piezosurgery tips  to outline a block of corticocancellous bone. A midline  vertical osteotomy may also be made to facilitate easy  removal of two blocks of bone. The bone graft is then    removed by completing the osteotomies with curved  osteotomes. Small amounts of additional cancellous  bone can be harvested up to the lingual cortical plate  using curettes.   Once the bone is harvested, the bony defect may be filled  with allogenic bone or collagen soaked in BMP (BMP-2  or BMP-7) and covered with a resorbable membrane. This  minimizes the bony defect after the healing phase com-  pared to simply closing the soft tissues without grafting  the donor site. The soft tissues are closed in layered fashion,  resuspending the bellies of the mentalis muscles prior to  closure of the mucosal incision with either non-resorbable  or resorbable sutures.   A genioplasty dressing may be applied to provide additional  support during the initial healing phase. Appropriate anal-  gesics (non-steroidal anti-inflammatory and narcotic) are  prescribed and most surgeons continue antibiotic therapy  (amoxicillin or clindamycin) for 5-7 days. The patient  should use saline rinses after meals. After 48 hours the  patient should use chlorhexidine mouthwash for 2 weeks,  in addition to saline rinses after meals. The diet should be  restricted to a clear liquid diet for 24 hours and advanced  to a soft mechanical diet for 2 weeks, to minimize the risk  of wound dehiscence.   Possible complications include bleeding, hematoma,  infection, wound dehiscence, nerve injury (mental  nerve or its branches), incisor/canine tooth devitaliza-  tion and mandible fracture. However, these complica-  tions can be minimized by careful surgical technique and  post-operative care.    The external oblique ridge of the mandibular ramus is  another convenient site for bone harvest. A corticocancel-  lous block of bone measuring up to 3 cm in length and  1 cm in height may be obtained from the ramus, although  the thickness of bone is limited to approximately 4 mm  due to the underlying inferior alveolar nerve. The dimen-  sions of the ridge determine the potential size of the graft.  This procedure may be performed under intravenous  sedation or local anaesthetic.    Panoramic radiographs are adequate to assess the volume  of bone available and the location of the inferior alveolar  nerve. Tomograms and CT scans may add more informa-  tion regarding bony undercuts, deficiencies and tooth root  position. Pre-operative chlorohexidine preparation and  perioperative antibiotics are used.    Local anaesthetics are administered intraorally for infe-  rior alveolar nerve block and infiltrative anaesthesia. The  external oblique ridge is accessed through a linear muco-  sal incision starting at the level of the occlusal plane and  extending down into the buccal vestibule as far forward as  the first molar region. Alternatively, an incision starting  on the external oblique ridge and extending crestally to the  distal aspect of the last standing molar and then turning  down into the vestibule as far forward as the first molar.  Periostial elevators are used to elevate a buccal mucoperi-  ostial flap, and also reflecting the lingual flap giving clear  visualization of the superior ramus and external oblique  ridge. Traumatic or supraperiosteal lingual flap elevation  may cause lingual nerve injury. The osteotomies may be  created with burs, saws or piezosurgery tips. The poste-  rior vertical osteotomy is made through the outer cortex  perpendicular to the external oblique ridge at the level  of the occlusal plane, or at a point of adequate thickness.  The anterior vertical osteotomy is also made through the  outer cortex. The distance between the posterior and ante-  rior cut is determined by the desired graft length and may  extend as far forward as the distal aspect of the first molar  tooth. The height of these cuts corresponds to the height of  the desired graft. The posterior and anterior osteotomies  are then connected superiorly with a horizontal osteotomy  3-4 mm in depth. The depth of all these cuts is monocor-  tical. The inferior connecting cuts are made with a no. 8  round bur or an angled piezosurgery tip. The inferior cut  simply scores the cortex, enabling fracture along this line  during subsequent luxation of the graft with osteotomes.  Thin osteotomes are used to complete the osteotomies  staying along the buccal cortical plate so as to avoid poten-  tial injury to the inferior alveolar nerve. Larger osteotomes  are then used to free the block of bone (Figure 11.4). The  surgeon should ensure that the inferior alveolar nerve is    not tethered to the graft prior to removal. The bed of the  osteotomy is then inspected and the inferior alveolar nerve  may be visualized. Small amounts of cancellous bone may  be removed with curettes while being mindful of the  location of the nerve. The donor site is then irrigated and  closed using resorbable or non-resorbable suture with or  without the use of haemostatic agents such as microfibril-  lar collagen soaked in thrombin. It is not usually necessary  to graft the donor site since bony regeneration is adequate.    An elasticated jaw bra-type dressing may be applied and  the patient instructed to apply ice to the area for 24 hours  to reduce the swelling. Analgesics and post-operative anti-  biotics are prescribed and oral hygiene and diet recom-  mendations are made.   The most common complications are hematoma, infec-  tion, wound dehiscence and inferior alveolar or lingual  nerve injury. The incidence of sensory deficit following  ramus harvest is reported to be lower than that at sym-  physeal harvest, at 8% and 16%, respectively. There is also  the possibility of fracture during the procedure or in the  post-operative healing phase.    The volume of bone available from these sites is limited but  may be mixed with allogenic material and/or supplements  such as PRP or BMP (BMP-2 or BMP-7) for added volume.  The pre-operative preparation and anaesthetic technique  are similar to that used for the mandibular symphyseal and  ramus donor sites. Once a standard mucoperiostial flap is ele-  vated bone shavings can be harvested from these sites using  shaving devices such as the MX-grafter, or using ronguers  to remove bone from the tuberosity area taking care not  to enter the maxillary antrum. There is also the option of  removing a small and thin window of bone from the anterior  maxillary wall in the buttress region. This window is typi-  cally only 2-3 mm thick and 1 cm X 1 cm in dimension.    Onlay grafts may be used to augment the width and/or  the height of the alveolus, although vertical augmentation  is challenging. Once the bone graft has been harvested it  should be stored in saline and kept moist until the time  of grafting. The success of onlay grafts relies on recipient  bed vascularity, close approximation and contact between  graft and the recipient site, and graft immobilization. In  addition, there must be tension-free soft tissue closure  over the site to minimize the risk of wound dehiscence,  which may result in graft failure and loss.    The incision for the recipient site may be made at the  crest of the ridge or in the vestibule. Incisions on the  crest give easy access but they are often directly over  the graft and are at risk of dehiscence with subsequent  graft failure and loss. Incisions placed in the vestibule  are away from the graft, but the flap relies on perfusion  from the lingual or palatal side and is therefore at risk  for breakdown, especially if the crest is composed of  dense fibrous tissue.   The recipient bed should be prepared to allow close  approximation between the recipient bed and the onlay  graft, as well as improve immobilization of the graft. This  is often achieved by reduction of convexities and mortis-  ing the bed to receive the graft. A small bur may be used  to perforate the recipient site as well as the graft itself.  The recipient site perforations are monocortical. This is  performed to encourage early capillary ingrowth and  vascularization (Figure 11.5). The block is then stabi-  lized using one or two 1.2-mm diameter screws to avoid  rotation (Figure 11.5). If greater width is desired than  the thickness of the graft will allow, the graft may be  placed as two layers, or secured using positioning screws  leaving space under the graft that can be filled with can-  cellous bone or allogenic bone (Figure 11.6). Any sharp  edges of the graft are smoothed to reduce the chance of    mucosal breakdown. Cancellous bone or allogenic bone  may be placed around the periphery to further augment  the site and anticipate some post-operative resorption.  This particulate bone graft may also be placed as an  interpositional graft between the block graft and recipi-  ent site for contour discrepancies that may create unfa-  vourable surgical dead space and soft tissue ingrowth.  Membranes may be overlaid onto the graft although  many surgeons feel that this increases the risk of wound  dehiscence and infection. However if the periosteum is  to be released and additional particulate bone graft is  used around the margins of the block graft, a membrane  should be considered. Loose and unstable particulate  bone graft should not be introduced into tissue planes  deep to the periosteum.   The soft tissue must be closed without tension. Prior to clo-  sure, the buccal periostium may be incised and undermined  to allow advancement of the flap. The incision is closed using  non-resorbable sutures. Analgesics and post-operative anti-  biotics are prescribed and oral hygiene and diet recommen-  dations are made. The grafted site should be allowed to heal  and consolidate for 4-6 months prior to implant placement.    Maxillary sinus grafting was first described in the 1970s  and its success has improved. The alveolus in the edentu-  lous posterior maxilla is often occupied by a large pneu-  matized maxillary antrum, resulting in vertical bone  deficiency. Grafting the floor of the sinus increases the  vertical dimension of bone available for successful implant  placement. Until recently, this has been performed with  simultaneous placement of the implants if there was at  least 5 mm of native bone height to provide primary sta-  bility for the implant, but if there was less than 5 mm of  bone height, implant placement was deferred to a second  procedure 4-6 months following the sinus graft. However,  recent literature reports successful implant placement in  as little as 1 mm of native bone height, provided there is  adequate width (8 mm or more). In these situations, some  surgeons will use corticocancellous blocks mortised into  the floor of the sinus to provide more stability for the  implants.    Panoramic radiographs are adequate to assess the vertical  height of bone available at the implant site, but CT scans  provide more detailed three-dimensional topographic  visualization of the sinus floor and surrounding walls,  including the presence of septae within the sinus. In addi-  tion, CT scans allow visualization of the sinus mucosa.  Patients with sinusitis or sinus disease should be referred  for appropriate management before grafting. Local mouth  preparation should include chlorhexidine mouth rinse  pre-operatively and many surgeons use a perioperative  antibiotic that is administered either enterally or paren-  terally before surgery.    Access to the sinus is performed through a Caldwell Luc  window in the lateral wall of the sinus. The initial muco-  sal incision may be placed in the vestibule although this  may increase the likelihood of oro-antral fistula formation  in the event of wound dehiscence. This may be avoided  by utilizing a crestal or sulcular incision away from the  bony window. Once a full thickness mucoperiostial flap  is elevated and the lateral wall of the maxilla and sinus is  exposed, a 1 cm X 1.5 cm bony window is created ante-  rior to the zygomaticomaxillary buttress (Figure 11.7).  The superior osteotomy is placed inferior to the infraor-  bital nerve at the level of the planned graft height, while  the inferior osteotomy should lie approximately 3 mm  above the floor of the sinus so as to avoid the multiple  septations and recesses often encountered along the sinus  floor, which make completing the osteotomy and infrac-  turing the bony window problematic. Occasionally, a  second window is needed if there is a septum within the  sinus. The bony window is created using a diamond bur or  a piezosurgery tip to minimize the chance of Schneiderian  membrane perforation. Small perforations (<3 mm) are  inconsequential, but larger perforations should be covered  with a resorbable membrane after elevation of the lining  and prior to insertion of the graft. Once the bony widow is  created and the sinus lining is visible around the periph-  ery, sinus curettes are used to carefully mobilize and ele-  vate the Schneiderian membrane with the cortical window  still attached. Once mobilized, the membrane and bony  window is turned into the sinus such that the bony seg-  ment now becomes the new elevated sinus floor. The space  beneath the elevated bony segment and the lining is filled  with bone or substitute graft material (Figure 11.7). The  volume of the graft placed should allow for 20% resorp-  tion prior to implant placement. The average volume  of graft material required to augment the sinus is 5 mL.  Autogenous bone remains the gold standard graft mate-  rial, but this may be mixed with or even substituted with  allogenic bone with good success. Recent literature also  reports good success with collagen soaked in BMP (BMP-2  or BMP-7).   To close the site, a resorbable membrane is placed over the  bony window and the mucoperiostial flap is sutured with  non-resorbable sutures which are left in place for 2 weeks.    In addition to the usual post-operative management of  intraoral graft sites as, the patient should be instructed  in sinus precautions. These are especially important if the  sinus lining was perforated, and should include no nose  blowing or sucking through straws for at least 3 weeks.  Nasal decongestants and saline nasal spray may also be  helpful.    Potential complications include infection, acute maxillary  sinusitis, wound breakdown and subsequent failure of the    graft, injury to the infraorbital nerve, injury to adjacent  tooth roots with devitalization and oro-antral fistula.    Osteotomies along the alveolar crest may be performed  in the maxilla and the mandible in order to increase the  width of the alveolus (Figure 11.8). The pre-operative prep-  aration is the same as other grafting procedure, however,  the flap dissection is different. To maintain blood supply  to the osteotomized inner and outer segments, the peri-  ostium is left attached to the bone. This is achieved by a  crestal or vestibular incision, and a supraperiostial dissec-  tion of the labial or buccal mucosal flap. The crestal oste-  otomy may be made with a saw, a small fissure bur or a  piezosurgery tip. The vertical osteotomies may be carried  through both inner and outer cortical plates if expansion  of both plates is desired. Alternatively, the vertical cut may  be through only the buccal/labial cortex if lingual expan-  sion is not required. The vertical osteotomies are usually 1  cm in height. Once the osteotomies are made, osteotomes  are driven into the crestal cut and the cortical plate(s) are  pedicled on the overlying periostium. The intervening  space may then be implanted or grafted with bone or sub-  stitute graft materials. The segments and intervening graft  may be stabilized using miniplates or screws for immo-  bilization during the healing phase. In addition, many    surgeons will cover the site with a resorbable membrane  prior to suturing with a non-resorbable suture.    Recombinant human bone morphogenetic protein-2 or  acellular collagen sponge (rhBMP-2/ACS) has proven to be  osteoinductive for several orthopedic surgical procedures.  Application to oral implantology includes horizontal and  vertical maxillary alveolar ridge augmentation and sinus  augmentation. rhBMP-2/ACS has chemoattractants for  stem cells and osteoprogenitor cells, serving as a source  of bone-forming cells. Studies have described the suc-  cessful use of additional materials in combination with  rhBMP-2/ACS as a composite graft, such as crushed can-  cellous freeze-dried allogeneic bone (CCFDAB), and PRP.  The graft material is then contained in a titanium mesh  crib, which is later removed as a second stage surgery. The  ACS gradually resorbs and the occupied space is replaced  by regenerated bone. Recipient sites are generally ready for  implantation in 4-6 months.    A chlorohexidine rinse is used and a local anaesthetic with  vasoconstrictor is applied to the surgical area. The inci-  sion for the recipient site may be made at the crest of the  ridge with releasing incisions. Full-thickness mucoperi-  osteal flaps are elevated to expose the atrophic alveolar  ridge. rhBMP-2/ACS is prepared according to the manu-  facturer's instructions: for example the ACS may be soak-  loaded with reconstituted rhBMP-2 and allowed to rest  for 15 minutes prior to graft delivery (Figure 11.9). Buccal  decortication or monocortical bur perforations of the buc-  cal cortex may be performed to prepare the recipient site  prior to graft implantation. The prepared grafting material  may be delivered in a space-maintaining titanium mesh  crib, 0.2 mm in thickness. The titanium mesh is contoured  to the desired height and width augmentation and the arch  form as well. Graft material is compressed to fill the tita-  nium mesh and the mesh is secured to the alveolar bone  using titanium screws (Figure 11.9). The mesh should be  non-mobile after implantation. Alternate methods of  space maintenance without using a titanium mesh crib    have been described: bone block fixation screws may be  inserted into the alveolar ridge with the screw heads posi-  tioned approximately 4 mm from the crest. At this point,  the graft material is compressed around the screws until  it extends above the screw heads, taking care not to cover  the screw heads. In all methods, it is important to achieve  a tension-free primary closure above the titanium mesh  and graft material. Further release of periosteum and  advancement of the mucoperiosteum may be necessary to  achieve primary closure. The flap is sutured closed with  non-resorbable sutures.    Analgesics and post-operative antibiotics are prescribed  and oral hygiene and diet recommendations are made.   In addition to complications discussed in previous sec-  tions, there may be resorption and loss of the alveolar seg-  ment. Mobility of the titanium mesh or screws may cause  infection and ultimately lead to graft failure and loss. One  of the most frequent complications is wound dehiscence  and subsequent exposure of the hardware. This may be  managed conservatively with hygiene and observation, or  may require surgical closure of the wound. There is always  a risk of inflammatory or foreign body reaction to hard-  ware placement.    In patients with a residual bone height of at least 5 mm,  augmentation of the sinus floor can be accomplished via a  transalveolar approach using the osteotome technique. This  technique may be used at the time of implant placement. The  main indication for osteotome sinus floor elevation is verti-  cal bone deficiency. This procedure is designed to increase  the density and height of bone. Using the elasticity of soft  maxillary bone, dilation and elevation of the sinus floor can  be achieved, thus increasing the length of implants. Adjacent  bone is compressed by mallet tapping as the sinus mem-  brane is elevated. Additional graft material may be added  to increase the volume below the elevated sinus membrane.  Local contraindications include inadequate bone height (<5  mm) and width allowing for primary stability of an implant  and oblique sinus floor (>45° inclination) due to the increased  risk of perforation of the Schnederian membrane. The sinus  floor may be elevated up to 5 mm without perforation of the  sinus membrane. Specific relative contraindications include  patients with a history of inner ear complications, positional  vertigo and smoking.    A chlorohexidine rinse is used and local anaesthetic with  vasoconstrictor is applied to the area of interest. If this  procedure is performed at the time of immediate implant  placement, standard procedures apply to atraumatic    tooth extraction and site debridement and preparation.  If this procedure is not performed for immediate  implant placement, a mid-crestal incision may be made  with or without vertical releasing incisions. A full thick-  ness mucoperiosteal flap is then raised for site exposure.  Small diameter pilot drills and implant drills are used to  prepare the implant site. It is important to underprepare  the implant site by 0.5-1 mm smaller than the intended  implant width. The implant site should be prepared with  careful consideration to avoid perforation of the sinus  floor. 2 mm of bone should remain between the most  apical extent of site preparation and the maxillary sinus  floor (Figure 11.10). At this point, a tapered osteotome  with a concave cup-ended tip is applied vertically into  the implant site and used to create a greenstick fracture  of the maxillary sinus and push the sinus floor apically,  increasing the length of the implant preparation (Figure  11.10). The concave and cutting edge of the osteotome  tip will both harvest bone from the adjacent walls and  compress the bone in an apical direction. The mallet  force should be carefully controlled to prevent mem-  brane perforation. A second tapered osteotome with a  larger diameter than the first is used to increase both  the width and vertical height of the osteotomy. Round-  tipped osteotomes may be used as depth guides between  osteotomies to confirm the preparation height. The last  osteotome used should be 0.5 mm less than the implant  width. The intrusion and elevation of the sinus floor and    membrane will create a tent and potential dead space  beneath the sinus membrane and bony sinus floor. At  this point the sinus membrane may be lifted beyond the  margins of the osteotomy through transalveolar access  with a series of curved curettes which are found in com-  ercially available sinus manipulation kits. After instru-  mentation of the membrane superiorly additional space  is created in order to place particulate bone graft. Many  surgeons will not perform further internal sinus mem-  brane manipulation once the desired height of implant  is achieved by intrusion alone. Implant placement may  then be performed with or without additional grafting  material (Figure 11.10).    Potential complications are similar to maxillary sinus  grafting. Sinus perforation is the main intraopera-  tive complication, which may be confirmed by direct  instrumentation and/or a Valsalva manoeuvre, visual-  izing a bubble or leak from the osteotomy site. Excessive  force or bone trauma may affect primary stability of the  implant and also cause resorption of bone. Benign par-  oxysmal positional vertigo has been described but is  uncommon.    Autogenous bone is considered the gold standard due  to its osteoblastic, osteoinductive and osteoconductive  properties.   Potential bone yields from various donor sites: mandib-  ular symphysis = 5 mL, mandibular ramus = 5-10 mL,  proximal tibia = 20-40 mL, anterior iliac crest = 50 mL  and posterior iliac crest =50-100 mL.   Membranous bone grafts show less rapid resorption  than endochondral bone grafts.   The mandibular symphysis provides blocks of cortico-  cancellous bone measuring up to 1.5-2 cm in length,  1 cm in height and 4-7 mm in thick.   The mandibular ramus provides corticocancellous  blocks of bone measuring up to 3 cm in length, 1 cm in  height and 4 mm thick.   Implants may be placed simultaneously with open  sinus floor augmentation if there is 5 mm or more of  native bone height, although recent literature shows  success in as little as 1 mm of native bone height, if  there is adequate width.   Implant length may be heightened with the use of  the transalveolar osteotome sinus lift. Preparation for  implantation should be approximately 2 mm from the  sinus floor prior to intrusion.    Block M. Color Atlas of Dental Implant Surgery. St. Louis,  MO: Saunders; 2007.   Esposito M, Grusovin MG, Coulthard P and Worthington  HV. The efficacy of various bone augmentation pro-  cedures for dental implants: A Cochrane systematic  review of randomized controlled clinical trials. Int J  Oral Maxillofac Implants. 2006; 21(5): 696-710.   Garg A. Bone Biology, Harvesting, Grafting for Dental  Implants: Rationale and Clinical Applications. New  Malden, UK: Quintessence; 2004.   Khoury FE, Hadi A and Missika P. Bone Augmentation in Oral  Implantology. New Malden, UK: Quintessence; 2007.   Class IV (bone expansion)  Class IV maxilla (inadequate nasolabial support)  Class V maxilla   Class II and HI mandible  Class IV and V mandible  Class VI mandible  Suggested readings    The introduction and development of endosteal implants  have brought about a revolution in that implant-supported  prosthetic devices have become the state of the art.   Nowadays, the establishment and maintenance of  osseointegration are very predictable if the relevant factors  are taken into consideration such as favourable anatomical  form and environment, biocompatibility and favourable  long-term biomechanical conditions. Advances in implant  design and surface modification such as anodic oxidation,  encourage direct bone formation onto the implant surface,  thus increasing initial implant stability and improving  outcome.   At present, the level of evidence indicative of absolute  and relative contraindications for implant treatment due  to systemic disease is low. Similarly, the evidence base  remains weak with regard to pre-existing periodontal  disease. Studies at the patient level suggest survival of  implants and superstructure is not significantly different  from non-periodontally compromised patients. However,  at the implant level, the incidence of peri-implantitis and  marginal bone loss is significantly increased in the peri-  odontally compromised patient. It should be noted that    no study has documented that the survival of an implant  exceeds that of a tooth properly treated for periodontitis.   The success rate for immediate loading of implants  varies between 80% and 100% after 1 year with higher  success rates recorded in the mandible than the maxilla.  Survival of conventionally loaded implants is reported as  98% after 1 year.   In bone graft patients, studies show increased bone con-  tact with implants and increased implant stability when  implant placement is delayed for at least 3 months to allow  revascularization of the graft, new bone formation and  remodelling of the bone graft.   Advances in both surgical technology and surgi-  cal techniques have increased the predictability of pre-  implant surgery and have also reduced the morbidity of  such surgery. Technological advances include improved  imaging techniques, dedicated instrumentation, bone  plates and screws and development of biomaterials such as  bone substitutes and membranes for guided tissue regen-  eration. Computerized tomography (CT) allows accurate  measurements to be made and provides information on  bone density. Interactive planning has refined treatment    Figure 12.1 Computer-generated steriolithographic model and surgical guide for control of implant placement.  (a) Stereolithographic model of mandible. (b) Computer-generated surgical guide for implant placement. (c) Surgical guide in situ    planning and treatment execution. Computer-generated  models (stereolithography) allow for simulated surgery  and provision of templates - further increasing the pre-  dictability of the treatment outcome (Figure 12.1).    Following tooth loss, there is loss of alveolar bone due to dis-  use atrophy. At first, bone loss is rapid. After 2-3 years, the  rate diminishes but loss does continue indefinitely (Figure  12.2). There is an associated decrease in mucosal coverage  of both the keratinized and non-keratinized mucosa which  quickly compromises the potential implant site.   Pre-implant surgery is intended not only to improve the  implant site per se but also to correct deficiencies in height  and width of the alveolus and to restore or improve the  intermaxillary relationship. This is because loss of bone  in the edentulous jaw, and to a lesser extent in the par-  tially edentulous jaw, leads to an alteration of the maxillo-  mandibular jaw relationship, encroachment of muscle  attachments in relation to the edentulous alveolus and a  decrease in the surface area of the overlying mucosa. The  effect of these changes combined with ageing, circumoral  hypotonia and collapse results in changes of facial form  and appearance (Figure 12.3).    There must be adequate bone volume both in height  and width to allow placement of implants of sufficiently  large dimensions to withstand functional loading and  permit optimal axial inclination in order to fulfil the  functional and aesthetic requirements without interfering  with adjacent anatomical structures - for example, the  neurovascular bundle, maxillary sinus and adjacent teeth.  Vertical transverse and antero-posterior intermaxillary  relationships should be favourable. If the foregoing  conditions do not prevail, pre-implant surgery — including  bone augmentation, soft-tissue procedures and possibly an  osteotomy — may be undertaken.   Based on the Cawood and Howell classification of the  edentulous jaws, a scheme for pre-implant surgery has  evolved (Figure 12.4).    Figure 12.2 Reduction of ridge height of the edentulous mandible and maxilla over time. (Adapted from Tallgren A, J Prosthet    Figure 12.3 Consequences of jaw atrophy. Decreased lower face height, prognathism and collapse of lower facial soft tissue are    encountered pattern of jaw atrophy is Class IV in the max-  illa and Class V in the mandible (Figure 12.4).   In the Class IV, V and VI edentulous or partially  dentate jaws, implant placement is usually combined  with bone augmentation using onlay grafts, inlay grafts  and/or interpositional grafts and in addition soft-tissue  procedures.   The choice of bone graft is influenced by the type of grafts  required, ie. block graft or particulate graft. The quantity  of bone required will determine the donor site, i.e. local  (intra-oral) or distant (e.g. iliac crest). Corticocancellous  block grafts are used to augment areas where there are  deficiencies in width and height of the alveolar process.  Particulate grafts are used to fill two- or three-walled  defects, e.g. augmentation of the floor of the maxillary  sinus or interpositional bone grafts.   There is a fundamental difference in the healing of these  grafts which should be taken into account when using  them. Unlike block corticocancellous bone grafts, most of  the particulate cancellous bone graft is able to survive with  areas of new bone formation occurring throughout the  original graft. Even when dehiscence occurs, usually only  a small portion of the particulate graft is lost. The primary    healing depends on capillary ingrowth, not only from the  bone surface of the recipient site but also from the envel-  oping soft tissue. Particulate grafts are difficult to use as  onlay grafts because containment is a problem. The use of  barrier membranes is useful when small alveolar defects  have to be filled.   Corticocancellous block grafts provide a scaffold that  will be resorbed almost completely to be replaced by new  bone by the process of creeping bone substitution. Rigid  fixation of corticocancellous grafts to the recipient site is  essential for this proves to take place unhindered. Any  micro-movement at the interface between the graft and  recipient site will jeopardize capillary ingrowth from the  recipient bed, resulting in avascular necrosis and loss of  the graft. It is always advisable to use at least two screws  to fix the bone to prevent any micro-movement. Other  important factors are the close adaptation of the graft itself  to the recipient bed and tension-free closure of the soft tis-  sue. Depending on the size of the graft, revascularization  will occur in approximately 2 weeks; subsequently remod-  elling begins. It is therefore advisable to delay insertions of  endosteal implants for at least 3 months following place-  ment of the bone graft.    The main objective of soft-tissue procedures is to improve  the peri-implant environment in order to eliminate mobile  mucosa or inflammatory hyperplasia. Ideally, implants  should be surrounded by an immobile keratinized  mucosa. For this reason, split-thickness mucosal grafts  are harvested from the palate in strips, using a mucotome,  which are draped around the implants and secured with a  dressing plate (Figure 12.5).    Connective tissue grafts are usually harvested from the  palate to correct mucogingival defects around implants and  also to augment residual small volume soft-tissue defects,  mainly in the aesthetic zone (Figure 12.6). Small rotational  flaps aid the envelopment of implants with keratinized  mucosa and to restore the shape of the inter-dental papilla.  The lip-switch technique, first described by Kazanjian, is  indicated in those patients who have a shallow buccal vesti-  bule in the mandibular vestibular area or a high attachment  of the mentalis muscle to give a deepened sulcus.    Figure 12.4 Scheme for pre-implant surgery based on Cawood and Howell classification of the edentulous jaw.  (a) Anterior maxilla. (b) Posterior maxilla. (c) Anterior mandible. (d) Posterior mandible. (Continued)    Figu re 12.4 (Continued) Scheme for pre-implant surgery based on Cawood and Howell classification of the edentulous jaw. (a)  Anterior maxilla. (b) Posterior maxilla. (c) Anterior mandible. (d) Posterior mandible.    Immediate placement of implants in extraction socket  has the advantage of reducing the number of surgical  interventions and reducing the time to delivery of the  prosthesis.    © Use of periotome and sectioning of roots to preserve the  integrity of the alveolar walls.    ® Complete removal of the periodontal ligament, any  granulation tissue and fibrous connective tissue.   ® Acute and sub-acute periapical or periodontal infection  is a contraindication to immediate implant placement.   ® Coronal aspect of implant should be placed 2 mm api-  cal to the coronal aspect of the socket to allow for bone  remodelling and osseous regeneration.    Split thickness mucosal graft to enhance implant environment, anterior floor of mouth. (a) Fasciocutaneous  free flap anterior floor of mouth and rim resection surgery. (b) Harvesting mucosal graft from palate using a mucotome.  (c) Alveolar ridge exposed and implants positioned. (d) Mucosal graft draped around implants. (e) Healed mucosal graft and    Small alveolar defects may be repaired by placement of  a barrier membrane over augmentation material, pro-  vided soft-tissue coverage is possible.    Placement of an immediate implant is contraindicated  where a defect of the coronal aspect of the socket exists.  Instead allow complete healing of the socket. After 3  months, the residual alveolus can be repaired with an  onlay graft (Figure 12.7).    Delayed implant placement in mature bone is a safe and  predictable procedure. Immediate loading is possible    provided there is a minimum height of 12 mm and a  minimum width of 6 mm of alveolar bone. However, in  the aesthetic zone the soft tissue should be level with the  papilla of the adjacent teeth, otherwise augmentation is  required. For delayed implant loading, a remote incision  is preferred to reduce the risk of implant dehiscence. For  immediate implant loading, a crestal incision is required.  A surgical guide is essential for optimal site selection for  implant placement and prosthetic outcome.   The direction of the implant bed is determined by the  adjacent teeth and the direction of the cortical plates.  Implant positioning should be no less than 2 mm from  the adjacent teeth and no less than 3 mm from an adja-  cent implant. The pilot bur establishes the direction and    Figure 12.6 Soft-tissue management in implant placement. Connective tissue graft. (a) Concavity over implant site. (b) Elliptical  incision on labial aspect. (c) Connective tissue graft harvested from palate. (d) Palatal flap sutured back. (e) Connective tissue graft  placed over defect. (f) Flap replaced over connective tissue graft restoring contour.    Loss of Loss of Loss of height  width height and width  (a)    Cortical block Cortical block  from symphysis from symphysis from retromolar  or retromolar or retromolar area    Figure 12.7 (a) Alveolar local bone deficiencies: |, loss of  width; Il, loss of height; Ill, loss of height and width. (b) Cor-  rection of local alveolar deficiency with locally harvested block  grafts: |, Veneer graft; Il, Onlay graft; Ill, Saddle graft. (Courtesy  of Dr A. Sethi.)    depth of the implant bed. The diameter of the osteot-  omy is sequentially enlarged using graduated burs with  copious irrigation to avoid thermal trauma to the bone.  In low-density bone, the use of bone condensers is pre-  ferred to enlarge the osteotomy site which also compacts  adjacent bone and aids primary implant stability. In  high-density bone, the implants bed must be completely  formed using hand reamers and bone taps. The implant  bed depth should be 1 mm greater than the implant  length.    © Bone expansion is indicated when the residual alveolar  height is no less than 12 mm and the nasolabial support  is adequate.   ® Bone expansion should be carried out in a healed site  with mature cortical plate.   © There should be intervening cancellous bone and no  fusing of the cortical plates - a CT scan is helpful for  this assessment.   ©@ In the aesthetic zone, the overlying soft tissue should be  level with the papillae of the adjacent teeth.   © CT scan should have reference radio-opaque markers so  that the tooth position can be assessed in relation to the   @ Expander is inserted into the cancellous bone between  the cortical plates.    In the anterior maxilla, the direction of bone loss is hori-  zontal initially. This converts the broad Class II ridge  into a narrow knife-edge ridge which had adequate height  but inadequate width of residual bone to accommodate  implants. The anterior maxillary osteotomy is designed to  increase the width of the alveolus in order to insert implants  and also to provide nasolabial support (Figure 12.8).   A CT scan is required to demonstrate that intervening  cancellous bone is present and that there is no fusion of the  cortical plates.    e@ A horseshoe-shaped incision is made in the labial  mucosa and a mucosal flap dissected to a point approxi-  mately 3 mm below the crest of the alveolar crest.   © The periosteum is incised and a full-thickness muco-  periosteal flap reflected onto the palatal aspect.   @ A sagittal osteotomy is developed using a scalpel blade  to penetrate the cancellous bone. The osteotomy is com-  pleted with a fine reciprocating saw. The cortical bone  of the nasal floor is osteotomized with a fine osteotome.  Vertical bone cuts are made through the buccal cortex  in the premolar region.   © The anterior nasal spine is removed and the anterior  part of the nasal septum is detached from the anterior  segment to be mobilized.    Where there is fusion of the cortical plates, augmentation  of the Class IV ridge is achieved using a block veneer graft  which is stabilized with lag screws.   For single tooth replacement in the anterior maxilla,  augmentation of the alveolus is required for optimal  implant placement and soft-tissue support using a veneer  graft harvested from the mandible.    © Remote palatal incision extended within the crevicu-  lar margin labially to involve one unit either side of the  recipient site. Papilla sparing incisions and bevelled  incisions optimize the aesthetic result.    Figu re 12.8 Anterior maxillary osteoplasty to broaden the narrow maxillary ridge. (a) Flap design (shaded area). Labial incision,  submucosal dissection deepened to full thickness over crest of ridge. (b) Contouring of crestal irregularities (shaded). Vertical  osteotomy cut extending into the nasal floor. (c) Mobilization of anterior segment labially. (d) Placement of interpositional bone  graft (shaded). (e) Placement of endosseous implants following incorporation of bone graft. (f) Anterior maxillary osteoplasty and    © Bone graft is contoured to fit the recipient site passively.   © Bone graft secured with two microscrews to avoid risk  of micro-movement.   © Tension-free closure of mucosa is obtained using a peri-  osteal release incision if necessary.    Sufficient bone can be obtained from the mandibu-  lar ramus area for placement of up to four implants. An  increase in width of 2-6 mm and an increase in height of  about 4 mm can be achieved.    The Class V maxilla is characterized by loss of the alveolar  process resulting in a vertical, transverse and antero-pos-  terior alteration of the interarch relationship. Extensive  augmentation with autogenous bone is required to restore  the alveolar dimension and provide the necessary facial  support. Bone is harvested from the iliac crest.   To determine the quantity of bone to be harvested,  the selected tooth position is related to a stone cast of the  edentulous ridge by means of a plater matrix. Silicone can  be used to form a template to facilitate both the harvesting    of bone from the iliac crest area and also to adapt the graft  to the recipient site.   The onlay graft is stabilized using position screws.  Tension-free closure is obligatory and is facilitated with a  periosteal release incision. Implant placement should be  delayed for at least 3 months.    Resorption of the maxillary alveolar process eventu-  ally leads to a relatively posterior and cranial position of  the maxilla resulting in a reversed intermaxillary rela-  tionship and increased vertical intermaxillary distance.  Reconstruction of the Class VI maxilla aims at restoration  of interarch relationship and augmentation of the alveolar  bone to provide support for the collapsed facial muscula-  ture and implant placement.    A horseshoe incision is made high in the vestibule from  first molar to first molar. The mucoperiosteum is reflected  and the lateral sinus wall and nasal aperture are exposed.    A No. 5 round bur is used to make the horizontal osteot-  omy cut. The thin sinus membrane is elevated (preferably  intact). The bone cuts are completed including the medial  sinus wall and nasal septum. The tuberosity is detached  from the pterygoid plate using a small osteotome. Due to  the fragile nature of the maxilla, the ‘down fracture’ pro-  cedure must be carried out gently. In cases of severe rup-  ture of the sinus membrane, the exposed sinus is sealed  with a cortical plate bone stabilized with a microplate.  The mobilized maxilla is fixed in the planned position  with four microplates. The intervening space is packed  with particulate cancellous bone. Tension-free closure of  the soft tissues is obligatory and periosteal release inci-  sion may be required for this to be achieved. Implants are  placed at least 3 months later in the planned position using  a surgical guide.    Unlike the maxilla, which is composed of trabecular  bone predominantly with a thin cortex, the mandible has  a thick cortical layer. This provides superior support for  endosteal implants particularly in the anterior mandible.  Following tooth loss, the blood supply of the edentulous  mandible differs from that of the dentate mandible. In the  dentate mandible, blood supply is principally centrifugal,  arising mainly from the inferior alveolar artery and peri-  odontal arterial arcades. The blood supply of the edentu-  lous mandible is mainly centripetal, being derived via the  subperiosteal plexus. Therefore, when carrying out pre-  implant surgery of the edentulous mandible elevation of  the mucoperiosteum must be performed carefully to avoid  damaging the periosteal layer and subsequent ischaemic  necrosis of the underlying bone.    Similar to the maxilla endosteal implants can be inserted,  minimal pre-implant surgery being required. However,  it should be noted that any surgical interference with the  inferior alveolar nerve may lead to sensory alteration and  loss which can be permanent.    In the Class IV anterior mandible, contouring to remove  the narrow ridge or onlay bone grafting will be influenced  by the prosthetic requirements. In the Class V edentu-  lous mandible, anteriorly implants may be inserted with-  out need for bone augmentation. However, the soft-tissue  environment is unfavourable with reduced keratinized  mucosa and a shallow sulcus. A Kazanjian flap is useful to    increase the area of attached mucosa and at the same time  deepen the labial sulcus.    The Class VI mandible is characterized by loss of basal  bone that can be extensive. Often the inferior alveolar  canal is exposed and pain results from compression of  the nerve during function. Augmentation of the Class  VI mandible is indicated when the residual height is less  than 10 mm. Augmentation is accomplished either with  an interpositional bone graft or an onlay bone graft. The  choice between these two techniques is partly operator  dependent and partly dependent on the relationship of the  soft tissues of the floor of mouth relative to the residual  ridge. If the lax tissues of the floor of mouth ‘spill’ over  the residual ridge, then an onlay bone graft is more effec-  tive in ‘damming back’ the floor of mouth tissues. Via a  subperiosteal tunnel, an onlay graft is placed in the poste-  rior mandible to cover the exposed inferior alveolar canal.  Implant placement is delayed for a minimum of 3 months.    Branemark Pl. The Osseointegration Book: From Calvarium  to Calcaneous. ISBN-10: 1-85097-090-4. Berlin:  Quintessenz Verlag-Gmbh; 2005.   Cawood JI, Stoelingo PJW and Blackburn TK. The evolu-  tion of preimplant surgery from preprosthetic sur-  gery. Int J Oral Maxillofac Surg. 2007; 36: 377-385.   Claven J and Lundgren S. Ramus or chin grafts for max-  illary sinus inlay and local onlay augmentation:  Comparison of donor site morbidity and complica-  tions. Clin Implant Dent Relat Res. 2003; 5: 154-160.   Sclar AG. Soft Tissue and Esthetic Considerations in Implant  Therapy. ISBN 0-86715-354-7 (hbk). Chicago, IL:  Quintessence Publishing Co.; 2003.   Stoelinga PJW. Preprosthetic reconstructive surgery. In  Peterson LJ (ed.) Principles of Oral & Maxillofacial  Surgery, Vol. 2, Chap. 46. Philadelphia, PA: Lippincott  Williams and Wilkins; 1992. pp. 1169-1207.   Mandible (partial or total edentulism) reconstruction  Membranes and biologic healing adjuncts    Implant reconstruction of the severely resorbed edentu-  lous maxilla frequently requires autogenous block bone  graft reconstruction. This can be accomplished with  iliac, cranial or mandibular corticocancellous block bone  grafts. Depending on the degree of bone loss, the patient’s  functional or aesthetic requirements, and the prosthodon-  tic requirements, the bone graft procedures can either be  a one- or two-stage reconstruction. The one-stage recon-  struction requires simultaneous placement of block bone  grafts and endosseous root form dental implants. In the  two-stage procedure, bone grafting and implant place-  ment procedures are separated by 3-6 months to allow for  bone graft healing. The bone grafting procedures are clas-  sified anatomically as onlay, inlay or interpositional types.    For totally edentulous patients with advanced bone loss,  there also needs to be adequate bone quality and quantity  between the anterior antral walls to accommodate four to  six endosseous implants to stabilize the one-stage onlay    bone graft. If there is insufficient bone, a two-stage onlay  bone graft procedure is performed. In the latter situation,  the bone graft is stabilized by miniplates or bone screws.  There must also be adequate interarch space to accommo-  date the onlay bone graft and dental osseoprosthesis. The  soft-tissue flap used to cover the onlay bone graft must be  free of infection and significant scar tissue. A periosteal  incision of the labial-buccal flap with mucosal advance-  ment is needed for a critical watertight non-tension  everted wound closure (Figure 13.1).   . Non-traumatic (low heat production) bone graft harvest-  ing is critical to preserve cell viability of the cancellous  and cambian layer of osteoblasts. Iliac bone is utilized  for large full arch reconstruction and cranial or man-  dibular ramus or symphysis bone for smaller segmen-  tal reconstruction (see section ‘Bone Graft Harvesting  Techniques’).   . Rigid onlay bone graft stabilization (endosseous  implants or miniplates and screws) is important to  promote bone graft healing and simultaneous implant  osseointegration (one-stage procedure).    This is indicated for totally edentulous patients with  advanced bone resorption but inadequate interarch  space to accommodate the onlay bone graft and associ-  ated osseoprosthesis. It is also indicated for patients with  inadequate soft-tissue elasticity for onlay bone graft soft-  tissue coverage. The surgeon can also elect to perform the  inlay versus the onlay bone graft, bearing in mind that the    final implant prosthesis will be affected (fixed-removable  versus continuous fixed). For partially or totally edentulous  patients, a two-stage bone grafting procedure can be per-  formed utilizing either corticocancellous block or particu-  late bone grafts from the iliac crest, mandible or cranium.  Various allogenic and autogenous bone particulate bone  grafts can also be mixed to increase the particulate bone  graft volume. This is not common in the author's practice  as adequate volumes of cancellous bone can be harvested  from the anterior and/or posterior iliac crest. If particu-  late bone grafts are utilized, the sinus membrane or vari-  ous membranes (collagen preferred) need to be utilized to  confine the graft material in the correct position for later  secondary implant placement. If there is adequate sinus  floor bone (5 mm or more), a one-stage procedure can be  accomplished. However, in this situation, the author is fre-  quently able to place short-wide diameter implants into the  sinus floor without adjunctive bone grafting (Figure 13.2).    Figure 13.1 (a) and (b) Maxillary onlay (one stage) corticocancellous block iliac bone graft.    Figure 13.2 Maxillary nasal/antral inlay (one stage) corti-  cocancellous block iliac bone graft.    . Nasoendotracheal general anaesthesia is generally  required for bilateral antral reconstruction in edentu-  lous patients utilizing autogenous corticocancellous  block bone grafts.   . Crestal incisions are indicated to permit a periosteal  releasing incision, limit sulcus scaring and allow peri-  osteum coverage.    . Non-tension watertight everted wound closure.  . Four to six months of minimal (physiologic) bone graft    Interpositional corticocancellous block bone  graft with Le Fort | down-graft osteotomy    This technique is indicated for partially or totally edentu-  lous patients, who in addition to their edentulism exhibit  two complicating factors: (1) horizontal and/or vertical  maxillary deficiency with associated facial deformity and  skeletal malocclusion and (2) inadequate bone quality  and/or quantity to support endosseous implants in the  edentulous area eventually requiring bone-anchored den-  tal prosthesis. These patients are generally younger individ-  uals, who have high functional and aesthetic expectations.  They also frequently exhibit high functional disability in  mastication, speech, deglutition and nasopharyngeal air-  flow (Figure 13.3).    This reconstructive effort is generally carried out in two  stages: (1) the first involves a low Le Fort I osteotomy  with correction of the vertical and/or horizontal skele-  tal deformity and malocclusion, and placement of inter-  positional block bone grafts to stabilize the repositioned  maxilla and (2) provide bone volume and bone density  for eventual endosseous implant reconstruction of the  edentulous alveolar areas.    repositioned maxilla and interpositional bone graft is  critical for physiologic bone healing and maintenance  of block bone graft volume for adequate numbers and  adequate size of endosseous implant.   block bone grafts across the  down-fractured nasal floor is critical in patients missing  anterior teeth and alveolar bone. This facilitates even-  tual endosseous implant reconstruction in this impor-  tant aesthetic zone.    . If the Le Fort I interpositional bone grafting is success-    ful, the secondary implant reconstruction 4-6 months  later requires routine implant surgical technique.    omy, autogenous bone grafting and endosseous implant  reconstruction is technically difficult (requires both    Figure 13.3 Interpositional corticocancellous block bone graft with Le Fort 1 down-graft osteotomy.    sulcus and alveolar ridge incisions) and may result in  compromised implant position for final prosthesis fab-  rication. For these reasons, the one-stage versus two-  stage procedure is rarely indicated.    Segmentallossofalveolarandbasalbonegenerallyissecond-  ary to congenital clefting or postsurgical/post-traumatic  aetiology. The surgeon and prosthodontist need to decide  whether bone grafting and implant reconstruction of the  segmental defect is required, resulting in complete arch  reconstruction with fixed or fixed/removable prosthesis,  or whether an implant-supported removable obturator  prosthesis is required. The size and aetiology of the dis-  continuity are an important consideration, as well as the  patient’s functional and aesthetic expectations. In general,    the congenital clefts and small defects are bone grafted  and secondarily reconstructed with a fixed implant pros-  thesis, whereas the large (hemimaxillectomy) defects are  reconstructed with implant-supported removable obtura-  tor prosthesis. Vascularized composite (bone and soft tis-  sue) is utilized in selected patients to reconstruct the large  defects, thus avoiding an obturator removal prosthesis  (Figure 13.4).    1. Alveolar-palatal cleft (and smaller postoncologic or  postsurgical defects) bone grafting needs to be accom-  plished in a manner where the osseous anatomy of the  nasal floor, piriform aperture and anterior portion  of the palate are fully reconstructed. In the author’s  hands, this requires a combination of corticocancellous  block and cancellous particulate bone grafts from the  iliac crest. In the growing cleft child, these bone grafts  are placed between the ages of 7 and 10 years, when  the cuspid roots is one-half to two-thirds formed, and    Nasal cavity Ostium Antrum  Zygoma  Findosseaus Periosteum  implant  Oral mucosa  Prosthesis Antral mucosa  retention  device Corticocancellous  iliac block bone  graft  Obturator  dental  prosthesis Endosseous  implant  Cancellous  bone chips  (a)  Periosteal Mucosa ridge Nasal Alveolar  incision incision mucosa mucosa  Residual    Figu re 13.4 Maxillary discontinuity reconstruction with corticocancellous block iliac bone graft. (a) Hemimaxillectomy defect;  (b) congenital alveolar/palatal defect.    in the adult, 4-6 months before endosseous implant  placement; again, complete reconstruction of the miss-  ing anatomy is important, especially in the anterior aes-  thetic zone.   2.In larger postoncologic or post-traumatic defects  (where non-vascularized bone grafts are contrain-  dicated), the endosseous implants and/or onlay or  inlay bone grafts are placed in the residual maxillary  bone. The surgical techniques are the same as those  described earlier (see under section ‘Maxilla (Partial  or Total Edentulism) Reconstruction’). This may be  in the form of antral inlay or onlay bone grafts, or  pterygoid and zygomatic implants. In this situation,  the implant-supported prosthesis is a fixed-removable  obturator type. More recently, vascularized composite  bone grafts have been utilized for the larger defects. In  this situation, it is important to have adequate volume  and position of the bone graft; also, the soft-tissue por-  tion frequently needs to be debulked to accommodate  the dental prosthesis.    Patients with bone height equal to or greater than 5 mm  and bone width equal to or greater than 7 mm between  the mental foramen are candidates for placement of four  or five endosseous implants (Figure 13.5).    Because of the advanced bone resorption, a number of  important surgical technique modifications are required:  (1) Crestal rather than sulcus incisions, to preserve  the mentalis integrity; (2) conservative periosteal ele-  vation to preserve a compromised (totally periosteal)  blood supply to the residual mandible; (3) isolation of  the bilateral mental nerve, which is positioned on the  crest of the residual alveolar ridge; (4) low speed-high  cooling bone cutting of dense hypovascular bone; (5)  bone cutting threading of all osteotomy implant sites  through the inferior border; (6) no implant osteotomy  site bone bevelling; (7) placement of autogenous osseous  coagulum obtained from taping the instrument through  the implant preparation site to the inferior border; (8)  place the endosseous implant at right angle to the occlu-  sal plane; (9) avoid straight line placement of the ante-  rior implant to avoid unfavourable cantilever prosthesis  loading (at times, this will require uncovering of the  thin bone overlying the inferior alveolar nerve and dis-  talizing of the nerve to allow more posterior positioning  of the right and left distal implant); (10) allow implant    Figure 13.5 Mandibular endosseous implant reconstruc-  tion. (a) Advanced bone resorption; (b) functional bone remod-  elling after implant loading (Wolff's law).    access holes to exit anterior to the dentition to counter-  act the dental class III occlusion tendency; (11) accept  a high incidence of non-keratinized peri-implant tissue;  (12) understand gradual physiologic increase of bilateral  mandibular body height and width following functional  prosthetic loading of the anterior mandible (Wolff's law  of bone physiology).    Adjunctive onlay bone grafting in the advanced bone  resorption patient is required when the anterior residual  bone is less than 5 mm in height and/or the width is less  than 7 mm in the future endosseous implant sites. This  group of patients can also avoid the onlay bone grafting  procedure if they are willing to function with an over-  denture-type prosthesis on two or three midline implants,  where there is invariably enough bone (genial tubercle and  mentalis muscle attachment area) for implant stability. In  this situation, the patient would be willing to accept vary-  ing degrees of aesthetic and/or functional compromise  (lower lip support and tooth position) (Figure 13.6).   In addition to the surgical techniques aforementioned  under implant reconstruction of advanced bone resorp-  tion without bone grafting.    2. Atraumatic bone grafting harvesting and atraumatic  recipient site surgery bone healing (bone conduction,  bone induction and transfer osteogenesis).   . Provide watertight, everted tension-free wound closure  to ensure early fluid nutrition and revascularization of  the bone graft. This requires mobilization of the sub-  lingual mucosa which is always highly redundant from  previous bone loss.   . Delayed placement (second stage) of the more poste-  rior implant may be necessary due to the narrow width  (<6 mm) in the mental foramen area. In this situation,  the corticocancellous block bone graft may need further  stabilization with miniplates or screws. The same situa-  tion exists when a unilateral posterior onlay bone graft  is placed above the inferior alveolar nerve.   . Delayed (2-3 weeks) placement of the interim prosthe-  sis to avoid disturbing wound closure and to avoid early  bone graft loading.   . Bone graft placement does not extend more than 1 cm  beyond most distal implants as this distal body bone  will eventually regenerate in height and width after  a period of time (1-3 years) of functional loading  (Wolff’s law of bone repose to physiologic loading ten-  sion in the bilateral body portion of the mandible, see  Figure 13.5b).    Figure 13.6 Mandibular onlay (one stage) corticocancellous block iliac bone graft.    Discontinuity reconstruction with  vascularized or non-vascularized block bone  grafts and endosseous implants (two-stage  procedure)   When mandibular discontinuity occurs following  trauma, infection or oncologic resection, it is gener-  ally necessary to establish mandibular continuity prior  to implant reconstruction. Contraindications to this  surgical reconstruction relates to significant patient  medical comorbidity, poor or uncertain oncologic  prognosis or severe postirradiation compromise  (decreased vascularity, cellularity and tissue hypoxia)  (Figure 13.7).    1. Vascularized or non-vascularized corticocancellous  block bone grafts are harvested and skeletally fixed to  the osseous defect. Non-vascularized block grafts are  primarily obtained from the ilium or calvarium. When  severe blood supply compromise is present, when the  length of the discontinuity is excessive, or when vascu-  larized soft tissue is required, harvest of vascularized  composite bone grafts from various anatomic sites (most  common include ilium, fibula or scapula) when bone and/  or soft tissue is required, radial, abdominal, lateral thigh  or various perforator grafts are indicated when only soft  tissue is required. On occasion, various non-vascularized  bone grafts are combined with vascular soft-tissue grafts  (vascularized abdominal with non-vascularized ilium).    Figure 13.7 Mandibular oncologic or post-traumatic (two stage) corticocancellous iliac block bone graft with titanium mesh    2. Endosseous implants are placed 4-6 months following  bone grafts when revascularization and remineraliza-  tion is nearly complete (two-stage procedure).   3. If bone grafting has been successful from a bone vol-  ume and bone position standpoint, endosseous implant  reconstruction follows routine implant reconstruction  techniques.   4. When placing implant into irradiated bone or into bone  graft previously placed into irradiated tissue, special  surgical protocol is followed and includes the follow-  ing: meticulous atraumatic bone drilling with exuber-  ant cooling, conservative periosteal reflection (bone  gets all of its blood supply from the periosteum in heav-  ily irradiated patients), meticulous bone tapping and  meticulous soft-tissue closure in a non-tension everted  watertight fashion.   5. Prosthetic reconstruction in irradiated patients requires  fixed continuous prosthesis to avoid compromised soft-  tissue loading.   6. Endosseous implants placed into the irradiated eden-  tulous mandible are better placed in the interforaminal  area where the central irradiation beam creates the least  damage to bone and where the cortical/cancellous bone  ratio is more favourable than the bone of the mandibu-  lar body or ramus of the same patient.    In the severely resorbed mandible, the mental and infe-  rior alveolar nerves are generally either herniated at the  crest of the ridge or are covered by relatively thin bone.  The technique of unroofing and repositioning the herni-  ated nerve is relatively straightforward and atraumatic.  Once the nerve is uncovered, the incisive branch must be  cut at least 2-3 mm anterior to the mental branch. This  allows the nerve to be lifted from its canal and reposi-  tioned posteriorly away from the implant osteotomy site.  If performed correctly, a short period (2-6 months) of par-  aesthesia and/or anaesthesia will follow. If a closed nerve  injury (crushing and/or tearing with a rotary drill) is cre-  ated in a situation where the exact location of the nerve is  not appreciated, the long-term potential morbidity is much  increased. The author feels a planned minor nerve injury  is much preferred over an unplanned closed nerve injury.  In addition, implant placement can be greatly enhanced  in many situations (such as an atrophic mandible) where  improved prosthesis biomechanical loading is achieved.  In the mandibular unilateral posterior edentulous patient  onlay bone grafting is more difficult, primarily because  of the presence of the inferior alveolar nerve. In addition,  an onlay block bone graft is technically difficult and more  risky to the nerve than the anterior block graft reconstruc-  tion described earlier. For these two reasons, the author  prefers unroofing and repositioning the nerve prior to    onlay bone grafting. In addition, frequently an onlay bone  graft is not required once the nerve is out of the operative  site. The surgical technique of uncovering and reposition-  ing the mental and inferior alveolar nerve is illustrated in  Figure 13.8, in the atrophic edentulous mandible and the  posterior partially edentulous mandible. Surgical instru-  mentation is minimal and simple and consists of small  round high-speed drilling burrs and small No. 2 anda No.  4 molt curette.    The author uses very little, if any, alloplastic membranes  in bone-grafted patients. Since the periosteum is highly  osteogenic and provides significant rigidity and anatomic  confinement, its proper use and positioning is preferred.  This frequently requires a selective periosteal release  (incision) at the height of a flap to allow it to be advanced  over a bone-grafted area. The elastic fibres immedi-  ately above the periosteum permits up to 12 mm of flap  advancement once the periosteum is accurately incised,  a significant distance from the surgical defect to be cov-  ered. The antrum membrane is also highly osteogenic  and can provide adequate confinement of a particulate  graft (in addition to its osteogenic potential). If a very  thin antral membrane ruptures, an appropriate collagen  material is the most physiologic replacement of either the  periosteum or antral membrane. An even better solution  in the author’s opinion is the use of small cortical grafts  properly stabilized with endosseous implants (one-stage  procedure) or miniplates or screws (two-stage procedure)  providing a predictable bone reconstruction of small  antral or alveolar defects.    The hallmark of predictable bone grafting augmenta-  tion and endosseous implant reconstruction of various    anatomic defects is meticulous and biologically sound  surgical planning and surgical technique. Most heal-  ing failures follow faulty diagnosis (wrong surgery for  a given problem), faulty patient selection (medical or  psychologic comorbidities) or faulty surgical tech-  nique. The latter include excessive tissue destruction  (cautery, laser, tearing or crushing of tissue), poorly  designed or poorly vascularized tissue flaps, inad-  equate haemostasis leading to hematoma, failure to  eliminate dead space with drains or suturing, devital-  izing bone with excessive heat and failure to achieve  watertight non-tension soft-tissue (mucosa-perios-  teum) closure. Extraoral approaches to the mandible  where incisions are placed low in the neck potentially  eliminate or reduce all the skin arterial perforators and  reduce subcutaneous fat. This blood supply compro-  mise combined with excessive cautery and thinning  of the skin provides poor soft-tissue coverage of the  osseous reconstructive efforts. Biologic enhancers will  not cover up compromised surgery, but may enhance  outcome if all other wound conditions are satisfied.  The latter, however, has not been established to date by  properly designed prospective studies.    Adjunctive bone grafting for all but the most simple osse-  ous defects warrant utilization of fresh autogenous bone  which most agree represents the well-established gold  standard of care.   Ideally, the bone graft should provide adequate bulk  to repair the anatomic defect, act as a strong bone  induction agent and provide viable osteogenic stem  cells which provide transfer osteogenesis when placed  in a closed biologic environment. The latter contains  cellular nutrition and early revascularized potential.  This graft must also be covered with a viable perios-  teum (osteoblasts) and surrounded with viable bone  (cambium layer osteoblasts) to take advantage of the  osteoinductive properties of the bone graft. Proper  rigid stabilization of the graft is critical to ensure  more specialized bone regeneration rather than less  specialized collagen production in the osseous defect.  The corticocancellous block or cancellous particu-  late bone from the ilium satisfies most, if not all, of  the aforementioned attributes if properly harvested.  Stabilizing the particulate grafts can become a prob-  lem which can lead to a loss of significant graft volume.  Cortical grafts from the cranium or mandible, if prop-  erly harvested, can provide all but the transfer osteo-  genic component listed earlier. Atraumatic harvesting  of the bone grafts is just as important as atraumatic  preparation of the recipient site. Both are required for  predictable bone grafting success. Ideally, the recipient  site should be fully prepared before the bone graft is    harvested. This allows immediate transfer of the bone  graft to the recipient site which theoretically helps  preserve the osteoinductive (protein) and transfer  osteogenic (cellular) potential. When proper healing  occurs, the bone graft will respond properly to physi-  ologic loading (Wolff’s law). The latter will not theo-  retically occur with allogenic bone grafts which may  take years to be replaced with normal bone. The latter  will provide osseous bulk, but not viable bone which  responds appropriately to physiologic loading of an  endosseous osseointegrated implant.    e Advanced maxillary bone graft reconstruction requires  autogenous corticocancellous block onlay, inlay or  interpositional bone grafting. Each type (onlay versus  inlay versus interpositional) has specific indications and  can be either one or two stage.   e Bone graft reconstruction of small- to medium-sized  congenital alveolar-palatal defects requires cortico-  cancellous block bone grafts to completely restore the  nasal floor, palate and piriform rim to achieve the most  ideal nasal and dental implant aesthetic result.   e The reconstructive surgeon, prosthodontist and  patient need to decide whether to replace lost anatomy  or obturate lost anatomy in early planning of corrective  surgery for large postsurgical or post-traumatic maxil-  lary defects.   e Endosseous implant reconstruction of advanced bone  resorption of the edentulous mandible can be achieved  with a minimum of 5 mm of bone height and 6 mm of  bone width.   e Bone regeneration of severely resorbed mandibular  body occurs following functional loading of osseoin-  tegrated endosseous dental implants placed in the  mandibular symphysis region (Wolff's law of bone  physiology).   e Mandibular discontinuity reconstruction with vascu-  larized or non-vascularized block bone grafts requires  metal trays or reconstruction plates which are physi-  ologic to avoid bone graft stress shielding during bone  graft healing.   e A planned minor nerve injury is preferred to an  unplanned major nerve injury when placing endosse-  ous implants close to the inferior alveolar and metal  nerve. Therefore, nerve uncovering and removal from  the surgical site may be prudent.   e The periosteum provides the most physiologic and  effective barrier membrane in all bone grafting situa-  tions. This requires selective periosteum incision and  repositioning techniques.   e Autogenous bone graft harvesting surgical techniques  must be atraumatic to preserve the bone induction  (bioactive protein), bone conduction and transfer  osteogenic (cellular) potential required for maximum  bone graft regeneration.   e Atraumatic management of the covering mucoperios-  teum or skin is required to provide a physiologic envi-  ronment for predictable bone graft regeneration.    Keller EE. Mandibular discontinuity reconstruction  with composite grafts. Free autogenous iliac bone,  titanium mesh trays, and titanium endosseous  implants. In Worthington P, Beirne OR (eds.), Oral  and Maxillofacial Surgery Clinics of North America.  Philadelphia, PA: WB Saunders; 1991. pp. 877-891.   Keller EE. The maxillary interpositional composite graft.  In: Worthington P, Branemark PI (eds.), Advanced  Osseointegration Surgery: Applications in the  Maxillofacial Region. Chicago, IL: Quintessence  Publishing; 1992. pp. 162-174.   Keller EE. Reconstruction of the severely atrophic edentu-  lous mandible with endosseous implants: A 10-year  longitudinal study. J Oral Maxillofac Surg. 1995; 53:  305-320.   Keller EE. Maxillary discontinuity defects: Tissue-  integration reconstruction. In: Branemark P,  Tolman DE (eds.), Osseointegration in Craniofacial  Reconstruction. Chicago, IL: Quintessence  Publishing; 1998. pp. 187-204.   Keller EE, Desjardins RP, Eckert SE and Tolman DE.  Composite bone grafts and titanium implants in  mandibular discontinuity reconstruction. J Oral  Maxillofac Surg. 1988; 3: 261-266.   Keller EE and Gandy SR. Modified mandibular body  step osteotomy-ostectomy. Int J Adult Orthodon  Orthognath Surg. 1993; 8: 37-45.   Keller EE and Tolman DE. Mandibular ridge augmenta-  tion with simultaneous onlay iliac bone graft and  endosseous implants: A preliminary report. J Oral  Maxillofac Surg. 1992; 7: 176-184.    Keller EE, Eckert SE and Tolman DE. Maxillary antral  and nasal one- stage inlay composite bone graft:  Preliminary report on 30 recipient sites. J Oral  Maxillofac Surg. 1994; 52: 438-447; discussion  447-448.   Keller EE, Tolman D and Eckert S. Endosseous implant  and autogenous bone graft reconstruction of man-  dibular discontinuity: A 12-year longitudinal study  of 31 patients. J Oral Maxillofac Surg. 1998; 13:  767-780.   Keller EE, Tolman DEand Eckert S. Surgical-prosthodontic  reconstruction of advanced maxillary bone compro-  mise with autogenous onlay block bone grafts and  osseointegrated endosseous implants: A 12-year  study of 32 consecutive patients. Int J Oral Maxillofac  Implants. 1999; 14: 197-209.   Keller EE, Tolman DE and Eckert SE. Maxillary antral-  nasal inlay autogenous bone graft reconstruction of  compromised maxilla: A 12-year retrospective study.  Int J Oral Maxillofac Implants. 1999; 14: 707-721.   Keller EE, Tolman DE, Zuck SL and Eckert SE. Mandibular  endosseous implants and autogenous bone grafting  in irradiated tissue: A 10-year retrospective study.  J Oral Maxillofac Surg. 1997; 12: 800-813.   Tolman DE, Desjardins RP and Keller EE. Surgical-  prosthodontic reconstruction of oronasal defects  utilizing the tissue-integrated prosthesis. J Oral  Maxillofac Surg. 1988; 3: 31-40.   Worthington P, Krogh PH and Keller EE. Does the risk  of complication make transpositioning the infe-  rior alveolar nerve in conjunction with implant  placement a ‘last resort’ surgical procedure? J Oral  Maxillofac Surg. 1994; 9: 249-254.   Introduction and review of the literature 139  Angulated implantology-zygomatic implants 139  Hemizygomatic implants 142  Quadratic zygomatic implants 142  Zygoma, zygomatic implants and oncology reconstruction 146  Zygomatic implants and nasal and naso-maxillary reconstruction 152  Zygomatic implants and gunshot reconstruction 153  Pterygoid implant 157  Extra-oral implants—cranial, auricular and orbital 157  Advanced digital technology in craniofacial reconstruction 158  Acknowledgement 163  References 163  Suggested readings 163    Modified reconstruction procedures are applied when  the facial skeleton has insufficient bone for conventional  implant placement. Extensive bone grafting is recom-  mended to create adequate bone volume for placement  of endosseous implants to restore the severely resorbed  or resected maxilla with a fixed prosthesis. Bone grafting  procedures include onlay grafts, inlay grafts into the floor  of the maxillary antrum and Le Fort I maxillary osteotomy  with advancement and down grafting techniques. Newly  grafted bone has to remain load-free to allow consolida-  tion and revascularization for 4 months. Staged bone graft  techniques increase treatment time, which is tedious and  socially unacceptable for the patient.    Maxillary atrophy makes quality of life for denture wear-  ers unbearable, made worse by continuous bone resorp-  tion and maxillary sinus pneumatization.' The zygomatic  implant has provided the clinician with an alternative to  grafting procedures in the reconstruction of the severely    resorbed maxilla. Branemark originally designed the  technique in 1989 and has a reported success rate of 97%.   This implant traverses the posterior maxillary alveolus  and lateral sinus wall into the body of the zygoma. The  restorative interface requires angular correction from the  long axis to allow for appropriate tooth position. Boyes-  Varley et al. (2003) described the use of a 55° restorative  head (Southern Implants™, Irene, South Africa) in order  to reduce the buccal cantilever by 20%. The use of a modi-  fied head angulation of 55° with implant placement as  close to the crest of the edentulous ridge as possible allows  restorative clinicians to achieve an ideal restorative posi-  tion in the posterior maxilla.”    Radiological assessment for the zygomatic implant pro-  tocol is used to detect the presence of pathology within  the maxillary sinuses and to evaluate the volume of bone  available in the maxillary alveolus and zygomatic body.  The following radiographic views are recommended:    . Panoramic view to detect bone height within the max-  illa and anatomical structures.   . Occipito-mental views to assess the extent of the maxil-  lary sinus and presence of sinus pathology.    4, Axial, coronal and reformatted computerized axial  tomography (CAT) scans give an excellent assessment of  the maxilla and maxillary sinus. In the case of cancer  and trauma surgery patients, three-dimensional (3D)  spiral reconstructions are useful and the DICOM data  is used to manufacture a stereolithographic model for  planned surgical resection and thus prosthodontic reha-  bilitation after resection. With the advent of cone beam  computerized tomography scan (CBCT) technology,  it may not be necessary to obtain a medical CAT scan  in every case and much valuable information can be  obtained from using a full volume CBCT (Figure 14.1).    Optimal implant placement is dictated by the position  of three distinct anatomical sites:    1. The position of the incisura between the zygomatic arch  and the frontal process of the zygomatic bone (Point A).   2. The confines of the lateral wall of the maxillary antrum  (Point B).   3. The thickness of the existing alveolar crest (Point C)  (Figure 14.2).    For optimal implant placement, the position of the  incisura of the zygoma is fixed and provides the superior  pivot point of the zygoma implant. Occasionally, the sur-  geon can place the exit point of the implant more medi-  ally towards the infero-lateral orbital margin and great  care should be taken to avoid perforation into the infero-  lateral aspect of the orbit. This uprights the implant  and brings the restorative head into the first molar site  instead of the second premolar site (Figure 14.3).   The lateral wall of the sinus is engaged by the implant as  far laterally as possible to obtain the most lateral position  of the implant in the sinus wall. The head of the implant in  the maxillary alveolus is placed as close to the mid-alveolar  position of the ridge as possible (Figure 14.4).    Placement of zygomatic implants is usually performed  under general anaesthesia. A crestal incision is made  extending from 1 cm in front of the maxillary tuberosity  to the same position on the contra-lateral side. Periosteal  elevation results in the exposure of the entire maxilla,  around the base of the piriform aperture, up to the infe-  rior aspect of the infraorbital nerves and exposing finally  the inferior aspect of the body of the zygoma bilaterally.   A round bur is then used to create a lateral window in the  supero-lateral aspect of the maxillary antrum, with sinus    mucosa reflection. Using a round burr, the proposed point  of entry of the fixture into the zygomatic bone is demarcated  through the sinus window (Figures 14.2, 14.5 through 14.7).    The final site preparation follows the graded pilot and  twist drills. Care should be taken to not perforate the bony  orbit with subsequent disruption of the orbital contents  (Figures 14.8 and 14.9).   A zygomatic implant with a head angulation of 55°  (Southern Implants’, Irene, South Africa) is the  preferred implant as this improves the emergence profile  and decreases the buccal cantilever (Figures 14.10  and 14.11).   Final placement of the fixture is accomplished by ensur-  ing proper angulation of the implant platform by place-  ment of a guide pin into the implant and the fixture  rotation to ensure optimal position (Figure 14.12).    Standard protocol is two zygomatic implants placed pos-  teriorly with four paranasal implants and a fixed porcelain  fused to titanium prosthesis (Figures 14.13 and 14.14).    Reconstruction of hemi-maxillary defects in partially  dentate patients where there has been premolar and molar  loss often predisposes to sinus pneumatization with mini-  mal bone in this area for conventional implant placement.  Treatment options include a unilateral sinus graft or the  utilization of a hemi-zygomatic protocol with the place-  ment of one standard endosseous fixture and a zygomatic  in the posterior maxillary region (Figures 14.15 through  14.19).    Balshi et al. (2003) described the use of multiple zygomatic  implants in reconstruction of the atrophic maxilla and  proposed the use of up to three zygomatic implants per  quadrant. Our clinical experience has shown that using  only two zygomatic fixtures per quadrant has proved ade-  quate for the rehabilitation of the atrophic maxilla with    fixed or fixed hybrid prosthesis. An autogenous bone graft This allows for an arch of 10-12 teeth even in patients with  can be avoided and is advantageous as the patient is saved inadequate anterior width and height of bone (Figures  the morbidity and possible complications of a bone graft. 14.20 through 14.22).    Quad zygomatic implant placement is usually the place-  ment of two zygomatic implants into each side of the max-  illa, usually the first fixture placed into the premolar site  and the second into the canine or lateral incisor positions.  The surgical technique is as for standard zygomatic fixture  placement and a more palatal mucosal incision is made  to include an adequate band of attached mucosa (Figures  14.23 through 14.29).   Care should be taken to not perforate into the infero-  lateral aspect of the orbit with the implant body in the  canine site. Post-operative radiology is thus mandatory.   It is possible to immediately load these implants with  a fixed hybrid acrylic strengthened prosthesis, which  remains in place for the three to 4 months whilst healing  takes place (Figures 14.30 through 14.32).   This avoids a second procedure to expose the implants  4 months after placement. This has a cost implication  since hospital stay, theatre time and recovery time are  all reduced allowing the patient to be integrated back    into society quicker. After healing has taken place,  the temporary prostheses are replaced with fixed por-  celain fused to titanium prosthesis (Figures 14.33  through 14.34).    Tumour ablative surgery and trauma to the mid facial  complex involves structures integral to phonetics,  deglutition and mastication and makes reconstruction  both difficult and controversial. The surgery is complex  and involves sealing of the oral cavity from the nasal  cavity, reestablishment of the paranasal sinuses and res-  toration of the facial contour.! Dental rehabilitation is  also a massive functional and aesthetic consideration  that should be considered when planning the proposed  reconstruction.”    Several methods have been proposed for post-surgical  reconstruction.? Reconstruction depends on_ the  extent of the resultant bony and soft-tissue defect and  obturation requires a working relationship between the  surgical and prosthetic teams. The prosthetic design  has evolved over decades* and osseointegration has  revolutionized facial reconstruction in these cases. This  technology can mostly circumvent the need for vas-  cularized osseomyocutaneous grafts or these grafts in  combination with non-vascularized free bone grafts.  The advantage of endosseous implant rehabilitation over  vascularized free flaps is the ability of the surgeon being  able to inspect the resection cavity for recurrent disease.  Visual inspection for recurrences in today,s world is  trumped by interval radiographic assessment, with the  use of computerized tomography (CT), magnetic reso-  nance imaging (MRI) and positron emission tomog-  raphy (PET) scans. These investigations are costly, are  often unavailable to patients with recurrent disease and  make maxillary rehabilitation with endosseous implants  a more viable and inexpensive treatment modality. The  placement of endosseous implants facilitates prosth-  odontic rehabilitation, which allows for secure, aesthetic  and functional replacement of ablated hard and soft tis-  sues and minimizes the disadvantages of silicone bulbs,  obturators and dentures.   Patients requiring resection for oncology are subjected  to a standardized pre-operative radiological survey. This  includes routine orthopantomogram, occipito-mental  views, lateral cephalogram taken in occlusion and  CAT scan of the affected area and neck (Figures 14.35  and 14.36).   Incisional biopsy of the tumour is performed to obtain a  definitive histological diagnosis and tumour grading and  helps to establish the surgical and post-operative chemo-  therapeutic or radiotherapy protocols.   Where possible a stereolithographic acrylic model is  grown from the DICOM Format CT scanning data.  Resection surgery is simulated on this model and allows  for optimal implant positions and conformation of pros-  thetic design (Figures 14.5 through 14.7) and diagnostic  casts are modified according to the expected resection and  a surgical obturator prepared and a temporary obturator  made (Figures 14.37 through 14.40).   Further pre-operative reconstructive planning is also  carried out at this stage and with possible free vascular-  ized free flap or implant supported obturation techniques  decided upon using computer-generated reconstructive  techniques (Figure 14.41).   Airway management is achieved most often by trache-  ostomy. Extra-oral access to the tumour is achieved in    most cases by a modified Weber-Ferguson flap with a  wide soft-tissue resection margin and hemi-maxillectomy  (Figures 14.42 through 14.44). After tumour resection,  frozen sections of the resection margin are done to ensure  complete tumour excision.    The objective of implant placement is to ‘recreate’ the but-  tresses and processes of the maxilla allowing for appropri-  ate force distribution of the prosthetic rehabilitation with  the remaining facial skeleton. Both standard and zygo-  matic implants are used to and zygomatic implants (or  a modified zygomatic ‘oncology’ implant) allows for the  lowering of the restorative platform at least to the level of  the palate (Figures 14.45 and 14.46).   The zygoma fixture was modified for insertion into the  resection stump, with the soft-tissue portion of the implant  being a smooth machined surface (Southern Implants™,  Irene, South Africa) (Figures 14.47 and 14.48).   A low nasal antrostomy is performed at the floor of the  intact sinus allowing for drainage of the maxillary sinus  inferiorly as well as through the osteum (Figures 14.49  and 14.50). The zygoma fixture was modified for inser-  tion into the maxillary resection stump, with the soft  tissue portion of the implant being a smooth machined  surface (Southern Implants TM, Irene, South Africa)    (Figures 14.50 and 14.51) A low nasal antrostomy is per-  formed at the floor of the intact sinus allowing for drain-  age of the maxillary sinus inferiorly as well as though the  osteum.    The surgical obturator is modified intra-operatively after  implant placement to restore normal soft-tissue facial con-  tour over the resection site and guide soft-tissue healing.  This obturator is secured by two 15 mm trans-osseous  titanium screws in the remaining palate and supported by  the zygomatic implants on the affected side.    The Weber-Ferguson flap is closed with a two-layered  technique, and a naso-gastric feeding tube placed in the  contra-lateral nostril (Figure 14.51).    Position and angulation of zygomatic  fixtures within the zygomatic stump projected towards the  occlusal plane using the palatal height as a guide.    Position and angulation of zygomatic fix-  tures within the zygomatic stump projected towards the  occlusal plane using the palatal height as a guide.    Master casts are poured and mounted on an articulator by  using the jaw relation from the modified duplicate surgical    obturator. The super-structure and the interim obturator Interim obturator clipped onto fixed  are then fabricated (Figures 14.52 and 14.53). prosthesis.   Prosthodontic rehabilitation can be achieved with  an over denture protocol (examples are shown in Post-operative radiographs are taken to confirm the  Figures 14.54 and 14.55) or with fixed dento-alveolar ele- position of the implants within the bone and to ensure  ments and a separate removable implant supported obtu- that the prosthesis is firmly to the implants (Figures 14.59    The surgical site is monitored closely by both the oncolo-  gist and reconstructive teams for adequate post-operative  healing and long-term recurrence. Prosthetic maintenance  is ongoing, particularly in the first year, where soft-tissue    changes can be extensive. The obturators may require con-  tinual peripheral adjustment and oral hygiene training  is undertaken using brushing techniques and pulsating  irrigation.   Occasionally the patient may request that the removable  acrylic obturator be replaced with a soft tissue flap to com-  pletely close the oral from the nasal or antral environment.  This may arise due to persistent air, fluid and food escape  into the nasal cavity. In such cases, and once the patient  has been investigated for tumour recurrence and has been  found to be tumour free, a microvascular-free tissue may be  used to completely close the oral cavity from the nasal cav-  ity. The flap choices in these cases are either a radial forearm  or anterolateral thigh microvascular free flap based on the  facial artery on the resection side (Figure 14.60a-—c).    Oncology cases which present in the anterior maxilla  often require anterior maxillary and nasal resection in  order to resect the tumour. Rehabilitation in these cases  often requires the provision of a combined intra-oral and  extra-oral prosthesis (Figures 14.61 through 14.67).   Nasal prostheses are generally implant retained and a  modified placement technique can be done to achieve enough  anchorage to secure a nasal prosthesis. It involves the place-  ment of two standard zygomatic fixtures almost horizontally  in combination with standard implantology into the anterior  maxillary floor (Figures 14.68 through 14.70). Temporary prosthesis at resection.    The rehabilitation of the midface after a gunshot wound  to the face ablates structures which are in the path of the Radiograph of implants.    missile and the resultant facial deformities after gunshot  wounds to the face can create serious psychological and  aesthetic complications for the patients. Facial trauma  from gunshot wounds is common in many countries,  especially when sustained in war. Little has been pub-  lished about reconstruction following gunshot wounds  and other trauma to the face after anatomical disruption  of the maxillofacial complex akin to oncology resection  following hemi-maxillectomy and the treatment protocols  used to rehabilitate these patients are similar to oncology  reconstructions.   The area of cavitation which is produced between  the entrance and exit wounds produces both hard and  soft-tissue defects. There is a secondary missile effect of  the bone and fractured tooth fragments and soft tissue is  destroyed in the process. The initial treatment is aimed  at resuscitation of the patient with debridement of the  avulsed area and attempt to obtain soft-tissue closure and  repositioning and reduction of facial bone fractures with  titanium mini-plates (Figures 14.71 and 14.72).   Rehabilitation takes place roughly 3 months after ini-  tial repair of the hard and soft tissues. A full radiological  examination is undertaken and this gives the restorative  team the necessary information required to plan rehabili-  tation. 3D spiral CAT scan imaging is the most useful in  this regard (Figure 14.73).   Facial gunshot wounds usually traverse the midline  and the soft and hard tissue defects are best obturated  to restore facial harmony. Occasionally, bone grafts are  performed into the area and sort tissue defects are closed  prior to bone grafting. Implant placement is done using a  combination of standard and zygomatic implants and an  immediate loading technique is employed (Figures 14.74  through 14.90).   Almost all maxillary defects resulting from anatomical  disruption of the maxillofacial complex can be particularly  well rehabilitated functionally and aesthetically using this    Figure 14.76 Intra-oral view of defect. Figure 14.79 Interim fixed prosthesis.    CAT scan of gunshot of low-velocity bullet. Gunshot reconstruction by zygoma implants.    The placement of extra-oral implants to replace missing  ears, eyes and cranium are accomplished with the place-  ment of small length implants, which are placed into very    The posterior maxilla has limitations in the extent of dense regions of the frontal bone, supra orbital margin  the maxillary sinus and the tuberosity and pterygoid and temporal bone (Figures 14.92 through 14.94).   plate region is an alternative to sinus lifting procedures. Auricular implants are placed into the temporal bone,  The placement of a cone-shaped implant into this region roughly 20-22 mm behind the external auditory meatus  requires the correct angulation and is placed into the max- and orbital implants into the supra orbital margin. These  illary tuberosity and angulated up the posterior wall of implants are usually about 4-5 mm in length and are splinted  the maxillary antrum. This is technically demanding, has by a titanium Dolder bar, onto which the auricular or orbital    limited access and has an 85% success rate (Figure 14.91). prosthesis is attached (Figures 14.95 through 14.99).    Tumours of the craniofacial region can result in often gro-  tesque facial disfigurement as a result of surgical interven-  tion and subsequent radiotherapy. Treatment often alters  the life-supporting functions of mastication, speech due to  the excision of the bony and soft-tissue facial skeleton.  Conventional reconstructive techniques can be time  consuming, relatively inaccurate and sometimes inva-  sive. The advent of 3D CT greatly enhances diagnosis and    treatment planning of craniofacial reconstruction and its  rehabilitation. This technology has been enhanced more  recently with the advent of CT manipulation and virtual  surgical planning. The use of this software can enhance  reconstruction by reducing clinical time and is therefore  cost effective, less invasive and more accurate.   The complexity of the surgery dictates the extent of the  pre-operative planning and the reconstructive plan can be  exported to a rapid prototyping platform, which further  enhances the 3D platform to a tactile 3D model (Figures  14.100 through 14.102).    Hemi-maxillectomy or total maxillectomy causes com-  plex defects in the maxilla, the zygoma and palate, orbital  floor, maxillary sinus, alveolar bone and mucosa. These  defects can have severe functional and cosmetic conse-  quences and resection, whether it is due to oncology or  ablation has to adequately reconstruct and rehabilitate the  patient both aesthetically and functionally.   The main aim of complex midface reconstruction  should recreate facial aesthetic appearance and symmetry,  improve mastication and to obliterate any communication  between the orbit, oral cavity and nasopharynx. Defects  have traditionally been managed using a large dental  obturator prosthesis, which can be an excellent and defini-  tive treatment for some patients. However, with the advent  of microvascular free tissue transfer, rehabilitation of the  maxilla and mandible has become possible with osseous  free flaps, which allow for implant borne dentition.   Bone from numerous osseous donor sites, such as the  scapula, radius, iliac crest, rib and fibula, has been used  for reconstruction of maxillary defects. The free vascular-  ized fibula flap has become the most popular because of its  length and acceptance of dental implants.   The use of virtual planning and rapid prototyp-  ing is increasingly popular in reconstructive surgery,    particularly in complex anatomical reconstructions.  Rapid prototyping facilitates the manufacture of 3D mod-  els and templates that allow the surgeon to plan the pro-  cedure before surgery, thereby closing the gap between  pre-operative planning and surgical resection and reha-  bilitation. Medical CAT scan DICOM data is utilized to  manufacture the stereolithographic templates, which help  the surgeon to accurately plan the operative resection and  subsequent rehabilitation (Figures 14.103 and 14.104).   Prior to surgery, a rapid prototyped stereolithographic  model template is manufactured to help determine the  planned lengths and angles of the fibula osteotomies, as  well as the position and angulation of the dental implants,  which are to be placed into the fibula (Figure 14.105).   The 3D digital model allows for the fabrication of a 3D  stereolithographic model, which also facilitates the pre-  positioning and pre-bending of the pre-bent titanium  bone plates. The pre-bent plates are then sterilized and  this significantly reduces theatre time at time of surgery  (Figures 14.106 and 14.107).   The surgical template was fixed to the fibula using  osteosynthesis screws after which the dental implants were  inserted into the fibula with the pedicled blood supply still  attached (Figures 14.108 and 14.109).   An innovative designed implant (X-type Implant;  Southern Implants™, Irene, South Africa) for insertion  into the fibula is used and a restorative guide is used to  correctly position the implants into their correct position  (Figures 14.110 and 14.111).    (a and b) Digital fibula cutting guide and  rapid prototyped drilling guide.    The surgical template of the fibula assists and guides  the surgeon with the insertion of dental implants, which  are placed in the free fibula graft prior to resection and  the planned osteotomies. Positioning guide prior to pedicle division.    The osseomyocutaneous flap is then fixed to the pre-  bent titanium reconstruction plate and placed in the exact  pre-planned position at the recipient site and fixed with  osteosynthesis screws (Figures 14.112 and 14.113).   The stereolithographic dental guides are then removed  and abutments are placed into the implants. The closure of  the surgical site is then affected and the patient transferred  to the intensive care unit for post-operative monitoring  (Figures 14.114 and 14.115).   After healing, the implants are exposed together with  soft-tissue pre-prosthetic surgery to reduce the bulk of the  skin paddles inside the oral cavity and the implants are  restored using conventional implant-supported crown and  bridgework (Figure 14.116).   In conclusion, virtual digital planning and rapid pro-  totyping are a valuable and precise technique for large  reconstructions of complex anatomical sites. Virtual  planning and rapid prototyping provides a method  to accurately evaluate the anatomy of a defect with  optimized pre-surgical planning. The accurate pre-  planning of bony osteotomies and optimized fit of the  graft without further need for osseous adaption signifi-  cantly reduces surgical time and also produces a highly  predictable outcome of surgery.    e Stereolithographic models are essential for planning.  e With implant retained prostheses, implants are often a  better option than surgical reconstruction.    The authors wish to acknowledge the contribution made  by Southern Implants™ in the development of the zygo-  matic oncology and x-type implants.    1. Malevez C, Daelemans P, Adriaenssens P and Durdu F.  Use of zygomatic implants to deal with resorbed pos-  terior maxillae. Periodont. 2000; 33: 82-89.   2. Boyes-Varley JG, Howes DG, Lownie JF and  Blackbeard GA. Surgical modifications to the  branemark zygomaticus protocol in the treatment  of the severely resorbed maxilla: A clinical report.  J Oral Maxillofac Implants. 2003; 18: 232-237.   3. Balshi TJ, Wolfinger GJ and Petropoulos VC.  Quadruple zygomatic implant support for retreat-  ment of resorbed iliac crest bone graft transplant.  Implant Dent. 2003; 12(1): 47-53.   4. Boyes-Varley JG, Howes DG, Davidge-Pitts KD,  Branemark P-I and McAlpine AJ. A protocol for  maxillary reconstructions following oncology resec-  tion using zygomatic implants. Int J Prosthodont.  2007; 20: 151-161.    Bothur S, Jonsson G and Sandahl L. Modified technique  using multiple zygomatic implants in reconstruction  of the atrophic maxilla: A technical note. Int J Oral  Maxillofac Implants. 2003; 18: 902-904.    Branemark P-I, Svensson S and Van Steenberghe D. Ten  year survival rates of fixed prostheses on four or six  implants ad modum Branemark in full edentulism.  Clin Oral Implants Res. 1995; 6: 227-231.   Brown JS, Jones DC, Summerwill A, Rogers SN, Howell RA,  Cawood JL et al. Vascularized iliac crest graft with  internal oblique muscle for immediate reconstruction  after maxillectomy. Br J Oral Maxillofac Surg. 2002;  40: 183-190.   Lekholm U, Wannfors K, Isaksson S and Adielsson B. Oral  implants in combination with implants. A 3 year retro-  spective multicenter study using the branemark implant  system. Int J Oral Maxillofac Surg. 1999; 28: 181-187.   Liu XJ, Gui L, Mao C, Peng X and Yu GY. Applying com-  puter techniques in maxillofacial reconstruction  using a fibula flap: A messenger and an evaluation  method. J Craniofac Surg. 2009; 20: 372.   Mustafa AR, Adams Jr. WP, Hartog JM, Rohrich RJ and  Byrd HS. Maxillary reconstruction: Functional and  aesthetic considerations. Plast Reconstr Surg. 1999;  104: 2172-2183.   Okay DJ, Genden E, Buchbinder D and Urken M.  Prosthodontic guidelines for surgical reconstruction of  the maxilla; a classification system of defects. J Prosthet  Dent. 2001; 86: 352-363.   Smolka W and Iizuka T. Surgical reconstruction of maxilla  and midface: Clinical outcome and factors relating to  postoperative complications. J Craniomaxillofac Surg.  2005; 33: 1-7.   Ten Bruggenkate CM and van den Bergh JP. Maxillary sinus  floor elevation: A valuable pre-prosthetic procedure.  J Periodontol 2000. 1998; 17: 176-182.   Urken ML, Bridger AG, Zur KB and Genden EM. The  scapular osteofasciocutaneous flap: A 12-year expe-  rience. Arch Otolaryngol Head Neck Surg. 2001; 127:  862-869.    In order for oral and maxillofacial surgery to advance as  a specialty, we must continuously investigate new treat-  ment options. Over the past quarter of a century, the  scope of tissue engineering has exploded in an attempt to  provide solutions to improve hard and soft-tissue heal-  ing. Restoring three-dimensional (3D) form and function  is of utmost importance through reconstruction of tissue  defects, and tissue-engineered products can minimize  morbidity associated with the harvest of autogenous soft  and hard tissue grafts. Materials and techniques con-  tinue to evolve and many are being investigated to be  able to provide unique alternatives to the oral and maxil-  lofacial surgeon in the near future. Soft-tissue constructs  attempt to decrease scar tissue formation and maximize  our innate healing potential. Recently, muco-cutaneous  (M/C) grafts have been successfully fabricated for lip  reconstruction. Regeneration of osseous, and carti-  lagenous tissues require the use of engineered scaffold  constructs fabricated from various materials with the  combination of numerous biological factors. In addition,  investigation into regeneration of craniomaxillofacial  structures is on the rise, and some have even evaluated  prefabricated free vascularized hard tissue grafts for use  in maxillofacial reconstruction.    Oral mucosa and skin are the most common autogenous  soft-tissue grafts used for preprosthetic surgery and resur-  facing of oral mucosal defects. Both require a second sur-  gical donor site resulting in significant patient morbidity.  Oral mucosa is limited in supply while the functional  and aesthetic outcomes of skin grafts are often unfavour-  able. Skin and oral mucosa substitutes prevent donor site  morbidity, provide more therapeutic options and accom-  plish better outcomes than conventional therapies in  reconstructive surgery. One method of creating a tissue-  engineered soft-tissue substitute is through the manu-  facture of an ex vivo produced oral mucosa equivalent  (EVPOME) in which an epithelial layer of autogeneous    oral keratinocytes is developed and grown on AlloDerm®  (LifeCell, Branchburg, New Jersey), an acellular, non-  immunogenic, human cadaver dermis (Figures 15.1 and  15.2). AlloDerm® confers excellent handling characteris-  tics resulting in a supple nature to the grafts, and is a tissue  product well established in the field of oral and maxillo-  facial surgery. The EVPOME graft is then used for recon-  struction of the desired soft-tissue defect by suturing it in  place over a recipient bed with adequate blood perfusion to    Figure 15.1 Package of AlloDerm, 3 cm x 7 cmin size (top);  inner pouch (bottom). The author prefers the thinnest piece  (0.009-0.013 inches, 0.22—0.33 mm).    allow rapid vascularization of the graft to occur. EVPOME  is utilized as a full-thickness oral mucosa substitute and  has characteristics of keratinization identical to that of  native oral mucosa (Figure 15.3). As an advanced appli-  cation of this EVPOME fabrication technique, we devel-  oped another technology growing human oral and skin  keratinocytes into a 3D construct to form a M/C junction  containing stratified oral mucosa and stratified skin on  the same AlloDerm® (Figure 15.4).   Ideally, a number of principles must be adhered for  proper success of a soft-tissue graft:   2. The graft must not be placed on bare cortical bone.   3. Stabilization and immobilization allows for vessel  inosculation from underlying capillary network.   5. Bolsters or surgical stents acting as a pressure dressing  must be used to ensure hematoma formation is avoided  under the graft.    The patient is usually scheduled four weeks prior to the  desired reconstructive surgery in order to harvest a biopsy  of the oral mucosa. A tissue punch provides adequate num-  ber of compatible keratinocytes to manufacture EVPOME  grafts prior to transplantation, while causing minimal  morbidity. Palatal tissue provides a keratinized mucosa  equivalent, while the retromolar pad or buccal mucosa  provides non-keratinized mucosa equivalent. The patient  is anesthetized using local infiltration techniques. A small  4-6-mm split thickness punch biopsy is performed to  the level of the dermis (Figure 15.5). At the palate, local  haemostasis is obtained with pressure, and the wound is  dressed with a haemostatic collagen material stabilized  with a figure-eight suture. At the retromolar area or buccal  mucosa, the wound is closed primarily. The harvested tis-  sue is transferred into a culture medium and transported  into the laboratory.    Figure 15.2 Tissue punch is used to isolate keratinocytes which are then cultured and seeded onto a basement membrane of    Figure 15.3 Haematoxylin and eosin stains of ex vivo produced oral mucosa equivalent graft at days 11 and 18, demonstrating    Figure 15.5 Oral mucosa keratinocytes in culture are  poised to be seeded on to AlloDerm.    The manufacturing and culturing procedures of the  EVPOME have been described in detail elsewhere. Briefly,  oral keratinocytes are dissociated by soaking the harvested  biopsy tissue in 0.04% trypsin solution. The cells are grown  in a culture medium free of bovine serum, mouse feeder-  cells and pituitary extracts. The lack of foreign xenogenic  cells avoids any cross contamination or immunization.  Following growth of a sufficient number of keratinocytes  over 2 weeks (F 5.6), cells are seeded onto pieces of  type IV collagen presoaked AlloDerm® (cells are seeded  on the roughened basement membrane side). For the first  4 days, a composite of keratinocytes and AlloDerm® is  incubated in a submerged culture. For the next 7 days, the    Figure 15.6 Rehydrated AlloDerm is soaked in human  type IV collagen ensuring that the epidermal side (retained  intact basement membrane) is positioned uppermost. A com-  posite of oral keratinocytes and AlloDerm is then submerged  in culture and transferred to an air-liquid interface.    composite is raised at an air-liquid interface culture. Upon  reaching day 11 after seeding the dermis with keratino-  cytes, the EVPOME grafts are ready to transplant (  Preparation of the recipient bed is created through  conventional surgical procedures such as vestibuloplasty  and tumour excision. These basic procedures are found in  and 19, respectively. Vestibuloplasty is often  used to create an appropriate environment for the place-  ment of implants or denture support in case of insufficient  vestibular depth and/or complete loss of a keratinized    Thick unattached oral mucosa overlying  posterior alveolar ridge is an impediment for dental implant  success and must be corrected prior to endosseous implant  placement.    Split thickness supraperiosteal dissection to  the desired vestibular depth with the leading margin tacked to  the underlying periosteum with sutures.    (attached, immobile) gingival (Figure 15.8). A supraperi-  osteal split thickness dissection is made with a scalpel or  metzenbaum scissors. The tissue is then pushed apically  to the desired height of vestibule and then sutured to the  underlying periosteum (Figure 15.9).   For cases of tumour excision, such as the lateral bor-  der of the tongue, it is common to place a soft-tissue graft  for suitable healing. Appropriate margins surrounding  the tumour are inked (Figure 15.10), and tissue is incised  using electrocautery. Haemostasis is achieved most com-  monly using electrocoagulation and rarely with ligation to  maximize preservation of the vascularity of the recipient  site (Figure 15.11).   The EVPOME is then trimmed to the desired size and  shape using a sharp no. 10 blade scalpel rotating over the  belly of the blade without pulling or dragging the blade,  to avoid disruption of the keratinocyte cell layer. In the    Tumour to the right lateral border of the  tongue (squamous cell carcinoma T2NOMO) with inked mar-  gins. (From Wakita M et al., Oral Histology and Embryology,  Ishiyaku Publishers, Tokyo, 2006. With permission.)    Wide local excision using electrocautery.  (From Wakita M et al., Oral Histology and Embryology, \shiyaku  Publishers, Tokyo, 2006. With permission.)    process of handling the grafts for reshaping and suturing,  one should be careful to avoid touching and rubbing the  EVPOME surface (Figure 15.12). Only blot dry the graft  with sterile cotton gauze being as atraumatic as possible,    Six pieces of ex vivo produced oral mucosa  equivalent are sutured over the wound bed in place. (From  Wakita M et al., Oral Histology and Embryology, \|shiyaku  Publishers, Tokyo, 2006. With permission.)    A bolster of antibiotics-soaked gauze is  used to apply pressure to the ex vivo produced oral mucosa  equivalent grafts for prevention of haematoma formation.  (From Wakita M et al., Oral Histology and Embryology, \shiyaku  Publishers, Tokyo, 2006. With permission.)    avoiding any wiping motion. EVPOME grafts are placed  with the Alloderm® side down over the recipient bed and  fixed in place to the surrounding mucosa with 4-0 silk ona  cutting needle. The graft is secured within the defect using  interrupted sutures cut short to the knot. Long uncut  marginal sutures opposing one another are tied over a  bolster of antibiotic-soaked gauze to apply pressure to the  defect to minimize dead space and hematoma formation  (Figures 15.13 through 15.16). For vestibuloplasties, a rigid  surgical stent can be created pre-operatively, and secured  in place intraorally with miniscrews or circumosseous  wires (Figure 15.17). The gauze bolster and sutures are  removed at post-op day 7 after grafting. The underlying  EVPOME grafts possess a characteristic red hue indicative  of early revascularization (Figure 15.18). After a period of  4 months, the graft will have integrated and will possess  adequate keratinization to allow for implant placement  (Figure 15.19).    Two pieces of ex vivo produced oral mucosa  equivalent configurated and sutured in place to the left poste-  rior alveolar ridge.    Healing ex vivo produced oral mucosa  equivalent grafts 7 days following placement demonstrating  early vascularization from the underlying tissue.    Figure 15.17 Conversely, grafts can be secured with a  surgical resin stent lined with tissue conditioner to avoid  pressure areas.    Figure 15.18 Incision made 4 months post-operatively  revealing healthy attached gingiva acceptable for implant  placement.    A complex structure of the face to reconstruct after surgery  or trauma/avulsion is the lips because they represent a  composite tissue of mucosa, skin and muscles. Since the  neuromuscular control of normal lip structures is required  for activities of eating, drinking, talking and social  gestures, significant loss of lips is a functional and aesthetic  concern for injured individuals. The fabrication of a M/C  tissue engineered construct in vitro has been recently  successful in our research laboratory (Figure 15.4). The  approach presented in the tissue-engineered lips will have  several advantages for the reconstruction of craniofacial    Figure 15.19 Patient is imaged using computed tomogra-  phy or magnetic resonance imaging.    soft-tissue injuries. In particular, the source of the cells to  develop the 3D lip constructs will come from small punch  biopsies from the oral mucosa and skin of the patient, thus  making the construct autologous. This 3D lip construct  contains all functional areas of the epithelium of the  human lip and can be used as the basis for the fabrication of  vascularized prelaminated flaps for full lip reconstruction  or for repair of the lips when both the oral and epidermal  areas require tissue replacement. Prelamination designates  a reconstructive process whereby a 3D structure is built at  a remote site by laminating different layers of components,  epithelium, dermis and muscle, as composite grafts into a  reliable existing axial vascular bed, allowing the structure  2-3 weeks to mature before transferring the unit en bloc  to the defect. In addition, this technique can be extended  to other anatomic areas for the repair of tissues where a  M/C junction is present, including the nares, eyelids and  urogenital system with the surgical procedures to create  prefabricated flaps with their own blood supply.    The underlying hard tissues offer the framework for  overlying facial aesthetics, as defects in osseous and car-  tilaginous tissues are visibly portrayed through the soft  tissues. Classically, significant morbidity and deformity is  traded in a distant donor area for reconstruction of cra-  niofacial structures. Allogeneic grafts are available; how-  ever, in order to achieve minimal immunologic response,  all cellular tissues are removed reducing the potential for  reliable integration. Lastly, alloplastic materials are at risk  for foreign body reaction, with significant inflammation  and increased risk of infection. Tissue-engineered scaf-  folds have been created to capitalize on a patient’s innate    healing response while adding specific factors at the  local site to attempt to improve hard tissue regeneration.  Tissue engineering has explored a number of materials  for creation of scaffolds including polymers, ceramics and  composites. Polymers (polylactic acid, polyglycolic acid,  polycaprolactone, polypropylene fumarate) have variable  properties and offer reliable biodegradation. More perma-  nent ceramics (hydroxyapetite, tricalcium phosphate) can  be used alone, but are frequently combined with polymers  in composite grafts. Composites can also include biofac-  tors such as purified concentrated growth factors, trans-  duced cells with various viral vectors, and autogenous  bone marrow cells.   Ideally, a number of principles must be adhered to prior  to the fabrication of any tissue-engineered scaffold for  replacement into osseous defects.   . Bioresorbable, allowing native structures to assume  load bearing as they degrade    The surgeon will often obtain pre-operative imaging to  determine the extent of the current or surgically cre-  ated defect. CT, both conventional and cone beam, as    Figure 15.20 Using image processing software, data set  reconstructed into three-dimensional image for treatment  planning.    well as magnetic resonance imaging can be used for this  purpose depending on the structures being evaluated  (Figure 15.4). The patient’s data set is captured on file  and a 3D image is rendered for treatment planning using  a variety of image processing software (Figure 15.20).  Depending on the location, shape and size of the defect,  an ideal scaffold template contour can be created  de novo electronically by virtual design, or by reversing  the data from the patient’s normal contralateral side  (Figures 15.21 and 15.22). Image software includes    Figure 15.22 Using image-based design, mandibular  condyle can be created to specific dimensions based on the  treatment plan or replicated from the normal contralateral  condyle. The remainder of the scaffold developed with well-  adapted overlying sleeve to secure the condyle in place.   ) and MATLAB® ( s  Once the template is created through a mapping data  set, the microstructure of the scaffold is then created  with a porous architecture database. Various micro-  structures can be applied based on the material used  and mechanical properties desired to attempt to pro-  mote growth of either cartilaginous or osseous tissues.  Mathematically designed interconnecting porous cylin-  ders and interconnecting porous spheres are two exam-  ples (F ) where effective modulus (strength)  and porosity are inversely proportional .  Additionally, shells without internal microstructure can  offer delivery of well-contained bone marrow directly  to the defect while minimizing load-bearing capabili-  ties. Portions of the scaffold are extended beyond the  defect and dilated over adjacent native bone for secur-  ing the scaffold once implanted. A scaffold is then fab-  ricated using solid free-form fabrication techniques  such as fused deposition modelling, stereolithography    Figure 15.23 Sphere (upper left) and cylinder (upper  right) unit cells can be used to create microstructure to por-  tions of the scaffold.    or selective laser sintering (SLS) . SLS is  a rapid prototyping method that offers layer-by-layer  fusion of particles to create complex geometric shapes,  as well as intricate microstuctures with porous spaces  that can be smaller than 1 mm. Virus-transfected cells  and biofactors can be directly linked to the scaffold  structure using various culture media and techniques  described elsewhere ( 6). Conversely, at the    Figure 15.24 Scaffolds can be created to replace complex  three-dimensional shapes with localized areas of microstruc-  ture and an attached sleeve to secure to native bone.    Figure 15.26 Various biologics can be used for creation  of composite scaffolds. Concentrated recombinant bone mor-  phogenetic proteins, viral transfected cells, bone marrow  osteoprogenitor stem cells and harvested cancellous bone  marrow are some examples.    Figure 15.27 Bone marrow is aspirated from the anterior  iliac crest to harvest osteoprogenitor stem cells.    time of surgery, bone marrow stromal cells can be har-  vested and isolated from aspirates and inserted directly  into the scaffold immediately prior to implantation  (Figure 15.27).    Figure 15.28 Scaffolds can be created to correct complex  geometric shapes of the craniomaxillofacial complex.    Specific structures that have been attempted for  regeneration include mandibular condyles, orbital rims  and segmental defects in the mandible (Figure 15.28).  The scaffolds themselves are of varying size and shape  to fill the defect as precisely as possible. Based on the  area of interest, standard surgical techniques are used  as discussed in Section III. Wide exposure of the bone  and cartilaginous tissues is performed through eleva-  tion and retraction of subperiosteal tissues, being care-  ful to avoid excessive trauma to the overlying mucosa  and periosteum. In cases of trauma or developmental  deformity, the defect is isolated, and an acceptable tis-  sue bed for placement of the scaffold is created in order  to ensure appropriate primary closure of the tissues.  Conversely, in cases of pathological resection, pre-  surgical evaluation determines approximate margins  which may change at the time of surgery depending  on the specimen resected. The scaffold may need to be  trimmed partially in order to fit into the defect precisely.  Bone marrow can be harvested from the hip either  by conventional exposure as described in Chapter 13,  or using a microaspiration device. Bone marrow stro-  mal cells can be isolated using a microfluidic device, or  cancellous marrow spicules can be crushed with mor-  tar and pestle, and cells or small cancellous fragments  can be injected within the scaffold porosities (Figure  15.29). Miniplates and screws are used to secure the  scaffold to the native bone to ensure four-point stabi-  lization. In order to advance the tissues over the scaf-  fold to obtain primary closure, the periosteum is cross    Figure 15.29 Cancellous bone marrow, harvested via a  conventional surgical approach, is packed into the hollow shell    hatched using a scalpel (Figure 15.30). Metzenbaum  scissors can also be used to dissect the tissues for larger  advancements. The overlying tissues are closed primar-  ily in layers using interrupted sutures. Horizontal mat-  tress sutures may be used to release tension if tissues are  tight to close.    A multidisciplinary team approach utilizing the services  of oral and maxillofacial surgeons, biomedical and  mechanical engineers, radiologists and adjunct scien-  tists is necessary for proper investigation and fabrica-  tion of tissue engineered materials.   Soft-tissue defects have the potential to be recon-  structed with minimal morbidity with the use of com-  bination grafts.   Computer-engineered scaffolds have the ability to  be combined with various biological components to  attempt to improve regeneration of osseous and car-  tilaginous tissues.    Figure 15.30 In animal models, following condylectomy, a well-adapted condylar-ramus scaffold is secured in place using    Coppit GL, Lin DT and Burkey BB. Current concepts in  lip reconstruction. Curr Opin Otolaryngol Head Neck  Surg. 2004; 12: 281-287.   Hokugo A, Sawada Y, Sugimoto K, Fukuda A, Mushimoto  K, Morita S et al. Preparation of prefabricated vascu-  larized bone graft with neoangiogenesis by combina-  tion of autologous tissue and biodegradable materials.  Int J Oral Maxillofac Surg. 2006; 35: 1034-1040.   Hollister SJ, Lin CY, Saito E. Lin CY, Schek RD, Taboas  JM et al. Engineering craniofacial scaffolds. Orthod  Craniofac Res. 2005; 8: 162-173.   Hollister SJ, Maddox RD and Taboas JM. Optimal design  and fabrication of scaffolds to mimic tissue properties  and satisfy biological constraints. Biomaterials. 2002;  23: 4095-4103.   Hutmacher DW. Scaffold design and fabrication tech-  nologies for engineering tissues-state of the art and  future perspectives. J Biomater Sci Polym Ed. 2001; 12:  107-124.   Izumi K, Feinberg SE, Iida A and Yoshizawa M. Intraoral  grafting of an ex vivo produced oral mucosa equiva-  lent: A preliminary report. Int J Oral Maxillofac Surg.  2003; 32: 188-197.   Izumi K, Neiva RF and Feinberg SE. Intraoral grafting of  tissue-engineered human oral mucosa. Int J Oral  Maxillofac Implants. 2013; 28: e295-303.   Izumi K, Song J and Feinberg SE. Development of a  tissue-engineered human oral mucosa: From the    bench to the bed side. Cells Tissues Organs. 2004;  176: 134-152.   Mikos AG, Herring SW, Ochareon P, Elisseeff J, Lu HH,  Kandel R et al. Engineering complex tissues. Tissue  Eng. 2006; 12: 3307-3339.   Peramo A, Marcelo CL and Feinberg SE. Tissue engineer-  ing of lips and muco-cutaneous junctions: In vitro  development of tissue engineered constructs of oral  mucosa and skin for lip reconstruction. Tissue Eng  Part C Methods. 2012; 18: 273-282.   Rohner D, Hutmacher DW, Cheng TK, Oberholzer M and  Hammer B. In vivo efficacy of bone-marrow-coated  polycaprolactone scaffolds for the reconstruction of  orbital defects in the pig. J Biomed Mater Res B Appl  Biomater. 2003; 66: 574-580.   Schek RM, Wilke EN, Hollister SJ and Krebsbach PH.  Combined use of designed scaffolds and adeno-  viral gene therapy for skeletal tissue engineering.  Biomaterials. 2006; 27: 1160-1166.   Smith MH, Flanagan CL, Kemppainen JM, Sack JA,  Chung H, Das S et al. Computed tomography-based  tissue-engineered scaffolds in craniomaxillofacial  surgery. Int J Med Robot. 2007; 3: 207-216.   Teot L, Cherenfant E, Otman S and Giovannini UM.  Prefabricated vascularized supraclavicular flaps for  face resurfacing after postburns scarring. Lancet.  20003355: 1695-1696.   Wakita M et al. Oral Histology and Embryology. Tokyo:  Ishiyaku Publishers; 2006.    There are relatively few ‘life- or limb-threatening’ emer-  gencies in oral and maxillofacial surgery (OMFS) and  as a result wide experience of dealing with them is rela-  tively sparse. This chapter is aimed at giving a ‘hands-  on text of how to assess and perform these procedures.  Because OMFS is a very specialized field, physicians  from other specialties are likely to have even less experi-  ence in dealing with these problems and it is therefore  essential that OMFS surgeons should be trained and  competent to deal with these emergencies should they  occur.   The indications for an emergency surgical airway are  failure to provide a definitive airway by either an oro-  or nasotracheal approach. A disrupted airway would  indicate maxillofacial trauma, while an obstructed air-  way would indicate the presence of a foreign body. This  may be either as a result of the airway being disrupted  or obstructed. Severe maxillofacial trauma, with sig-  nificant disruption of the midface anatomy and asso-  ciated profuse haemorrhage occasionally may make    standard endotracheal intubation impossible, even by an  experienced anaesthetist. If it is impossible to oxygenate  the patient and protect the airway by other means, then  an emergency surgical airway must be performed. All  procedures described should be performed using univer-  sal precautions.   There are only two emergency surgical airways proce-  dures, which are as follows:    In children, the same procedures must be carried out,  using the same techniques. Emergency tracheostomy is  fraught with the same dangers and difficulties in children  as in adults and needle and surgical cricothyroidotomies  are quicker, more straightforward and therefore less risky  procedures.    Needle cricothyroidotomy is performed as an absolute  emergency on a patient dying from hypoxia and is carried  out when oxygenation and protection of the airway is fail-  ing by conventional means.   If the patient is in the resuscitation room, with cervi-  cal collar, sandbags and tapes to immobilize the cervical  spine, it is easier to carry out this procedure if these are  removed and an assistant performs in-line cervical immo-  bilization supporting the head.    The cricothyroid membrane is identified by finding the  superior end of the thyroid cartilage (Adam’s apple) and  sliding down the thyroid cartilage in the midline. The fin-  ger drops in to the cricothyroid membrane. Confirmation  that this is the cricothyroid membrane is made by carry-  ing on down to the hard cricoid cartilage (Figure 16.1).   Unfortunately, if there is any risk of cervical spine  injury the neck must not be extended.   Wipe the skin with an alcohol wipe; attach a 10-mL  syringe, with 1 mL of air in it, to the large-bore (12-14G)  venflon and pass it through the cricothyroid membrane,  aiming 45° inferiorly (Figure 16.2). There is a ‘give’ as  the needle goes through the membrane, which is quite  superficial. Eject the air and skin-plug from the syringe  and aspirate the syringe. Getting air back shows the  needle must be in the trachea. Slide the venflon in,  sliding out the trocar - just like putting a venflon into  a vein.   6. 12G venflon with 10-mL syringe with 1 mL of air in it   9. Remove trocar, connect to oxygen supply at 15 mL/min  10. Y-connector (or hole in tube) 1 second on, 4 seconds off  11. Monitor oxygen saturations  12. Prepare for surgical cricothyroidotomy    The connecting tube must have a Luer-type lock to  attach to the venflon at one end, a Y-connector (or just cut  a hole in the tubing) in the middle and a connector at the  other end to attach to the oxygen cylinder or wall oxygen  supply. The oxygen should be running at 12-15 L/min. Put  a finger over the hole in the tubing in a ratio of 1 second on  and 4 seconds off.   Jet insufflation via needle cricothyroidotomy can pro-  vide adequate oxygenation but unfortunately does not  enable sufficient ventilation and there will therefore be a  gradual rise in the pCO). It also does not protect the air-  way. Although theoretically a needle cricothyroidotomy  with jet insufflation may give 30-40 minutes before the    Figure 16.1 Needle cricothyroidotomy. Insertion of large-  bore venflon at 45° caudally, in the midline, into the trachea.  Inline immobilization of cervical spine by assistant.    pCO, rises to a critical level, it should only be looked upon  as a very temporary (life-saving) measure before conver-  sion to a surgical cricothyroidotomy.   This may enable time for a more experienced surgeon to  arrive, but the time should anyway be spent preparing the  necessary equipment.   In the case of a patient with severe maxillofacial trauma  and a head (brain) injury, management of the following  must be aimed at    1. Preventing any rise in pCO, which would exacerbate the  brain injury  2. Protecting the airway from the associated haemorrhage    Surgical cricothyroidotomy  As soon as the oxygen saturation starts to rise follow-    ing the needle cricothyroidotomy, confirming that oxy-  gen is reaching the lungs, equipment must be collected    to convert this to a surgical cricothyroidotomy, with an  inflated cuffed tube protecting the airway.   Local anaesthetic with vasoconstrictor (lidocaine 2%  with adrenaline 1:100,000) should be infiltrated around  the area so that this can be working while the necessary  equipment is gathered (Figure 16.3) and an experienced  surgeon is called.    . Local anaesthetic - lidocaine 2% + adrenaline 1:100,000  . Scalpel with No. 11 blade    Surgical cricothyroidotomy is a more controlled proce-  dure and the skin should be properly prepared with anti-  septic and local anaesthetic with vasoconstrictor given to  make the procedure easier. It also protects against the risk  that the patient’s conscious level may rise as a result of  the improved oxygenation and also the pain associated  with a procedure not carried out with local anaesthetic.  An experienced surgeon may elect to go straight to sur-  gical cricothyroidotomy, bypassing the needle and jet  insufflation. It is important to familiarize yourself with  the equipment and to check the cuff on the tube before  proceeding.   Ifa needle cricothyroidotomy has been performed, once  the area has been cleaned with antiseptic, local anaesthetic  given and the necessary equipment is to hand, then con-  version to surgical cricothyroidotomy should be made.    Ideally, this should be within 5-10 minutes of the needle  cricothyroidotomy.   Remove the venflon - it is in the way, making the pro-  cedure more difficult and runs the risk of cutting it with  the scalpel if it is left in situ. Hold the skin under tension  and make a 3-cm horizontal incision so that the skin  edges part, revealing the membrane. Stab vertically down  with the blade through the membrane and draw the blade  towards you, making a hole approximately 1 cm long. Do  not twist the blade in your hand or turn the scalpel round  in your hand to use the handle to open up the membrane.  These risk either snapping the blade (the thyroid and  cricoid cartilages can become calcified) or sustaining a  sharps injury.   Put the scalpel down, pick up the tracheal dilator and  insert it into the cut membrane horizontally (so that it  engages against the inferior surface of the thyroid carti-  lage and the superior surface of the cricoid) and open it so  that the cut edges of the membrane are separated, expos-  ing the trachea.    1. In-line immobilization of head by assistant  2. Universal precautions  3. Prepare the skin with antiseptic and local anaesthetic +  vasoconstrictor  4. Tense the skin with finger and thumb  . Remove the cricothyroidotomy venflon  6. 3-cm horizontal incision through the skin so that skin  edges part  7. Stab vertically down through membrane and make  1-cm incision  8. Insert tracheal dilator (or curved haemostat) horizon-  tally and open it so that it separates the thyroid and  cricoid cartilages  9. Keep dilator in place. Insert Yankaeurs sucker to clear  trachea  10. Insert tracheostomy tube, remove introducer, inflate  cuff  11. Connect to Ambu-bag and oxygen supply  12. Assess oxygen saturation, end-tidal CO, and air-entry to  lungs  13. Fix tracheostomy tube with tapes or sutures    Suction out the trachea with the Yankaeurs sucker and  assess the trachea. Insert the tracheostomy tube into the  trachea. After removing the central introducer, inflating  the cuff and connect to an Ambu-bag and oxygen supply,  assess air entry to both sides of the chest and start to moni-  tor oxygen saturations and end-tidal CO,.   If all is well, then secure the tracheostomy tube with  either the tapes provided or sutures. If insertion fails then  either open up the trachea again with the dilator, apply  oxygen, suction and reassess or even go back to reinsert-  ing a venflon and further jet insufflation.    As the trachea passes caudally below the cricoid cartilage,  it becomes progressively posterior (deeper) and access to  the trachea becomes more difficult and hazardous both  because of poorer visibility and also the rich vasculature  of the area and the thyroid gland.   Neither of these techniques should therefore be con-  sidered as an emergency procedure. Ideally, they are  performed on an already endotracheally anaesthetized  patient, as an elective operation. This may be as a pre-  lude to major head and neck cancer surgery or before  definitive treatment of severe maxillofacial trauma,  enabling the airway to bypass the planned operative field.  Alternatively, they may be required for a patient on long-  term ventilation to enable bronchial toilet. Both tech-  niques provide a definitive airway - a cuffed tube in the  trachea.   Occasionally, an awake tracheostomy must be carried  out under local anaesthetic on a patient maintaining his  own airway (but in danger of losing it) where oro- or  naso-tracheal intubation cannot be performed. Severe  fascial-space infections, such as Ludwig’s angina, with  tense swelling of the tissues of the neck and around the  upper airway, often with associated trismus, make either  endotracheal intubation or awake tracheostomy a dif-  ficult and hazardous procedure. Frequently, an expe-  rienced anaesthetist may be able to perform an awake  naso-tracheal intubation with an intubating fibre optic  bronchoscope, thereby avoiding the need for the trache-  ostomy. However, it is wise to have the potential incision  marked out and the local anaesthetic already injected in  case the attempted intubation fails.    Percutaneous tracheostomy is an elective procedure that  enables a definitive airway to be placed using an essentially  blind (closed) technique. It is not suitable for children as  the airway is small and the trachea is mobile and soft,  making the procedure technically much more difficult.    It is therefore a procedure that can be carried out, on  adults, in the intensive care unit, particularly for an  already orotracheally intubated patient requiring a trache-  ostomy for longer term airway support.   This is a sterile ‘surgical’ procedure and the field  should be properly cleaned and draped. The tracheal  rings should be palpated below the cricoid cartilage and  local anaesthetic with vasoconstrictor injected both  subcutaneously and also more deeply down to the  trachea. Assuming there is no risk of cervical spine  injury, the neck can be fully extended, facilitating the  procedure.   The operation is based on the Seldinger technique,  whereby a guidewire is slid down through a large-bore  venflon inserted into the trachea, usually between tracheal  rings two and three. As soon as the guidewire is in the  trachea, its position can be checked by viewing down  the orotracheal tube with an intubating bronchoscope.  The guidewire is left in situ while the venflon is removed  and then progressively larger dilators are introduced over  the guidewire. When the tract is adequately dilated, the  tracheostomy tube can be slid into place. Usually it is sen-  sible to let the orotracheal cuff down (to reduce the risk  of puncture by the venflon or guidewire) at the begin-  ning of the procedure and to withdraw the tube slightly to  facilitate insertion of the dilators and tracheostomy tube.  The orotracheal tube must still remain through the vocal  cords until satisfactory position and function of the tra-  cheostomy tube is confirmed. Percutaneous tracheostomy  is a time-consuming procedure that should be carried out  when the airway is already protected with a definitive tube  in place.    Surgical tracheostomy is an elective ‘open’ technique which  again is ideally performed on an already intubated patient.  Before fibre optic intubation and the wider acceptance of  surgical cricothyroidotomy, emergency tracheostomy was  more frequently attempted. Under such circumstances, it  is an extremely hazardous procedure and was associated  with significant mortality due to distorted anatomy, poor  access and visibility and associated haemorrhage.    If the patient is anaesthetized and assuming there is  no risk of cervical spine injury, the neck should be fully    extended. If tracheostomy under local anaesthetic is  being performed, the patient may not tolerate well lying  back and a compromise position may be needed with the  patient partially sitting up.   Whether under general or local anaesthetic, local  anaesthetic should be liberally injected throughout the  whole operative field, both into the skin and also down  through the deeper tissues to the trachea. A 5-cm trans-  verse incision should be made halfway between the cri-  coid cartilage and the suprasternal notch (Figure 16.4).  Subcutaneous fat and platysma are divided and retracted  and fastidious haemostasis must be maintained through-  out the procedure. Blunt scissor-dissection absolutely in  the midline will show the strap muscles on either side  which should be retracted. Keep palpating the tracheal  rings through the incision to ensure that dissection con-  tinues in the midline.   The thyroid isthmus will be seen. Although it may be  possible to retract this, it is safer to divide it (Figure 16.5).  The pretracheal fascia should be divided at the superior  end and the thyroid isthmus gradually lifted off the tra-  chea from above downwards before clamping, dividing  and tying the ends off and retracting them to the sides  (Figure 16.6). There is still some pretracheal fascia that  must be carefully dissected to come down on to the tra-  cheal rings. Identify the second and third rings.   The anaesthetist should be warned that the trachea is  about to be incised, so that the endotracheal tube cuff  can be let down and the tube retracted a couple of cen-  timetres to avoid risk of cutting into the cuff. The tube  must remain between the vocal cords until safe and  satisfactory placement of the tracheostomy tube has  been confirmed by checking the end-tidal CO, and O,  saturation.   Using a No. 11 scalpel incise transversely through the  membrane between the second and third tracheal rings.  Cut down through the third ring and excise a window  about 1 cm in diameter (Figure 16.7). In children, a verti-  cal incision in the midline through the third and fourth  tracheal rings should be made. Stay sutures should be  inserted on either side of the incision and retracted,  opening up the incision into the trachea (Figure 16.8).  Having sized (the same as the orotracheal tube in situ) and    checked the tracheostomy tube cuff, insert it into the tra-  chea, inflate the cuff, connect up to the anaesthetic tubing  and assess the end-tidal CO, If all is satisfactory, then the  skin incision can be closed around the tracheotomy tube  and the tube secured either with the tapes provided or by  suturing the flanges with heavy duty sutures. Once airway  entry has been identified in both lung fields, the orotra-  cheal tube can now be removed.    Figure 16.5 Tracheostomy dissection showing the thyroid  isthmus overlying the trachea.    Figure 16.7 A circular window is created using a scalpel  with a No. 11 blade.    Figure 16.8 The tracheostomy tube flanges are sutured to  the skin.    It is important to ensure adequate humidification of  the air or oxygen to prevent crusting within the lumen  and potential obstruction. If the tracheostomy is being  performed for longer term use, then a double lumen  tube can be inserted. This enables the inner tube to be  removed and cleaned without affecting the position of  the tube itself.   3. Local anaesthetic with vasoconstrictor both to skin and  deeper tissues.   4. 5-cm slightly curved (smiling) incision in skin crease,  halfway between cricoid cartilage and suprasternal  notch.   6. Dissection down through fat and platysma in midline,  exposing the strap muscles of the neck.   7. Blunt scissor-dissection in midline separating strap  muscles and retracting them laterally.   8. Thyroid isthmus should be identified, clamped, divided  and tied off.   9. Continue careful dissection down to tracheal rings -  identify second to third tracheal rings.   11. Check tracheostomy tube size (same as orotracheal  tube being used) and cuff.   12. Cut with No. 11 scalpel blade horizontally through  membrane between rings two and three; continue this  to excise a window, including the anterior surface of the  third tracheal ring.   14. Inflate cuff, connect to anaesthetic tube, check end-  tidal pCO, and oxygen saturations.    It is important to be familiar with measures which can be  employed to arrest maxillofacial haemorrhage.   Intra-oral haemorrhage following exodontia usually  can be addressed with the use of local anaesthesia with  vasoconstrictor, packing and suture. Elsewhere in the  maxillofacial region, haemorrhage needs to be dealt with  promptly and effectively as large volume blood loss can  occur quickly if not adequately controlled. As always, air-  way and breathing must be addressed first and a secure  definitive airway placed and supplemental oxygen sup-  plied before addressing the circulation. While the patient  continues to haemorrhage, fluid resuscitation alone will be  unsuccessful; blood loss must also be controlled.   Haemorrhage may be arrested by direct pressure on a  wound when a bony structure lies deep into the laceration,  as in the scalp. In the face, lip, peri-orbital area and neck,  such compression seldom controls blood loss and in these  circumstances, clamping and ligation of transacted vessels  will be required. Where the soft tissues are extensively dis-  rupted as in high energy injuries such as gunshot wounds,    haemorrhage control may only be achievable with ligation  of the external carotid.   Where severe midfacial bony trauma has occurred  (with Le Fort II or III fractures) and torrential nasal haem-  orrhage has resulted, and where anterior and posterior  nasal packs have been unsuccessful, forward manipula-  tion of the maxillary segment may stop maxillary artery  haemorrhage. If this fails, external carotid artery ligation  is indicated.    This commonly follows maxillofacial trauma, but may  also occur in uncontrolled hypertension or indeed spon-  taneously. When there is no history of trauma, sitting the  patient up and applying pressure to the area may result  in sufficient control to be able to examine the nose and, if  necessary, cauterize the bleeding point using local anaes-  thetic, bipolar diathermy or silver nitrate sticks.   An anterior nasal packing with ribbon gauze soaked in  a fluid such as SofradexR should control anterior bleeds.  Use of expansile cellulose devices such as MerocelR is a  simple method of haemorrhage control.   Post-nasal packing will be required if bleeding is from  the post-nasal space or if severe trauma has resulted in  severe bleeding requiring both anterior and post-nasal  packing. Either Epistat (a preformed device with inflatable  balloons for both posterior and anterior packing) can be  used or, alternatively, Foley catheters are introduced into  both nasal cavities and advanced along the nasal floor  until they reach the soft palate (Figure 16.9). The balloons  are inflated with sterile saline and then gentle traction is  applied to both catheters until the balloons lodge at the  posterior nasal choanae. The catheters can be held in posi-  tion by tying them together around the anterior nasal  spine. The catheters are deflated at 24 hours and, if no epi-  staxis ensues, can be removed.   In patients with Le Fort II or Le Fort II fractures and  disruption of the cribriform plate, care must be taken  to ensure that the Foley catheters and packing are not  aimed cranially, with risk of forcing them into the cra-  nial cavity.   Nasal packing is only effective by tamponading the  bleeding vessels against a solid base provided by the  rigid floor of the nose. Occasionally, with severe midface  trauma and Le Fort I level fracture, such packing just acts  to displace the maxillary fracture rather than compress-  ing the bleeding vessels. Placing bilateral mouth props  to support the maxilla against an intact mandible may  help. In the additional presence of displaced or commi-  nuted mandibular fractures, cranial (barrel) bandaging  may help until such time as definitive intervention can  be provided.   Rarely, severe nasal haemorrhage is not controlled  by these approaches. Ethmoidal artery ligation can be    considered and is usually achieved endoscopically. Where  these skills are not available, the anterior ethmoid artery  can be ligated via a medial orbital approach (Figure 16.10).    Figure 16.9 Nasal packing showing Foley catheter in post-  nasal space and anterior nasal packing with ribbon gauze.    Figure 16.10 a) Inner canthal incision; (b) the anterior eth-  moidal artery is clamped with a ligaclip.    1. Push Foley catheter with 20-mL balloon along floor of  nose until it is visible behind the soft palate; repeat for  the second side.   3. Pull the catheters forward until the inflated balloons  occlude the post-nasal choanae.    Pack the nasal floor and cavity with 5-cm ribbon gauze,  soaked with Sofradex® or bismuth iodoform paraform paste  (BIPP).   3. 2.5-cm curved incision at inner canthus - see Figure  16.10.   6. Anterior ethmoidal artery is identified at its foramen,  2.5 cm from the orbital rim and just above the medial  canthal ligament.    This procedure is indicated where torrential haemorrhage  in the area supplied by that artery has not been controlled  by other means. This may arise as a result of maxillofacial  trauma but is very occasionally warranted during ablative  oncological surgery of the tongue or maxilla. In general  terms, if significant haemorrhage is anticipated during an  oncological procedure, a neck dissection, if appropriate, with  vessel exposure should be performed prior to the ablation.  Very rarely, it is required during orthognathic procedures.   The patient is prepared, anaesthetized and positioned  with the neck extended and rotated to the contralateral  side. Where the neck has already been accessed for another  procedure, such as a neck dissection, this approach is used.  In non-oncology cases, rapid access is best achieved with a  5-cm incision along the anterior border of sternomastoid.  Dissection through the subcutaneous fat and platysma  exposes the muscle. The deep cervical fascia investing ster-  nomastoid is divided, the muscle retracted posteriorly and  the internal jugular vein is exposed. The jugular vein is mobi-  lized by dissecting the carotid sheath and freeing the vein  superiorly and inferiorly. The common carotid artery will be  seen medially (see Figure 16.11). At this point the anaesthe-  tist should be warned as manipulation of the carotid bulb at  the bifurcation may cause cardiac dysrhythmias.    Figure 16.11 The carotid sheath is opened to expose the  internal jugular vein and carotid artery.    The artery is followed superiorly to the bifurcation and  the (anterior, multiple branching) external carotid is iden-  tified. The hypoglossal nerve is an adjacent structure and  should not be damaged. Prior to ligation of the vessel, the  external carotid should be clamped with a non-crushing  vascular clamp to confirm that haemorrhage can be con-  trolled by this procedure. Very occasionally, especially in  midface trauma, exposure of the contralateral external  carotid may be required to achieve haemorrhage control. In  very difficult situations, the assistance of an interventional  radiologist may be required to identify the disrupted vessel  or consider translumenal methods of haemorrhage control.   6. Free up vein inferiorly and superiorly, exposing com-  mon carotid artery deep to the vein.    This condition is one of the few true emergencies in max-  illofacial surgery. The presence of orbital pain, reduc-  ing visual acuity, proptosis and ophthalmoplegia in the  acute presentation of midface trauma or following surgi-  cal management should be assumed to be a retrobulbar    haemorrhage. Fundoscopy to note a pale optic disc is the  only investigation required - computed tomography (CT)  imaging wastes time and rarely assists the diagnosis.    On diagnosis, several simple preliminary steps are of value  in preserving or restoring vision.   c. Remove the skin and deep sutures immediately if  peri-orbital lacerations (or surgical incisions) have  been sutured. This may allow decompression of the  orbit.   a. 2 mL of 2% lignocaine and adrenaline are injected  into the lateral canthal region. Sharp dissect-  ing scissors are used to divide the lateral canthus  through the lateral fornix down to periosteum -  this will release some pressure and will buy time  before formal intra-conal decompression.    Following this intervention, book theatres and an  anaesthetist, explaining the urgency of sight preserv-  ing surgery. Surgical decompression is almost always  required and should never be delayed. However, some  clinicians advocate megadose steroid therapy alone, with  surgical intervention only if no clinical improvement is  seen within 30 minutes. The surgical aim is to decompress  the intra-conal space and a surgeon who performs this  procedure for the first time should not expect to encoun-  ter a copious bleed.    1. Through an existing laceration or surgical incision  2. Via a lateral eyebrow incision (Figure 16.12)  3. Via an infra-orbital approach    It is important to avoid an incision in eyelid skin, such  as a blepharoplasty approach, since this technique also  confers a risk of a retrobulbar bleed.   The peri-orbita is incised and the intra-conal space  entered by blunt dissection between the lateral and infe-  rior rectus muscles (Figure 16.13). Any surgical implants  should be removed.   A small drain (or the finger of a surgical glove) is sutured  in place and left for at least 24 hours.    Figure 16.12 A lateral brow incision is performed and the  peri-orbita incised.    No attempt should be made to treat any bony injuries at  this stage. A retrobulbar haemorrhage is commonly asso-  ciated with comminution of the orbital floor and therefore  required detailed CT evaluation. Additionally, there is  an increased risk of a further bleed when definitive treat-  ment is undertaken. Surgical treatment would therefore  be contraindicated where the contralateral eye is visually  impaired because of pre-existing pathology.   Following medical and surgical management, close eye  observations are mandatory. Any increasing pain or visual  deterioration may indicate re-exploration. Further doses  (250 mg) of methylprednisolone are warranted at 8-hourly  intervals for 24 hours, but the blood glucose should be  monitored, especially in diabetics.    Airway and haemorrhage are two of the most sig-  nificant emergencies to be dealt with in maxillofacial  surgery.   Surgical tracheostomy is always an elective procedure  once initial airway control has been achieved.   The technique of needle cricothyroidotomy is a life-  saving procedure with which all trainees need to be  conversant.   Arrest of haemorrhage is critical - iv resuscitation alone  cannot be effective with an open circulation.  Retrobulbar haemorrhage is a medical and surgical  emergency. Always consider this diagnosis as it can be  missed or recognized too late to save vision.    This chapter covers the principles and practical usage  of selected local and pedicled flaps in the oral and facial  regions to repair or restore relevant congenital and  acquired tissue defects and deformities.   Although the list of selected procedures is not compre-  hensive, those covered in this chapter arguably represent  some of the most common and most useful in the broad  armamentarium of the surgeon dealing with orofacial  defects and deformities.   Each procedure is described and illustrated in a  way to highlight the key features relevant to its use,  the ‘pearls and pitfalls’ specific to that procedure. No  attempt is made to cover any of the aspects important  to the management of the pathologic condition that may  have given a reason for performing the procedure as that  would be impractical in a chapter devoted to operative  aspects.    Principles - The classical example of the buccal advance-  ment flap is in the closure of an oro-antral fistula (OAF)  resulting from an upper molar extraction. This is a    random flap that depends on the principle of a wider  base to ensure adequate blood supply for the advancing  mucoperiosteal tissue. The ratio of width of the base to  length of the flap must not be less than 1-2. A similar flap  is used to close over an alveolar cleft after bone grafting  with the advancement being in the anterior direction.  Periosteal release incision is an essential component of  the procedure to enable the desired advancement with-  out tension and adds safety to the sutured flap during  function.  Pitfalls - Flap dimension depends on the size of the fistula  and must ensure a wider base.  Inadequate periosteal release leading to tension on  the suture line and dehiscence.    Principles — This is an axial flap based on the greater palatine  artery and thus can be raised all the way forward to the  incisor region; but care must be taken to ensure a subperi-  osteal dissection off the palatal bony shelves which can be  difficult in adults and progressively so with increasing age  due to the irregular surface of the palatal bony shelves.   The arc of rotation of the palatal rotation flap (PRF) is  centred on the axial vessel and can reach close to 90° on  each side thus enabling rotation to close an OAF later-  ally or a palatal oronasal fistula medially. However, no  forward movement is possible.    Procedure - The flap is outlined starting 0.5-1 cm from the    attached gingiva buccally up to the midline medially,  with the length varying according to the need. Once the  flap is raised it is rotated and sutured over the defect  (which should already have a nasal layer closure com-  pleted), as an oral layer. The exposed bone of the palate  is covered with Whitehead’s varnish or bismuth iodo-  form gauze for 10 days (Figure 17.1).    Figure 17.1 (a) Palatal fistula with outline of palatal axial  rotation flap and turnover lining flap. (b) Turnover flap closes  the fistula as inner lining. (c) Axial flap rotated to provide cover  over the lining turnover flap.    Pitfalls - Inadvertent raising of the mucosa without the  artery, the latter remaining tethered in the irregular  bony surface of the palatal shelf.   Trauma to the pedicle during flap raising.  Haemorrhage from vessels at the edge of the flap.    Principles - The buccal fat pad (BFP) as a pedicled flap has a  random blood supply from the maxillary, superficial and  facial arteries. It is a mass of fatty tissue located between  the buccinator muscle and mandibular ramus extending  below the zygomatic arch into the temporal fossa and  surrounded by a thin fascia. The BFP is capable of lining  an oral defect and epithelializing within 3-4 weeks. Use  of the BFP is suitable for closure of an ipsilateral check  defect, a maxillary bone defect or an OAF.   Procedure — Access to the BFP is easy as it has a tendency to  herniate into the oral cavity once its fascial envelope is  breached. The most convenient site for access to the BFP  is at the level of the coronoid process in the buccal vesti-  bule through a periosteal incision, however, it is mostly  accessed through the excision or resection defect.   Mobilization of the BFP is achieved indirectly by  opening the fascial envelope with blunt dissection  movement of the scissors thus prompting further her-  niation of the BFP into the surgical defect by gravity.   Suturing the BFP without tension using a round body  needle taking two bites of the BFP for each mucosal  suture. No dressing or graft required. Mucosalization  begins immediately (Figure 17.2).   Pitfalls - Handling of the BFP must be gentle to avoid  traumatic fat necrosis or disintegration of the tissue  mass and avascular fat necrosis.   Avoid masticatory trauma by use of nasogastric feed-  ing in cases of maxillary bone defect repair.    Principles — The tongue flap is a pedicled random flap  based on the submucosal vascular plexus. It is typically  raised at about 7-10 mm thickness to ensure full inclu-  sion of the vascular plexus and a narrow cuff of tongue  muscle. The principle of 2:1 length to base width ratio  thus applies and the flap may be anteriorly or posteri-  orly based. It is most commonly used to repair an oro-  nasal fistula in the hard palate but may also be used to  provide mucosal lining for a partial-thickness upper or  lower lip defect.   Procedure -Local anaesthesia may be used and diathermy  is best not used on the flap itself. The flap is raised by the  knife taking care to raise it at the level of tongue muscle  throughout. Planning the flap length must take into  account the location of the defect to enable reaching the  whole defect and suturing without tension. Six equidis-  tant sutures in total on the flap are generally sufficient.    Figure 17.2 (a) Maxillary defect with BFP visible. (b) BFP  mobilized to reach defect perimeter. (c) BFP sutured to defect  margins providing a single layer cover.   Pitfalls - Short flap, thin flap, loose sutures, uncooperative  patient (consider inter-maxillary fixation).   - Two-layer closure for oronasal fistula is preferred  (nasal layer created by everting palatal tissue around  fistula thus increasing diameter of oral defect and flap  width requirement).    Figure 17.3 (a) anteriorly based tongue flap outline.  (b) Flap raised and donor site closed primarily. (c) Mirror view of  tongue flap inset to palatal defect.    Principles - The Abbe flap is an axial flap based on the lower  labial branch of the facial artery. It is generally used as a  midline flap to correct a defect of the upper lip, often in  bilateral cleft patients or after excision of pathology. It is  a lip-switch flap whereby one labial artery is divided and  the full-thickness (FT) lower lip is turned upward, pedi-  cled on the contralateral vessel and sutured to the upper    lip. The donor site is closed primarily and the pedicle is  divided 2 weeks after operation.   Procedure - Measurement and marking of the required  length and width are done before local anaesthesia with  vasoconstrictor is given.   The lower lip is cut through and through on one side  and the position of the labial artery in relation to the ver-  milion is noted to facilitate avoidance of damage to the  contralateral vessel and enable dissection close to it. With  the pedicled flap raised and supported by a skin hook, the  donor site is closed. The flap is inset in the upper lip and  sutured in three layers (mucosa, muscle and skin) taking  care to restore form and continuity of upper lip while not    component, while the deep temporal fascia overly-  ing the muscle is supplied by the superficial tempo-  ral artery (which is necessarily divided whenever the  TMF is raised).   The TMF is a reliable bulky muscle flap which can be  used as a single layer to close a large maxillary defect  or to fill the orbit after exenteration. It can also repair  defects in the oropharynx or cheek, obliterate mastoid  cavities or be used in facial palsy camouflage.    Procedure - The flap is exposed at the level of the deep    temporal fascia through a hockey-stick skin incision  and raising the superficial temporal fascia subperioste-  ally at the zygomatic arch to avoid injury to the zygo-   The muscle is outlined together with the adherent  deep temporal fascia and raised off the temporal bone as  a whole pedicled muscle with its overlying fascia (myo-  fascial flap) (Figure 17.5a).   Once raised, the muscle flap may be divided coro-  nally to enable the anterior portion to be used as a pedi-  cled flap which is then rotated under the zygomatic arch  into a maxillary defect (after maxillectomy) while the  posterior portion is advanced anteriorly into the tem-  poral recess lateral to the orbital wall thus avoiding an  aesthetic deformity (Figure 17.5b).   If the whole muscle is needed, then it is similarly  rotated and transposed to the defect below the intact  zygomatic arch (Figure 17.5c). If difficulty in transfer  is encountered, the arch is temporally fractured and  replated after flap transposition is complete. The donor  site is camouflaged with cold-cure acrylic commercially  available for the purpose.   Transfer of the flap to the defect is achieved by a  combination of downward blunt pushing and upwardly  inserted Kocher forceps through the defect to take  delivery of the flap (Figure 17.5d).   The flap is rotated in such a way that the fascial sur-  face is left exposed in oral cavity without the need for  a skin graft (Figure 17.5e). Epithelialization of the fas-  cial surface begins immediately and is complete in 5-6  weeks.   Pitfalls - The pedicle is located on the medial aspect  of the coronoid process thus flap dissection from  above must avoid instrumentation near the coronoid  process.   Incision to outline the extent of muscle to be raised  must be made at the muscle periphery to avoid cutting  into the terminal vessels located in the muscle close to  its periphery. This will serve to diminish bleeding and  oedema.   Delay in raising the flap will result in oedema  which will make transposition below the zygomatic  arch more difficult or impossible thus requiring arch  osteotomy.   Transposition must be done by careful handling of  the flap through the use of artery forceps at multiple  sites of the muscle periphery.   Pitfalls - Damage to the pedicle by excessive dissection  close to it can be avoided and adjustment in final flap  insetting is done at pedicle division stage.    Principles - The temporalis myofascial flap (TMF) is  an axial flap based on the anterior and posterior  branches of the deep temporal arteries for its muscle    Figure 17.4 (a) Abbe flap outlined ready to be rotated to  upper lip defect pedicled on one labial artery. (b) Flap inset in  upper lip defect as pedicled flap.    Figure 17.5 (a) Full temporalis myofascial flap raised. (b) Flap can be divided coronally into anterior and posterior segments.  (c) Flap rotated below zygomatic arch down into oral cavity. (d) Flap delivered into oral cavity within reach of defect. (e) Defect closed  with pedicled temporalis flap.    GALEA APONEUROTICA FLAP supratrochlear arteries for use on the anterior skull  base as a galea-pericranial flap. The tissue of the flap lies   Principles — The Galea flap is an axial flap that may be lat- between the skin (just below the hair follicles) and the  erally based on the superficial temporal artery for use pericranium and is easily separated from the latter but    on the face, or anteriorly based on the supraorbital and not from the former.    The galea aponeurotica flap (GAF) in the orofacial  region may be used as a subcutaneous filler to correct  facial contour or as a lining of the oral cavity after cheek  resection.   Procedure - The lateral flap is raised through a hemicoro-  nal skin incision down only to the base of hair follicles.  This is followed by sharp (knife) dissection just below  the hair follicles in all directions to widen the exposed  galeal surface as much as required taking care to pre-  serve the superficial temporal artery. Supero-medial  dissection can safely reach the midline. The flap is then  raised off the pericranium easily and rotated on its ped-  icle as required (Figure 17.6). Transfer is done through  a subcutaneous tunnel to reach the desired destination.    lowermost portion of the raised muscle is divided  longitudinally and its anterior portion sutured to the  orbicularis oris anterior to the melolabial fold, while  the muscle’s posterior portion is sutured to the lower  lip and commissure (Figure 17.7). Distal suturing  of the flap at the corner of the mouth must be done  through a skin incision at the melolabial fold and tied  over a bolus to maintain the muscle in position over  the lip and orbicularis oris for several days.    intra-oral approach.  Large steri-strips and bandages, nasogastric feeding to  immobilize the face and maintain the mouth at rest.    Donor site is primarily closed.  Pitfalls - Damage to hair follicles leads to localized alopecia.  Rotation must be over (above) the zygomatic arch and    Principles - The muscle is fused anteriorly at the anterior  ramus border while posteriorly it is split into three parts  enabling the masseteric artery (between the outermost  two portions) and masseteric nerve (between the mid-  dle and deepest portion) to enter the muscle from above  and behind. The flap may be used when a part of the  anterior ramus is resected as a crossover flap for oral/  oropharyngeal lining. The other use is as an entire mus-  cle raised for transposition to the oral commissure and  upper and lower lip in cases of facial nerve palsy.    resected ramus portion by stripping the muscle from its  lowermost attachment at the angle of the mandible and  raising it enough to reach the medial defects.   In paralysis cases, access to the masseter for  transposition to the corner of the mouth can be  achieved intra-orally or extra-orally. The whole mus-  cle must be raised off the bone and mobilized. The    bed to enable graft vascularization, hence local infec-  tion, diabetes and irradiation are unfavourable factors.  Close adaptation of the graft to the recipient bed is  essential, hence graft dressing is critical.   FT grafts are more aesthetic but amenable to smaller  dimensions while split-thickness grafts are suitable to  cover large surfaces and more quickly vascularized but  are more susceptible to shrinkage.   Commonly, FT grafts are used in closure of the fore-  arm free flap donor site while split-thickness grafts are  used in maxillectomy defects under an obturator and in  fibula flap donor sites.    de-fatted on the table before applying to a defect such as  the forearm flap donor site.   Split-thickness skin grafts (STSG) are raised with a der-  matome set at a thickness of 0.3-0.45 mm (Figure 17.8a)    Figure 17.7 Masseter flap raised off mandible pedicled  superiorly and sutured to corner of mouth for facial animation.    (a) STSG raised by dermatome. (b) Graft  sutured to cheek defect.    Principles - Free mucosal grafting is indicated as an  adjunct to implant rehabilitation of edentulous or  reconstructed jaws. These grafts heal under specially  prepared dental splints and provide a firm basis around  implants or implant-supported prostheses.   Procedure - The cheek is ballooned intra-orally with a  saline injection and the graft is outlined and raised with  a sharp knife.   De-fatting/thinning is done on the table before  insertion at the prepared site.   In the prepared site on the alveolar ridge or ridge  equivalent (Figure 17.9).    (a) Mucosal graft outlined with knife and  ballooned with saline injection. (b) Graft defatted on the table  avoiding perforation. (c) Graft inset in buccal sulcus.    First described by Ayrian in 1979, the pectoralis major  rapidly became the workhorse in head and neck recon-  struction. Raised as either a myocutaneous or muscle flap,  only the flap developed a reputation for a reliable easy-to-  use reconstruction. It is based on vessels of the thoracro-  mial artery. The muscle exists as two portions: a clavicular  head, from its sternal half, and a sternocostal head, from  the sternum to the level of the seventh costal cartilage and  from the upper sixth rib. The muscle is attached by a flat  tendon into the lateral lip of the inter-tubercular sulcus of  the humerus.   Its blood supply is based on vessels of the thoracro-  mial artery. This artery, on entering the deep ‘clavipec-  toral fascia’ of the muscle, splits into a deltoid branch to  supply the humeral head and a pectoral branch to supply  the remainder of the muscle. The pectoral potion of the  muscle also gets its blood supply from the lateral thoracic  artery and perforators from the internal mammary artery.  Both of these vessels are almost always sacrificed to enable  mobilization of the flap, as the pectoral branch is almost  always the dominant vessel. However, this axial patterned  flap is not without limitations and problems. The first is  bulk; although the muscle bulk disappears with time, this  deformity is never lost. As the muscle traverses the neck  much needed cover of exposed vessels may be desirable.   Pedicle length may be a problem particularly where  a myocutaneous flap is desired for a cutaneous defect.  Although it is adequate for most intra-oral defects, except  those where maxillary obturation is required where exter-  nal skin coverage is required, pedicle length is lost as the    skin flap is effectively doubled over to achieve the correct  skin orientation.   The biggest problem is skin reliability although a total  necrosis rate of between 3% and 7% was found, a partial  necrosis rate of 29% was noted of the skin paddle.   Other operators have published better results. The pad-  dle is usually taken at the extreme end of the flap. In the  female, it is not possible to harvest skin more superiorly  as the breast tissue will make the flap bulky and awkward.  The viability of skin is dependent on perforators in the  area that come predominantly from the pectoral branch.  In the author’s experience, skin will be lost in 1:10 male  flaps and 1:3.5 female flaps. Fortunately, this is not usu-  ally a problem as the underlying muscle will usually  obturate the defect to prevent a fistula, but this cannot be  guaranteed.   Therefore, for greater safety a muscle only flap can be  raised. This may cause some loss of mobility in oral recon-  structions and diminish the bulk where it may require.    Many surgeons justify the use of this flap over a free flap  to reduce operating time and by conjecture operative mor-  bidity. In the author’s experience, this is a fallacy. It is diffi-  cult to raise this flap synchronously unlike most free flaps,  and the time taken in raising this flap is not that much  less than the time taken for an experienced microvascular  surgeon to complete an arterial and venous anastomosis.  It is certainly an option where previous surgery and  or radiotherapy have made access to reliable vessels for    microvascular anastomosis difficult, particularly when this  affects both sides of the neck. When using this flap after  radiotherapy, a backup flap should always be planned to  deal with the possibility of a dehiscence around part of the  flap or elsewhere in the head and neck. It is certainly useful  to obturate defects where a free tissue transfer has failed.   It provides a useful myocutaneous flap for larger rather  than small defects as this increases the number of perfora-  tors to the skin. It can be used for large tongue and floor  of mouth defects, particularly total glossectomy defects.  It is useful for lateral mandibular defects where a recon-  struction plate is not to be used. By conjecture, this is not  a useful reconstruction for defects involving an anterior  segment of the mandible where some form of spacer such  as a reconstruction plate would be required. Dehiscence  for plates use in conjunction with pectoralis major flaps  has been recently put at 30% for lateral defects and 50%  for anterior defects. It can be used as a tubed flap in laryn-  geal reconstruction, but leakage and dehiscence are high.  If used for cutaneous defects in the neck, the reliability of  the flap can be enhanced by using a myocutaneous flap and  overlying this with a split skin graft. Within 3-6 months,  a surprisingly good aesthetic result can be achieved.    The patient is supine with the arm on a board and  abducted to 90°. A line should be drawn from the medial  tip of the coracoid process to the tip of the xiphisternum  (Figures 18.1 and 18.2). This approximates to the surface  markings of the pedicle; the thoracoacromial vessels. The  muscle extends inferiorly to the costal margin of the fifth,  sixth and seventh ribs. It is not recommended to mark or  develop the skin paddle beyond the costal margin, it is sur-  prisingly easy to incorporate parts of the rectus abdominis  muscle into the flap in an effort to increase pedicle length,  but this should be avoided if possible to achieve maximum  skin reliability.   The skin paddle (if required) should therefore be  situated on the line of the pedicle with the costal margin as  its lower margin. In males, ellipsoid paddles should be ori-  entated lengthways along the pedicle marking. In females,  for cosmesis, the pedicle can be orientated horizontally in  a sub-mammary position.    To access the pectoralis major, there are three basic options  to access the fat and underlying pectoralis muscle.! The sim-  plest is from the thoraco-acromial process in a straight line  towards the lower point of the xiphoid process, stopping at  the skin paddle if present, or if not until the lower border  of the pectoralis muscle is easily visualized (Figures 18.1  and 18.2). From the top of the anterior axillary line,    a sub-mammary incision is developed (Figure 18.3). The  incision in 1 is used but begins on the deltoid muscle hav-  ing a superior horizontal margin that is effectively the lower  border of a deltopectoral flap, enabling this to be used. This  is known as the defensive incision (Figure 18.4). The skin  paddle should be incised through subcutaneous fat to the  underlying muscle. To increase the number of perforators,  a layer of subcutaneous fat can be raised along the length of  the muscle pedicle (Figure 18.5) and this will mean at the  superolateral aspect of the skin paddle. The incision passes  only down to the subcutaneous fat. However, this still does  not guarantee success of the skin layer and, as the pedicle  passes directly below the breast, at least some subcutaneous  fat should be left in females.    The skin paddle having been defined, the muscle should  be dissected off the underlying chest wall. Although it is  less well-defined inferiorly, a plane can be developed on  the surface of the rib periosteum and the fascia over the  inter-costal muscles. Proceeding first in a superolateral  and then lateral direction, dissection and elevation of the  flap can begin. Laterally, it should be easy to palpate and  see the lateral border of the muscle. During the dissection,  perforators will be encountered running into the muscle  from the chest wall. They can usually be left on the muscle  but those on the chest wall should be diathermized.    Figure 18.5 To increase the number of perforators, a layer  of subcutaneous fat can be raised along the length of the mus-  cle pedicle.    As the muscle is dissected off the chest wall midway,  the pectoralis minor will be encountered (Figure 18.6).  This muscle should be spared and is separated from the  pectoralis major by its fascia. At this stage, the pedicle  should be visible through a thin layer of fat below the  pectoralis major muscle (Figure 18.7). At the lateral part    Figure 18.6 As the muscle is dissected off the chest wall  midway, the pectoralis minor will be encountered.    Figure 18.7 The pedicle should be visible through a thin  layer of fat below the pectoralis major muscle.    of the dissection, the antechostal brachial nerve will be  encountered and should be divided. Just above this are the  lateral pectoral vessels. Unless the flap is required for the  lower neck, providing the thoracoacromial vessels have  been identified, these should be divided as its integrity will  restrict the vertical movement of the flap.   If the thoracoacromial vessels have not been visualized  at this stage, the dissection should proceed no further, as  the thoracoacromial vessels are laterally disposed beneath  the muscle and can conceivably be confused with the lat-  eral pectoral vessels. Having divided the vessels, it will  probably be necessary to diathermy muscles in the axillary  fat. At this stage with the pedicle visualized, the humeral  head should be divided in the axilla and this will add con-  siderable length to the flap.   Elevation of the flap is almost complete and should  proceed upwards to just below the clavicle if necessary,  which in most cases, it will be to ensure adequate pedicle  length.    A tunnel should be made above the clavicle and below the  skin and subcutaneous tissue into the neck (Figure 18.8).  This is usually achieved by dissecting downwards from the  neck and upwards from the donor site wound. The space  within this tunnel can be assessed by inserting the four  fingers of a hand. Recently, the supraclavicular flap based  on supraclavicular artery and vein a branch of the trans-  verse cervical artery that enters the subcutaneous fascia  from the subclavian vessels approximately at the point of  the medial third of the clavicle. By visualizing these ves-  sels and then preserving them during tunnel formation, a  supraclavicular flap will still be a possibility, after transpo-  sition of the pectoralis major flap.   The upper border of the skin paddle or lower border of  the muscle should be grasped from above by a large clip  after its insertion through the tunnel and then pulled gen-  tly upwards. If resistance is encountered, the tunnel and  pedicle should be reassessed to see where there is snag-  ging. Some surgeons suture the edges of the skin paddle to  the muscle below to prevent shearing of the skin paddle.  In the author’s opinion, this is unnecessary if the flap is  handled with care and respect.    When the flap has been placed in situ, it must not be under  any tension. Not only might this affect the flow within  the pedicle, but over the next 2 weeks as the muscle scars  and contracts it will pull the healing wound edges away  inferiorly leading to wound dehiscence. The flap can reach  further if muscle only is used, but again lack of tension is  vital. The flap should be secured with muscle, subcutane-  ous and skin layers.   The donor site can usually be closed primarily (Figure 18.9)  and the cosmetic result is particularly good after a sub-  mammary incision in females (Figure 18.10). Suction drain-  age is recommended, particularly in the axilla.    Figure 18.8 A tunnel should be made above the clavicle  and below the skin and subcutaneous tissue into the neck.    Figure 18.10 A healed sub-mammary incision showing its  invisibility.  POST-OPERATIVE CARE    Monitoring is less crucial than free tissue transfer. Twice  a day should suffice as little can be done to correct any  apparent arterial or venous problem, and certainly in the  immediate post-operative phase, pallor and the colour and  quantity of blood on pinpricking are unreliable.    e Flap necroses: It is extremely unusual, though not  impossible, for the entire flap to become ischaemic and  necrose.   @ Partial necroses: More commonly, this applies to the  skin and subcutaneous fat. If this occurs intra-orally, a  leak into the neck and fistula formation are not inevi-  table in the presence of viable muscle. The dead tissue  should be debrided and, if carried out in an operating  room, local anaesthetic may be an option in patients  who are not SA 1.    e Leave the subcutaneous fat along the line of the pedi-  cle to increase the number of perforators supplying the  flap.   e¢ In women, always use a sub-mammary incision and  avoid taking too much fat with the flap.   e If replacing external skin in the neck, using a split skin  graft over a muscle only flap will increase flap length  and reliability. In time, a very acceptable result will  be obtained from the skin graft with less donor site  morbidity.   e Always plan at least one backup flap either deltopec-  toral or supraclavicular when operating after radiother-  apy in case of anon-healing dehiscence.    1. Ariyan S. The pectoralis major myocutaneous flap.  A versatile flap for reconstruction in the head and  neck. Plast Reconstr Surg. 1979; 63: 73-81    Baek SM, Lawson W and Biller HF. An analysis of 133  pectoralis major myocutaneous flaps. Plast Reconstr  Surg. 1982; 69: 460-467.   Bussu F, Gallus R and Navach V. Contemporary role of  pectoralis major regional flaps in head and neck  surgery. Acta Otorhinolaryngol Ital. 2014; 34(5):  327-341.   Mariani PB, Kowalski LP and Magrin J. Reconstruction  of large defects postmandibulectomy for oral can-  cer using plates and myocutaneous flaps: A long-  term follow-up. Int J Oral Maxillofac Surg. 2006; 35:  427-432.   Ord RA. The pectoralis major myocutaneous flap in oral  and maxillofacial reconstruction: A retrospective  analysis of 50 cases. J Oral Maxillofac Surg. 1996; 54:  1292-1295.   Shah J, Haibhakti V, Loree TR and Sutaria P. Complications  of the pectoralis myocutaneous flap in head and neck  reconstruction. Am J Surg. 1990; 160: 352-355.    Vartanian JG, Carvalho AL, Carvalho SM, Mizobe L, Zbar RI, Funk GF, McCulloch TM, Graham SM and  Magrin J and Kowalski LP. Pectoralis major and Hoffman HT. Pectoralis major myofascial flap:  other myofascial/myocutaneous flaps in head and A valuable tool in contemporary head and neck  neck cancer reconstruction: Experience with 437 reconstruction. Head Neck. 1997; 19: 412-418.  cases at a single institution. Head Neck. 2004; 26:    Other than for burns, which are beyond the remit of  this chapter, the most common requirement for replac-  ing skin in the head and neck region is after removal of  large skin cancers. Skin grafts can be particularly useful  in areas such as the scalp where for large defects local flaps  do not often provide enough skin for tension-free closure.  Furthermore, some scalps have very little ‘give’ resulting  in difficulty closing defects with scalp-based local flaps.  In some third world countries, skin is used for replace-  ment of oral mucosa, but this technique is rarely used in  the western world with modern techniques including local  and distant flaps being readily available. Skin grafts may  also be required to close donor sites following free flap  harvest, with examples being the radial forearm free flap  (Figure 19.1) and for large anterolateral thigh flaps.    There are a variety of options for closure of cutaneous  defects, each having advantages and disadvantages (see  Table 19.1).    This is best achieved by using an elliptical incision that  is placed in Langer’s lines. Skin becomes more lax with  age and certain areas such as the cheek, neck and temple  region may be suitable for direct closure following exci-  sion of a lesion. Ideally a 3:1 length to width ratio is used,  which can be marked pre-operatively. The skin incision  should be made at right angles to the skin itself to avoid  shelving and local undermining of the surrounding tissue  will allow for a tension-free closure. With direct closure,  a two-layer suture technique is useful, so as to take off as  much tension on the skin sutures. For the deeper layers, a  resorbable suture such as 3/0 or 4/0 Vicryl or 4/0 Maxon  (the author’s preference), ensures the skin sutures ideally  5/0 non-resorbable monofilament sutures such as Ethilon,  Prolene or Novafil.    While local flap repairs are covered elsewhere in this book,  there are certain surgical principles which are common  to all. The local flap can be either ‘advanced’ or ‘rotated’  into the defect (see Figures 19.7 through 19.10). Some also  consider the transposition flap as a separate category, but  this is usually a variation of rotation and/or advancement  (Figure 19.11a through c).    ® The skin of the flap should be from within the same aes-  thetic zone.   ® The final scar should, as much as possible, lie along  lines of tension, but this is rarely possible with all the  incisions.   ® The choice of flap is dictated by seeking tissue from  an area of lax tissues. Thus, the decision as whether to  rotate or advance is based on the site of the lesion and  the site of available tissue.    Figure 19.1 Excellent result with skin graft to radial  forearm flap donor site.    ® On the face, the flap length to width ratio should be  no more than 4:1 for fear of compromising the blood    The two types of skin graft are full-thickness (which  includes the underlying dermis) and split-thickness  grafts, which should ideally be at a depth (often about  0.15-0.2 mm) to cut across the rete pegs to enable heal-  ing. Full-thickness grafts can be harvested from the lax  neck skin, post-auricular region or for larger defects, the  abdomen.    The following are the key points to remember for the  donor site (see Figures 19.12 and 19.13):    Figure 19.2 Direct closure; the ratio of length to width  should be 3:1 and create 30° angles.   Skin graft - split skin Almost limitless amount of skin in terms of the head  and neck    Incision lines can be kept along the lines of natural  tension, improving aesthetic outcome    Limited defects only, as closure will create  excessive tension leading to wound  breakdown and infection   Unlikely that all the skin incisions will run  along natural tension lines   Better aesthetics, in terms of thickness of the graft and  aesthetic skin match than split skin but not as good    Problems of a donor site, produces a  second area of scarring    Figure 19.5 Undermining of the tissues should be in the  subcutaneous level and only about 1 cm distance. Sharp dis-  Posterior Anterior section is better but may induce more bleeding than blunt  dissection.    Figure 19.3 incisions along the lines of tension, as shown,  create narrow scars. Crossing these lines produces a broad ugly  scar.    © Sufficiently lax to provide enough skin and enable  primary closure of the donor site   © Provide good colour and thickness match (ideally use  head and neck skin where possible rather than abdomi-  nal skin to help with colour match)    Donor sites: In practical terms, the following donor sites  are frequently used:    ® Root of the neck: This can often provide up to 4-6 cm  grafts, and can be hidden in a skin crease and the scar  can be covered by clothing. The skin is thinner than that  of the abdomen.   © Post-auricular: The biggest issue with this site is the lim-  ited size of graft that can be obtained (usually no more  than 2-3 cm in width). The scar is hidden and the colour  match can be good. It can sometimes cause the pinna to  be pulled back. It is not easily seen. The skin is thin with  good colour match.   @ Pre-auricular: This provides a good colour and texture  match for the facial skin but as with the post-auricular  harvest site, is limited by width.   @ Abdomen: A large graft can usually be taken from the  lower abdomen and hidden in the underwear line. These  grafts are particularly good for larger defects (such as  large scalp lesions).    The graft can be harvested under local or general anaes-  thesia, and is usually marked on the skin to reflect the  size needed. It should be marked as an ellipse to enable  primary closure. The two end parts can be subsequently  removed. The skin is excised in to the underlying subder-  mis/fat using a scalpel or cutting diathermy. It is impor-  tant to have meticulous haemostasis at the excised site to  allow intimate contact between the skin graft and wound  bed - small stab perforations in the graft are ideal for this.  The harvested graft should be de-fatted using scissors and  the donor site should be closed in a two-layer technique.  For a large graft, a small suction drain for the first 24 hours  is often useful.   Once the skin graft is secured in place, either by fine  resorbable sutures such as 5/0 Vicryl, while some advocate  cyanoacrylate glue, dressings should be firmly placed over  the graft to oppose it to the wound bed. Silicone mesh covered    Figure 19.9 Island flaps rely on the subcutaneous tissues for their blood supply, so the rotation or advancement is over a short    by proflavine-soaked cotton-wool dressing or a foam dress-  ing all secured by tie over sutures or staples are ideal.   Pain is not usually a feature of the donor site (unlike a  split-graft harvest).    Figure 19.11 (a-c) Transposition flap in the right temple  area showing marking, flap raised and post-operative appear-  ance (labelled as transposition flap 1 and 2 and post-operative  appearance).    The wound at the surgical site should ideally be left  undisturbed for 10 days, although it should be regu-  larly inspected to check for haematoma and wound  infection.    Any part of the skin is a potential donor site for a split  skin graft, but ideally a flat surface which is not too vis-  ible and has adequate dimensions means that the anterior  or inner aspects of the upper thigh or upper arm are usu-  ally used (ideally the non-dominant arm). These harvest  sites do not immobilize the patient, normally has enough  skin, is easily kept clean and can be readily observed (see  Figures 19.14 and 19.15).    ® Topical cleaning prior to and after surgery may be help-  ful, but the routine use of antibiotics is not indicated.   ® Meticulous haemostasis is needed to ensure good con-  tact between the graft and the nutritional wound bed.   © Firm pressure to stabilize the graft and prevent a hae-  matoma forming beneath the graft. A similar dressing  technique as used with a full-thickness graft is ideal.   @ Again, stab perforations or meshing of the graft helps to  prevent haematoma formation.   ©@ Ideally the wound should be left untouched for 7-10 days.    The thinner the graft the more likely it will form a blood  supply but the greater the contraction. Normally, the graft    should be about 0.2 mm, which is about the thickness of a  No. 15 scalpel blade.   The skin can be harvested with a conventional hand-  held instrument (Humby knife), but it is very difficult  to get an even thickness and the edges can be serrated.  The standard traditional skin-grafting knife has more  or less been replaced by either an electric- or air-pow-  ered dermatome. This produces a very even-thickness  graft, but more importantly the width of the graft can  be more easily predicted. The success of the technique  is very much related to acquiring the experience to get  a good ‘feel’ for the depth of the cut. However, certain  techniques can make it more predictable, and the author  routinely sets the blade depth to 0.2 mm using a No. 15  scalpel blade.   e A flat board should be advanced just in front of the  dermatome to ensure a flat surface is presented to the  blade. Slow even progression of the dermatome pre-  vents folding of the skin ahead of the blade producing  a more even cut.   © Meshing of the graft can increase the size of the graft  by about 30% but in most cases the meshing is merely  to create small perforations to prevent haematoma  formation.    Figure 19.14 The stages of split skin grafting: (a) setting the correct thickness, the width of a No. 15 blade is a good guide; (b) the  area must be well lubricated and the piece of wood just ahead of the dermatome ensures an even thickness across the whole width  of the cut; (c) typical appearance and (d) the graft should have small perforations to prevent haematoma formation.    The donor site can be extremely painful and this must  be anticipated and prevented. A commonly used tech-  nique is to apply an alginate-soaked dressing (such as  Kaltostat) impregnated with long-acting local anaes-  thetic, such as 0.5% buvicaine. Regular systemic anal-  gesia is also useful. The alginate dressing is then, and  importantly, stabilized with an adhesive dressing such  as Opsite or Tegaderm™. The wound should be left  untouched for 14 days. It is essential to keep the wound  under observation to check for haematoma formation  or infection as the wound may need to be exposed and  cleaned up.    Resorbable suture materials are in theory highly desirable,  since they avoid the often uncomfortable removal for the    Figure 19.16 Subcuticular sutures are easy to remove than  interrupted sutures and may help to prevent ‘stitch’ marks if a  resorbable suture is used.    patient. Unfortunately, these materials have a number of  problems on the skin itself, in that they excite a foreign  body reaction, producing significant inflammation. They  are of course very useful to reduce tension and aid skin  closure in the deeper tissues.   When used on the skin surface itself, the resorption  process is too slow for facial wounds, as the material  should have disappeared within 5-7 days. Fine resorbable  sutures (such as 5/0 and 6/0 Vicryl rapide) can be very  useful in some clinical situations (such as in children)  but these are braided and their resorption is not entirely  predictable. The use of resonrbable subcutaneous sutures  with cyanoacrylate glue is another option for children.  Suturing technique including, removal of a dog ear, is  shown in Figures 19.16 through 19.18.    The ideal material is a non-resorbable monofilament  material (e.g. Ethilon, prolene or Novofil - the latter being  the author’s choice, also having a good suture needle).  These materials have minimal tissue reaction and can be  removed at 5-7 days.    As with the skin, these flaps can be directly closed, or be  taken as local rotational and advancement flaps. As with  skin flaps, excessive tension will reduce the blood supply  and lead to dehiscence and infection and the flap length/  width ratio should be no more than about 4:1 (see Figures  19.19 and 19.20).   The only non-muscle flap with a true vascular pedicle is  based on the greater palatine vessels, the rest are random  pattern flaps. Unlike skin, the local anatomical variations  of the mucosa demand special attention. For example, it  is most important that attached mucosa is attached to the  gingiva of the teeth so flaps must be designed to ensure  that relationship is maintained.   In some cases, this is not possible and free full thickness  attached mucosa, normally harvested from the palate may  have to be used. A micro-dermatome is an excellent way of  achieving such a harvest.    Non-vascularized bone grafts do not survive once trans-  planted, but provide growth factors and a hard tissue  skeleton, stimulating angiogenesis and ultimately facili-  tating new bone formation. This process takes time and    Figure 19.19 Posterior view of the right shoulder show-  ing the blood supply to the trapezius muscle and spine of the  scapula.    it is essential that the graft is placed in a highly vascular-  ized environment free from any infection. In practical  terms, bone grafts in the mouth need to be in a sealed    Figure 19.20 Lateral advancement flap for closure of an  oro-antral fistula. In this case, the periosteum is cut gently to  give much greater laxity to the overlying mucosa enabling  closure.    environment with good vascularized mucosa covering the  graft. Clearly, in young growing children this is most read-  ily achieved but in elderly patients who smoke and have  significant comorbidity (such as osteoradionecrosis), it  is difficult to achieve. Free vascularized tissue transfer is  often indicated in these patients. If, however, the patient  is young or the defect is small and easily and quickly  becomes re-vascularized, a free non-vascularized graft  may be used (Figure 19.21).   The surgery for vascularized free tissue transfer is dis-  cussed elsewhere.    As mentioned earlier, non-vascularized bone grafts have  some use, with the literature, particularly from the third  world, still widely advocating their use, primarily in sur-  gical centres which do not have access to microvascular  techniques.   The main indications for free non-vascularized bone  grafts are as follows:    e Alveolar bone defects in children with a cleft lip and  palate.   © Small defects in the jaws, whereby the bone defect is  surrounded by bone walls except at the surface (e.g.  after removal of a benign tumour from the alveolus).   © Small bone defects in which an implant is to be placed  (such as an atrophic ridge or where the maxillary  antrum is very low).   ® Secondary jaw reconstruction of small continuity  defects, in which the fragments have been stabilized by  bone plates. Again only small defects in patients with  good overlying soft tissues are likely to be successful.    A few sites are commonly used for bone harvest (see  Table 19.2).    Bone may be harvested at the time of bicoronal flap or an  incision can be made over the parietal bone prominence  with care being taken to avoid damaging hair follicles (see  Figure 19.22).   The incisions are taken down to the bone, and the peri-  osteum is elevated. The outline of the bone graft is cut  in the outer Table and, either with a very thin flexible  oscillating saw or small curved chisels, the outer plate is  raised. In children it may be helpful to do a pre-operative  computed tomography (CT) to ensure adequate bone  thickness. In some circumstances, if working with neu-  rosurgeons, the full-thickness grafts can be taken and  repaired appropriately.   As the bone is very rigid and hard, it has to be fashioned  with cuts and bending forceps to the desired shape. It may  be necessary to grind the bone to produce small fragments  to pack around the main graft and produce a smooth con-  tour at the recipient site.    Closure usually requires a small vacuum drain and  should be in layers.   The incision is in the submammary area, usually 5-7 rib,  but no more than two consecutive ribs should be har-  vested, to prevent a flail segment.   The incision is usually made in the mid-clavicular  line unless a costochondral graft is needed, when it is  made more medial. The incision is down to bone and a  careful circumferential subperiosteal dissection is car-  ried out using a curved stripper or Doyen. If cartilage is  to be harvested, then a small layer of periosteum is left  intact to hold the cartilage to the bone. Care is needed  to remain in the subperiosteal plane to prevent pleu-  ral damage. The rib is cut with care to avoid damaging  the pleural lining. Once removed, the cavity should be  filled with saline and the chest inflated by the anaes-  thetist to look for any air bubbles (implying a leak).  Closure is made in layers with a vacuum drain placed  for 24 hours. It may be helpful to inject long-acting local  anaesthetic (such as 0.5% bupivacaine) into the overly-  ing muscle after deep closure to help with pain relief (see  Figures 19.20 through 19.23).    The anterior approaches are the most common graft site  (see Figures 19.24 through 19.27). The incision is out-  lined after having marked the anterior superior iliac spine  (ASIS) (Figure 19.24). The approach is deepened through  the soft tissues (Figure 19.25) and down to the iliac crest  (Figure 19.26). Once down to bone, either the lateral or  medial tissues should be elevated depending on which    surface is to be harvested. On most occasions, it will be  the medial side, since less muscle stripping is needed and  it is said to be less painful. The bone cuts should be made  so that most of the crest remains intact.   This is done by elevating the crest and hinging it lat-  erally, so allowing access to the bone for harvesting, and  then returned once the harvest is complete. In some cir-  cumstances, if only a thin piece of bone is needed, two-  thirds of the crest can be preserved and a thin slice of    Figure 19.22 A groove is scored through the outer table  and the outer table is removed with fine chisels.    Small volume, very soft but pliable bone. With the cartilage in 30% of cases harvested in young  children it will continue to grow. Small risk of chest complications especially in the elderly,    pneumothorax and chest infection. Can be painful.  In young females, the harvesting may, if too high, damage breast development    One of the commonest sites yields large volumes of bone (especially with the posterior approach), it    has an unobtrusive scar. While it is very painful, unless a trephine is used, it has few significant side  effects. Damage to the lateral cutaneous nerve of the thigh should be easy to avoid, but it does  happen and is a significant problem. Fractures of the iliac crest can occur. The posterior approach is  much less frequently used as it is necessary to rotate the patient prevent synchronous surgery to    Tibia This is a trephine approach which yields small volumes but ideal for alveolar defects. Few complications  and little pain, but unrewarding in elderly patients as the bone is replaced by fat and blood.    Intra-oral - used  predominately in  implantology where  small volumes of  particulate bone are    Chin: easily accessed, small volume, quite vascular, but leaves anterior teeth numb for some time   Cortical bone scarification. This involves paring off the cortical surface of the lateral mandible. It  produces a good volume of particulate bone, ideal in implantology, but no value for continuity    medial bone removed (Figure 19.27), if for example an the muscle so a perfusion of long-acting local anaesthetic  orbital floor is being grafted. The iliac crest if temporar- can be established for the first 24 hours for pain relief  ily hinged laterally, should be kept attached to periosteum (Figure 19.28). The use of suction drains is controversial.  to preserve the blood supply and stability to the replaced If the drain is placed on the cut bone surface it seems to  crest.    Supplementary fixation is not normally needed. Prior  to closure, an epidural catheter should be placed beneath    Figure 19.23 A curved instrument (Doyen) is placed care-  fully around the rib in the subperiosteal plane.    Figure 19.24 Incision marked for iliac bone harvest on the  left side. The anterior superior iliac spine (ASIS) is shown. For  orientation the groin in superiorly and the umbilicus is under Figure 19.26 Exposure of the iliac crest with muscle and  the green marking pen. periosteal stripping.    keep draining blood for days. Ifthe periosteum and muscle  are tightly approximated, this seems to reduce the haema-  toma by tamponade action. Bone wax should be avoided as    Figure 19.27 Bone cuts have been made using saws and  and the medial part of the crest can be removed using an  osteotome. It is important to protect the medial structures  when completing the bone cuts.    Figure 19.28 Epidural catheter placed in the wound for  instillation of regular local anaesthesia to reduce post opera-  tive pain.    this produces a foreign body reaction often requiring fur-  ther exploration of the wound. It may be helpful to place  the suction drain just subcutaneously to avoid a more  superficial haematoma.   The process can be made less painful by a trephin-  ing technique. A small 1-cm stab incision is made on to  the anterior crest and a trephine is directed posteriorly/  inferiorly.   This produces a core of cortical cancellous bone and a  much smaller volume than an open procedure. It is closed  in two layers.   This is usually a trephined procedure so that the  cores of corticocancellous bone are harvested (see  Figure 19.29). The bone is taken from the pyramidal  shaped plateau, above the shaft and away from the joint,  and in children away from the epiphyseal growth centre  (Figure 19.30).   The landmark to make the 5-mm stab incision down to  bone is on the medial aspect just above the patella protu-  berance. The head of the fibula provides a useful guide to  the position of the growth centre at the epiphysis, which  is above this imaginary horizontal line. Multiple cores are  harvested into the pyramidal area. Closure is normally a  single layer.   The fibula can on occasion be harvested as a non-  vascularized graft, but this is unusual. In the author’s  experience, a non-vascularized fibula has been success-  fully used as a free graft when the carotid artery failed to  flow during arterial anastomosis. In these instances, it is  advisable to remove all soft tissue from the bone. Clearly  this would not be suitable when a skin flap was being har-  vested as well but the fibula itself might be successful as  a free bone graft.    Figure 19.29 The outer sleeve of the trephine stabilizes  the trephine on the iliac crest, so a core can be extracted.  Normally only a small ‘stab’ incision is needed.   After local anaesthetic injection, wide exposure via a  mucoperiosteal flap is performed to identify and preserve  important structures (such as the mental nerve). It is advis-  able to use a suction device with a bone trap to supplement  the harvest. If bone is to be removed from the anterior  mandible, a small strut of bone is preserved in the midline  to maintain the chin contour. Two small box-shaped cuts  are made in the cortical plate and lifted free. The bone is  then curetted from the marrow, which is usually very vas-  cular. It is not necessary to have any suction drainage, but  closure of the mucosa should be in two layers, the deeper  sutures should pick up the mentalis muscle and ensure  its re-insertion high up the alveolus. An elastic adhesive  dressing is then applied in the mental groove further pull-  ing up and supporting the muscle insertion to prevent pto-  sis. Patients will sometimes have a feeling of numbness to  their anterior teeth, which may persist for a considerable  time. Posterior lateral harvest from the mandible follows  the same principle, removing the lateral cortical plate from  behind the last molar to the lateral ramus. Closure has less    Figure 19.30 (a) 1, Head of fibula, which can be easily pal-  pated, below the epiphysis; 2, epiphysis; 3, the trephine should  not enter the shaft; 4 entry site. (b) The tibial graft easily fills  this cleft alveolar defect.    tension as it is supported by the masseter and a drain is  not needed.   As with all intra-bone harvesting, the yield is small and  it is necessary to grind up the cortical plate as well as use  the bone trapped from the suction.    There are a number of frequently used sites as outlined in  Table 19.3.    There are two sites, the small concave conchal bowl area  and the longer curved area between the helix and anti-  helix. The site is infiltrated with local anaesthetic for pain  relief and to aid the dissection. The flap is raised and the  clean cartilage surface exposed. Both sites are approached  anteriorly, although they can be harvested from behind if  prevention of a visible scar is essential. The skin flaps are  sutured in one layer and a compression dressing with tie  over sutures placed to prevent haematoma formation.   After infiltration with local anaesthetic, two approaches  can be used. Traditionally, a small curved anterior inci-  sion is made on one side of the septum. An alternative is to  make a high anterior intra-oral incision around the nasal  spine. This has the advantage of picking up the septal carti-  lage low down on the palatal shelf and the stripping of the  mucoperiosteum is significantly simpler and easier than the  traditional approach. Stripping of the mucoperiosteum is  the difficult part of the procedure and a sharp dissector is  essential, to ensure no perforations of the mucosa occur. Ifa    Cut edge of  septal cartilage  Rotating cutting  edge of Ballinger  swivel knife    (a) mucosal cut anteriorly and (b) septal cut a few millimetres  posterior to this.    Figure 19.33 View of the cut surface of the septal cartilage from the front through the right nostril after retraction of the muco-    perforation does occur in both surfaces, a permanent fistula  is likely to create an irritating whistling sound on breathing.  Once the mucoperiosteum has been raised on the operative  side, an incision is made through the cartilage and strip-  ping commenced on the contralateral side. The septum can  then be excised and harvested. If the nose is not to ‘collapse’  a horizontal and anterior vertical strut of cartilage about  5 mm in width must be preserved. Closure is in a single  layer and supplemented by through and through mattress  sutures to prevent haematoma formation. Sometimes, bilat-  eral packs are placed to prevent haematoma formation but,  while a traditional approach, its value in producing com-  pression in the right place is doubtful.    e When replacing skin in the facial region, the donor skin  or skin flap should ideally be from same aesthetic zone.   e Meticulous technique and haemostasis and a two-layer  closure is essential for the best results.   e A split-thickness skin graft should be no thicker than  0.2 mm (the thickness of a size no. 15 scalpel).   e There are many sites for harvesting non-vascularized  grafts but the iliac crest and costal cartilage provides a  good amount of bone and cartilage, respectively, with  low morbidity at the donor site.   e Anon-vascularized bone only fibula may be successful  if when harvested it is not possible to do microvascular  reconstruction for whatever reason.    Bater MC, Brennan PA, Mellor TK and Tilley E. Occult  stenosis of the common carotid artery complicating  mandibular reconstruction with a fibular free flap. Br  J Oral Maxillofac Surg. 2006; 44: 52-53.   Brennan PA, Mahadevan V and Evans BT. Clinical Head  and Neck Anatomy for Surgeons. Boca Raton: FL: CRC  Press; 2015.    Ward Booth P. Maxillofacial Surgery, Second Edition.  Amsterdam, the Netherlands: Elsevier; 2008.   Ilankovan V, Ethunandan M and Seah T. Local Flaps in  Facial Reconstruction. A Defect Based Approach. New  York, NY: Springer; 2015.   Indications  Contraindications  Pre-operative workup  Selection of donor site  Microsurgical principles  Basic anastomotic technique  Post-operative care  Complications    Within the head and neck, microsurgical reconstruction  is employed when other options such as local and dis-  tant flap transfers are deemed inappropriate. Although  microsurgery is widespread it is not the first choice in the  reconstructive ladder and may not be the best solution for  all defects. It does, however, offer the surgeon the widest  range of possibilities for complex reconstruction.    Microsurgical transfers are commonly long and tech-  nically demanding operations. In addition, emergency  re-intervention may be necessary. Contraindications for    this type of procedure therefore include medical illnesses  that preclude the ability of a patient to tolerate prolonged  anaesthesia. Advanced age is not necessarily a contraindi-  cation, nor is a potentially severe medical problem so long  as it is well controlled.    A comprehensive history and physical examination is  mandatory as is close liaison with involved anaesthetic  and intensive care staff. Pre-optimization of patients may  be advantageous in selected cases. Many patients under-  going microsurgery will have already undergone imaging  dependent on their primary disease but additional inves-  tigations specific to the reconstruction may also be appro-  priate, e.g. limb angiography.    Decision-making is critical to the success of microsurgery.  The choice of the optimal flap is based on a combination  of factors that include the type of tissue required, pedi-  cle length and flap reliability. In addition, consideration  should be given to donor-site morbidity.   Within the head and neck, a large number of options  exist. The microsurgeon should be familiar with the   Within the head and neck, most forms of reconstruc-  tion can be comfortably undertaken with 10 flaps:    1. Radial forearm free flap (RFFF)  2. Anterolateral thigh flap (ALT)  3. Lateral arm flap  4. Rectus abdominis  5. Latissimus dorsi  6. Fibular  7. Vascularized iliac crest (deep circumflex iliac artery  [DCIA])  . Scapular/parascapular  9. Jejunum  10. Gracilis    In broad terms, the above can be divided into three groups,  namely soft tissue flaps, hard tissue flaps and combina-  tions. The choice of soft tissue flap very much depends on  the volume of the defect. The body habitus of the patient in  part determines bulk although variation in operating tech-  nique may overcome this (e.g. intra-operative thinning of  ALT). In bony reconstruction, the operating surgeon may  have a lesser degree of control (e.g. double-barrelled fibu-  lar to confer alveolar height).    Attention to detail is mandatory. Having planned the flap  based on the size and type of tissue required an alterna-  tive reconstruction should always be considered as a ‘life-  boat’. Recipient vessel location should be planned out  with potential zones of injury (e.g. previous radiotherapy  fields). Two-team operating should be employed wherever  possible to both minimize the length of the operation and  ensure that a well-rested surgeon is available for the more  technically challenging aspects of the operation.   The overall plan should be discussed with the anaes-  thetist including details of the length of procedure and  required positioning of the patient. Potential donor sites  should be devoid of vascular access. During the operation  and in the immediate post-operative period, prolonged  use of vasoconstrictors should be avoided. The patient  should be adequately hydrated with a good central venous  pressure. Likewise, the patient's core temperature should  be maintained to avoid vasospasm. If hypotensive anaes-  thesia is adopted at any stage (e.g. during ablation) then  this should be reversed prior to microsurgery.   The main enemy of the microvascular surgeon is fatigue.  Physical exertion, alcohol and caffeine should be avoided for  at least 24 hours in individuals prone to a tremor. The operator  should take short breaks to minimize waning performance  that can accompany long periods of concentration. Above all,  both the microsurgeon and assistant should feel physically  comfortable throughout with appropriate seating.    © Magnifying ocular loupes. Loupes are often more  convenient than the microscope for preliminary dissection  and can be used for anastomosis of vessels greater than 3  mm in diameter. Simple models with elasticated headbands  magnify up to 1.8x whilst more sophisticated binocular  loupes fitted to spectacles can provide up to 4x magnifica-  tion (Figure 20.1). Loupes with higher magnifications tend  to have small fields of vision and depth of focus.   © Operating microscope. Although the operating micro-  scope has many advantages in providing magnification  and illumination, it brings with it additional problems of  cost, set-up time and intra-operative positioning. A dou-  ble-headed operating microscope with the surgeon and  assistant at opposite ends is essential for head and neck  reconstruction (Figure 20.2). Most commonly this set-  up is achieved through the use of beam splitters so that  the surgeon and assistant have the same view. Coaxial  illumination is also important to avoid shadows. Because  of the frequent need for changing magnification zoom  systems operated by either a foot or finger should be  incorporated. Through-the-microscope photographic or  DVD capabilities enhance teaching and documentation.    Most microsurgical procedures can be performed with  a simple, well-maintained basic set of instruments  (Figure 20.3).    © Jeweller’s or watchmaker's forceps (hereafter called  microsurgical forceps). The tips of these must meet  evenly over a length of at least 2 mm.    Vessel dilators. These are microsurgical forceps rounded  and polished at the tip. Closed tips can be inserted into  the end ofa divided vessel with minimal trauma.  Needle holders. Purpose-designed models have spring-  loaded handles that have a round or flat grip and are  curved, angled or straight depending on operator  preference.   Dissecting scissors. These should be spring handled. The  curved blades can be short or long.   Adventitia scissors. These are identical to dissecting  scissors but have straight blades.   Vessel clamps (Figure 20.4). Spring-loaded variet-  ies are available for arteries and veins. Some sur-  geons also use double-approximater clamps to aid  anastomosis.    At least two sets of microvascular instruments should  be available in case emergency re-operation is necessary.  Whenever instruments are not in immediate use, the tips  should be protected with rubber tubing. Regular demag-  netization is necessary.    There are several essential requirements to ensure an  adequate anastomosis with long-term patency:    There should be meticulous, atraumatic dissection of  involved vessels with ligation or selective coagulation of  branches.   The vessel wall and the intima at the site of the intended  anastomosis must be resected to apparently normal tis-  sue. Care should be taken to inspect the lumen of an  artery for atherosclerotic plaques or vein for adjacent  valves.   Adequate blood flow should be demonstrated from the  recipient artery prior to anastomosis. If flow is impaired,  dilation can be attempted or pharmacological agents  can be applied (e.g. papaverin).   Anastomoses should be completed without tension,  employing vessel immobilization or vein grafts as  necessary.   Overhanging adventitia should be removed and sutures  placed without trauma to the intima. All traces of con-  taminants should be irrigated with heparinized solu-  tions (100 U/mL) prior to completion of the anastomosis.    Personal preference means that some surgeons use  interrupted sutures and some prefer a continuous  pattern. The technique most commonly taught is the    joining of vessels end-to-end using a triangulation  method whereby two stay sutures are inserted 120°  apart so that when they are placed under tension the  front wall of the anastomosis is stretched laterally  (Figure 20.5). As a result, the back wall tends to fall  away and is less likely to be picked up inadvertently.  In the clinical situation, this is not always possible and  many prefer two sutures at 180°.   After vessels have been prepared, the two stay  sutures should be placed and the ends left long, such  that they can be anchored to the cleats of a double  clamp or held by an assistant. The front wall is then  sutured using square or reef knots that must lie flat  against the anasto-mosis line so that the threads do  not project into the vessel lumen (Figure 20.6). Two or  more co-optation sutures are then placed between the  stay sutures before the vessel is rotated through 180°.  The anastomosis should be critically appraised before  the back wall is closed (Figure 20.7).   The venous anastomoses is performed in an identi-  cal manner to the artery but can be technically more  demanding because the absence of a substantial mus-  cularis means the vein wall collapses easily. Minimal  adventitial stripping is therefore recommended. Overuse  of irrigation should also be avoided since it tends to strip  the adventitia.   Once the anastomosis is complete, the necessary clamps  are released and blood flow observed under magnification.    An initial small ooze commonly occurs but generally stops  within a few minutes. Pulsatile bleeding requires place-  ment of further sutures.    The arteriotomy or venotomy in the recipient vessel is  the most critical step in this procedure since it must  match the size of the vessel to be anastomosed. The  adventitia around the intended site should be carefully  removed so that it does not protrude into the newly  formed lumen. Stay sutures are initially placed at the  proximal and distal ends of the arteriotomy or venot-  omy (Figure 20.8). Secondary co-optation sutures are  then inserted along the anastomosis line with either  the front or back wall being closed first depending on  operator preference (Figure 20.9).    Discrepancy in vessel size can be solved by performing an  end-to-side anastomosis. Alternatively the smaller vessel  can be dilated, transecting on a 45° diagonal (Figure 20.10)  or incised to create a fishtail (Figure 20.11).    A critical assessment should be made prior to accepting  the anastomosis. The most common errors in technique  include as follows:   ® Stitches are too loose so that a loop of material intrudes  into the lumen    Some surgeons prefer the use of microvascular anas-  tomotic couplers to hand-sewn anastomosis. The cou-  pler is a mechanical implantable device comprising an    interlocking ring-pin design. Its use is most established in  the end-to-end anastomosis of veins.    Anastomotic patency can be assessed in a variety of ways.  Arterial patency is indicated by well-dilated vessels dem-  onstrating either pulsatile elongation or expansile pul-  sation. The empty and refilled patency test (‘milking’ an  anastomosis) is traumatic and should be performed as gen-  tly and infrequently as possible. Ultimately, anastomotic    patency can be assessed by a return of colour and capillary  refill to the revascularized tissue.    Post-operative staff must be familiar with free-flap moni-  toring and the general care of the microsurgery patient.  A hyperdynamic circulation with adequate hydration, fill-  ing pressures, urine output and body temperature should  be the aim. Pain should be controlled to prevent anxiety  that in turn leads to vasoconstriction. Anti-coagulation  may be used depending on the surgeon's preference (e.g.  Dextran 40, heparin, aspirin).   Free-flap monitoring is also dependent on preference.  The criterion standard remains careful and regular clini-  cal examination of the flap (colour, skin turgor, refill etc.).  Some surgeons prefer a needle test which should result in the  oozing of bright red blood up to a minute after the needle is  withdrawn. Other monitoring techniques include as follows:    If vascular compromise is suspected within a free flap,  immediate measures should be taken as follows:   @ In the absence of haematoma release of the vacuum on  any relevant drain in case the pedicle is in contact with  the drain holes    If such simple manoeuvres are not successful, immedi-  ate re-exploration is critical so long as the patient's general  condition allows it.    Microsurgical operations are by their very nature physiologi-  cally traumatic for the patient. Potential major complications  may occur including myocardial infarction, stroke and death.  Informed consent is mandatory and should include detailed  discussions with appropriate warnings to include as follows:    The delivery of blood into and out of the flap depends  on meticulous harvesting of the nutrient pedicle, careful  preparation of the recipient vasculature and a technically  perfect anastomosis. Care must also be paid to the geom-  etry of the pedicle to prevent tension and kinking caused  by head mobility.    Recipient vessel selection is one of the most critical steps  in ensuring a successful outcome. Careful intra-operative  selection greatly facilitates the process of revasculariza-  tion and as a result vessels should be selected and isolated  prior to flap division to minimize the ischaemic period.  The majority of the flap insetting should be completed  prior to the anastomosis since this is not only facilitated by  working on an ischemic flap but the position of the donor  vessels becomes fixed after insetting which allows tension  on the vascular pedicle to be predicted.   Aside availability, a number of other factors must be  considered when selecting recipient vessels. The choice  of vessel is in part limited by the site of the defect and  particular flap employed (e.g. in the DCIA, the venae  commitantes can be unsuitable for anastomosis until  they join to produce a vein of suitable calibre). The  presence of a previous ipsilateral radical neck dis-  section may limit the availability of recipient vessels.  Advanced age and previous irradiation may also lead  to athrosclerosis.    The two major sources of arteries are branches of the exter-  nal carotid artery and the thyrocervical trunk. Because of  their proximity to defects, the upper branches of the for-  mer are the most commonly employed. However, the thy-  rocervical trunk and in particular its transverse cervical  artery (TCA) are almost always preserved following neck  dissections and provide a useful alternative. The TCA can  be traced for a significant distance underneath the tra-  pezius muscle and comfortably transposed into the mid  portion of the neck. This vessel is far less prone to athro-  sclerosis than the external carotid artery and usually lies  outside the area of most intense radiation therapy. Rarely,  the internal mammary system can be used.    There are three primary recipient veins in the neck. Whilst  the internal jugular vein or its immediate branches serve  as an excellent outflow, the external jugular and transverse  cervical veins are alternatives. The anterior jugular vein    should be avoided since its caudal portion is at risk during  tracheostomy. The cephalic vein may be used as a source  of vein grafts or can be used as a recipient vein if traced  distally into the arm and then transposed over the clavicle.  Rarely, a Corlett loop can be fashioned from a vein graft to  produce a temporary arteriovenous fistula.   e The microsurgeon should be well rested prior to the  operation and comfortable throughout it.   e Flaps used should reflect anatomical and functional  considerations rather than the surgeon’s favourite.   e The surgeon should be critical about every suture  placed. If he or she is not satisfied that suture should  be replaced.   e The surgeon should be critical about the completed  anastomosis. It is far better to repeat an anastomosis  during the time of primary surgery than return to it  once vascular compromise is apparent hours later.    Bozikov K and Arnez ZM. Factors predicting free flap com-  plications in head and neck reconstruction. J Plast  Reconstr Aesthet Surg. 2006; 59(7): 737-742.   Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A and Mehrara  BJ. Free flap reexploration: Indications, treatment,  and outcomes in 1193 free flaps. Plast Reconstr Surg.  2007; 119(7): 2092-100.   Chalian AA, Anderson TD, Weinstein GS and Weber RS.  Internal jugular vein versus external jugular vein  anastomosis: Implications for successful free tissue  transfer. Head Neck. 2001; 23(6): 475-478.   Chang EI, Zhang H, Skoracki RJ, Yu P and Hanasono MM.  Defining an algorithm to guide salvage ofa failing free  flap in head and neck reconstruction. Plast Reconstr  Surg. 2014; 134: 12-13.   Okazaki M, Asato H, Takushima A, Sarukawa S, Nakatsuka T,  Yamada A and Harii K. Analysis of salvage treatments  following the failure of free flap transfer caused by vas-  cular thrombosis in reconstruction for head and neck  cancer. Plast Reconstr Surg. 2007; 119(4): 1223-1232.   Urken M, Cheney M, Sullivan M and Biller H. Atlas of  Regional Free Flaps for Head and Neck Reconstruction.  New York, NY: Raven Press; 1995.    The radial forearm flap may be harvested as a fasciocu-  taneous, septocutaneous, fascial or osteocutaneous flap.  A sensory nerve or the palmaris longus tendon may also  be included. The soft tissue flap is an accepted ‘workhorse’  for oral reconstruction, providing a large area of relatively  hairless and thin pliable skin. The flap is straightforward  to raise and has a long vascular pedicle.   Management of morbidity at the donor site has focussed  on the cosmetic defect and the relatively high incidence  (typically over 10%) of skin-graft loss, delayed healing and  tendon exposure. The incidence of these complications  can usually be reduced to below 5% by elevation of the  flap in a suprafascial plane. In addition, over 70% of the  strength of the original radius is lost after the harvest of  an osteocutaneous flap and the mean incidence of fracture  is 25%. A fracture results in further significant morbid-  ity and often requires secondary surgery. This complica-  tion and the relative lack of bone volume resulted in the  radial osteocutaneous flap being superseded by alternative  options. However, the use of prophylactic internal fixation,  with a bone plate, has now become well established and  has reduced the incidence of fracture to approximately 2%.   © Not an ideal cosmetic replacement for facial skin but use-  ful for reconstruction of lip and circumoral defects when  the palmaris longus tendon improves lip competence.    ® Indications for the osteocutaneous flap have declined  as other donor sites offer greater volume of medullary  bone or better quality cortical bone.   ate, nasal bone and orbital rim. It may still be useful for    In the distal forearm, the radial artery lies in the super-  ficial subcutaneous tissues between the brachioradialis  and flexor carpi radialis tendons. It is enveloped by the  conjoining of two layers of deep fascia (Figure 21.1) and  gives off multiple small vessels (septocutaneous perfo-  rators) to the overlying skin from a subdermal plexus.  Musculoperiosteal perforators pass inferiorly to the  musculature and periosteum of the radius through the  flexor pollicus longus (Figure 21.2). Drainage of the flap    Figure 21.1 Cross section of wrist with radial artery enveloped by deep fascia.    is via the radial venae comitantes and/or the superficial  subcutaneous veins, often the cephalic vein. A single vena  comitans often provides satisfactory venous drainage but  a double anastomosis or confluent vein may be preferred.   Although conventionally raised as a fasciocutaneous  flap the deep fascia is not essential for skin perfusion. The  enveloping fascia around the pedicle may be opened and  a septocutaneous flap elevated in the suprafascial plane  (Figure 21.3). If the fascial covering of the flexor tendons  is retained the problems associated with skin graft heal-  ing may be minimized when compared with the subfascial  donor defect.   A branch of the lateral or medial cutaneous nerve of the  forearm is incorporated if a sensate flap is required.    The non-dominant forearm is preferred (Figure 21.4).  The sufficiency of the residual ulnar supply to the hand is  confirmed clinically by the Allen test and supplemented  by Doppler studies. The entire skin of the forearm may be  safely transferred but most intra-oral defects are recon-  structed with flaps of 7 cm x 5 cm or smaller. The flap  is designed with the artery towards the lateral aspect to  avoid the more hirsute skin and an unsightly extension  over the radial aspect of the forearm. If the distal fore-  arm skin is especially thin then the flap may be positioned  more proximally. Most defects are repaired with a full-  or partial-thickness skin graft but small defects may be  closed directly with an ulnar transposition flap or a V-  to Y-closure, although these latter techniques may cause  additional oedema and numbness.   The flap is raised under tourniquet control (200-mmHg  pressure) following partial exsanguination by elevation.  Binocular loupes are useful to identify small feeding vessels  that should be carefully managed with bipolar diathermy  or preferably ligation clips. Starting at the medial (ulnar)    border the incision is deepened through subcutaneous fat  and fascia to expose the underlying muscle. The incision  is extended around the proximal and distal aspects. The  assistant applies gentle traction to facilitate sharp dissec-  tion beneath the fascia from medial to lateral. Remaining  in the subfascial plane but taking care to avoid damaging  the paratenon as the palmaris longus and medial edge of  the flexor carpi radialis are exposed (Figure 21.5).   As the lateral (radial) border of flexor carpi radialis is  approached, continue in the subfascial plane and identify  flexor pollicis longus lying at a deeper level. This avoids  inadvertent detachment of the vascular pedicle now seen  on the undersurface of the flap. The distal radial artery    Figure 21.5 Ulnar elevation of fasciocutaneous flap in sub-  fascial plane.    should be divided and ligated to confirm the position of  the pedicle (Figure 21.6).   The circumferential incision is completed on the lateral  (ulnar) aspect ensuring that the pedicle lies within the  margins of the flap. The superficial cephalic vein, or a main  branch to it, may also be included. The brachioradialis ten-  don is exposed and retracted laterally to identify and pro-  tect the superficial sensory branch of the radial nerve. The  skin paddle is now elevated taking care to ligate any small  vessels passing to the underlying muscle and bone. Flap  elevation is facilitated by opening the proximal forearm  incision at an early stage. Proximal and lateral subcutane-  ous dissection is necessary if the cephalic vein or lateral  cutaneous nerve is included.   The proximal forearm incision is often completed with a  z-plasty incision in the cubital fossa. The fascial septum  between brachioradialis and flexor carpi radialis is opened  to expose the arterial pedicle. The skin flap is held in a  damp swab and gently lifted. Small muscular side branches  are carefully ligated. A variable amount of subcutaneous  tissue may be harvested with the pedicle. The limit of the    Figure 21.7 Elevation of vascular pedicle with confluent  deep and superficial venous systems.    arterial pedicle is the bifurcation of the brachial artery but  full length is rarely needed and the radial recurrent artery,  just distal to the bifurcation, can often be spared. The deep  and superficial venous systems usually unite at the cubital  fossa and the confluent vein will provide additional length  (Figure 21.7).    The tourniquet is released and perfusion of the flap and  hand is checked. Complete hemostasis is obtained along  the pedicle and on the undersurface of the flap. Allow  time for relaxation of small vessel spasm and apply topi-  cal papaverine. Closure of the distal forearm incision  may be performed at this stage. The flexor tendons may  be oversewn with muscle or left exposed (Figure 21.8).  The author prefers to repair the donor defect with a full-  thickness skin graft from the inner upper arm or inguinal  crease and a partial-thickness graft from the outer upper  arm or thigh is used for large defects. The veins may be  divided first to assess the venous outflow before clamp-  ing and dividing the arterial pedicle. A suction drain is  inserted and the proximal forearm wound closed. The  wrist may be splinted to minimize movement of the ten-  dons. Alternatively, a negative pressure wound dressing is  applied without a deep suction drain or splint. The nega-  tive pressure dressing holds the skin graft in close proxim-  ity to the donor site and the wrist remains mobile (Figure  21.9). The perfusion of both the flap and hand should be  closely monitored.   Incise the skin to expose the deep fascia. Sharp dissec-  tion is carried out in the immediate suprafascial plane.  The technique is slightly more demanding and binocu-  lar loupes are essential. Flap elevation begins at the ulnar  (medial) border as usual and progresses laterally over  flexor carpi radialis, stopping short of the radial artery    (Figure 21.10). A few small fasciocutaneous perforating  vessels to the inferior surface of the flap are cauterized.    The distal end of the arterial pedicle is ligated and divided.  Lifting the pedicle exposes the floor of the fascial enve-  lope between the flexor tendons (Figure 21.11). The medial  and lateral aspects of this envelope are incised parallel  and close to the pedicle. The floor of the fascial envelope  becomes progressively thinner and larger musculoperi-  osteal perforating vessels from the inferior surface of the  pedicle are ligated. Dissection on the radial aspect is in  the plane of the superficial radial nerve, taking care not  to disrupt the subcutaneous plexus. The forearm skin and  fascia overlying the brachioradialis and flexor carpi radia-  lis are incised to retract these muscles and the proximal  dissection of the pedicle is completed as described in the  section ‘Flap mobilization’. The donor site remains largely  covered with investing deep fascia and often some deep  subcutaneous tissue on the radial aspect (Figure 21.12).  The author prefers to manage the defect with a fenestrated  full-thickness skin graft and a negative pressure wound  dressing.    The skin paddle and bone graft are marked out. Typically, a  maximum of 11-13 cm can be harvested. The limiting fac-  tor is the attachment of pronator teres, although this may be  reattached if stripped. If prophylactic internal fixation is to  be applied allow at least 2 cm from the distal osteotomy to  the radial styloid to place a straight bone plate (Figure 21.13).    Dissection of the skin flap is easiest in the subfascial plane  but an incomplete suprafascial approach is an option.  Starting on the ulnar aspect proceed as far as the lateral  (radial) border of the flexor carpi radialis. The distal ped-  icle is ligated and divided. If the initial dissection is in the  suprafascial plane, the fascia must be incised along the lat-  eral border of the flexor carpi radialis.    The proximal investing fascia is divided to retract the flexor  carpi radialis. Damage to the median nerve which lies  medial to the distal aspect of the tendon is to be avoided.  Retraction exposes the flexor pollicis longus and prona-  tor quadrates, which are incised along the length of the    Figure 21.14 Retraction of flexor carpi radialis and identifi-  cation of lower (posterior) border of radius.    bone graft to reach the ulnar (anteromedial) aspect of the  radius. Preserve sufficient muscle cuff to protect periosteal  perforating vessels passing through the muscles from the  inferior surface of the pedicle. Most perforators run close  to or in the lateral intermuscular septum which remains  attached to the lateral aspect of the bone graft.   The periosteum is incised and the cuff of flexor pollicis  longus sparingly elevated to mark out the osteotomy site.  Identify the interosseous and lower (posterior) border of  the radius to avoid excessive bone removal, particularly in  the mid-section where it curves upward in a convex man-  ner (Figure 21.14). Plan to remove one-third to one-half of  the radial circumference of the bone. A computer-gener-  ated osteotomy planning template may be utilized.   The horizontal anteromedial osteotomy is performed from  the ulnar aspect with either a narrow fissure burr using  the ‘postage stamp’ method or a fine saw. Usually 6-12 cm  of bone is required. Take care to protect the cuff of flexor  pollicis longus (Figure 21.15). The end osteotomies are    bevelled and may be rounded out with a stop hole to avoid  over-cutting and stress concentration. The graft is gently  mobilized with a fine-curved osteotome.   Retract the brachioradialis and dissect on the deep sur-  face down to the osteotomy site, taking care to preserve  the attachment of the intermuscular septum to the lateral  aspect of the bone. The distal aspect of the flap is lifted  superiorly by incising the periosteum and dividing any  other retaining soft tissues, taking care to avoid damaging  the pedicle. The proximal dissection is completed as nor-  mal. If proximal muscle attachments have been stripped,  these may be reattached.   An anterior or posterior approach may be utilized but  the former is probably the most common. The dis-  tal osteotomy must be at least 2 cm proximal to the  radial styloid to allow space for two screws and to  avoid the wrist joint. The proximal and distal mus-  cle attachments are stripped and repositioned later.  A 3.5-mm_ straight dynamic compression plate is  adapted to bridge the defect on the anteromedial sur-  face of the radius. At least two bicortical screws are  inserted at each end in a neutral (non-compressive)  position ensuring both medial and lateral cortices are  engaged (Figure 21.16). A weaker but more malleable  3.5-mm pelvic reconstruction plate may be placed over  longer defects. More recently, anatomically contoured  low-profile 3.5-mm radial plates with unilocking screw  systems have been shown to be as effective and a T-shaped  plate is helpful if distal space is limited (Figure 21.17).   The flexor pollicis longus and brachioradialis muscles  are approximated to cover the plate (Figure 21.18) then  the donor site is managed with a skin graft and negative    Figure 21.16 Prophylactic internal fixation with a 3.5-mm  steel dynamic compression plate.    pressure wound dressing. A complete above-elbow cast,  which may be pre-fabricated, is applied and the arm sup-  ported in a sling. A below-elbow cast is placed for 6 weeks  when the skin graft is inspected after 10 days. The plate  rarely requires removal.    e Plan flap with artery at the lateral edge. This avoids hair  remaining on the flap and improves aesthetics.   e Using the deep venous drainage system (venae comi-  tantes) simplifies the dissection.   e Let the flap rest at the donor site after elevation. This  allows vascular spasm to relax.   e With a composite flap never harvest more than 50% of  the circumference of the radius.    Arganbright JM, Tsue TT, Girod DA, Militsakh ON, Sykes KJ,  Markey J, et al. Outcomes of the osteocutaneous radial  forearm free flap for mandibular reconstruction. JAMA  Otolaryngol Head Neck Surg. 2013; 139: 168-172.   Avery C. Review of the radial free flap: Is it still evolving, or  is it facing extinction? Part one: Soft-tissue radial flap.  Br J Oral Maxillofac Surg. 2010; 48: 245-252.   Avery C. Review of the radial free flap: Still evolving or fac-  ing extinction? Part two: Osteocutaneous radial free  flap. Br J Oral Maxillofac Surg. 2010; 48: 253-260.   Avery C. Prospective study of the septocutaneous radial free  flap and suprafascial donor site. Br J Oral Maxillofac  Surg. 2007; 45: 611-616.   Avery C, Bujtar P, Simonovics J, Sandor G, Pan J and  Varadi K. A finite element analysis of bone plates  available for prophylactic internal fixation of the  radial osteocutaneous donor site using the sheep tibia  model. J Med Eng Phy. 2013; 35: 1421-1430.   Avery C, Martin T, and Parmar S. The use of the anatomi-  cally contoured low profile unilocking titanium radial  plate for prophylactic internal fixation of the radial  osteocutaneous donor site. Br J Oral Maxillofac Surg.  2011; 49: 152-153.   Bowers KW, Edmonds JL, Girod DA, Jayaraman G, Chua  CP and Toby EB. Osteocutaneous radial forearm free  flaps. The necessity of internal fixation of the donor-  site defect to prevent pathological fracture. J Bone  Joint Surg Am. 2000; 82: 694-704.   Bujtar P, Simonovics J, Sandor G, Jingzhe P and Avery C.  Refinements in osteotomy design to improve struc-  tural integrity: A finite element analysis. Br J Oral  Maxillofac Surg. 2013; 51: 479-485.   Lutz BS, Wei FC, Chang SC, Yang KH and Chen IH. Donor  site morbidity after suprafascial elevation of the radial  forearm flap: A prospective study in 95 consecutive  cases. Plast Reconstr Surg. 1999; 103: 132-137.   Villaret DB and Futran NA. The indications and outcomes  in the use of osteocutaneous radial forearm free flap.  Head Neck. 2003; 25: 475-481.    The subscapular-based system of flaps has enjoyed much  popularity in head and neck reconstruction since 1978  when Saijo provided the potential of raising a muscu-  locutaneous flap from the back based on the circumflex  scapula vessels.   Subsequently, Gilbert and Teot in 1979 were the first to  report the use of such a flap, but it was dos Santos in 1980  who extensively described the vascular anatomy of this  donor site.   In 1982, Nassif further elaborated on the vascular terri-  tory of the subscapular system and published his variation  of the subscapular flap.   In 1981, Teot described the vascular anatomy to the lat-  eral border of the scapula.   Swartz et al. in 1986 and Baker and Sullivan in  1988 are credited with the popularization of this com-  posite osteocutaneous flap for use in head and neck  reconstruction.   Furthermore, since 1991 various authors have published  extensively on use of the scapula tip as a bone only flap  based on the angular branch of the thoracodorsal artery  which significantly increases pedicle length.    e Segmental resection of the mandible with or without  soft-tissue skin paddle    The subscapular system of flaps arises from the subscapu-  lar artery and vein which are branches of the third part of  the axillary artery and vein, respectively. The circumflex    scapula artery (CSA) and vein (CSV) together with the tho-  racodorsal artery and vein form the two primary branches  of the circumflex scapular vessels.   The CSA exits through the muscular triangle formed  by the teres minor and major muscles and the long head  of triceps brachii muscle. It divides further into bony and  cutaneous branches in a predictable fashion to supply the  lateral scapula border and skin overlying the scapula.   The lateral scapula border is supplied by periosteal  branches arising from the CSA whilst the remaining  terminal cutaneous branches form the transverse and  descending branches supplying the scapula and parascap-  ula skin paddles, respectively.   The CSA is usually accompanied by two venae comi-  tantes which frequently drain into the thoracodorsal vein  but in 10% of cases have been shown to drain directly into  the axillary vein. The CSV averages 3 mm in diameter. At  its origin from the subscapular artery, the CSA averages  4 mm in diameter, whilst at its origin from the axillary  artery the diameter increases to 6 mm.   Vascular pedicle length is dependent on the extent of  proximal dissection with a pedicle length measuring up to  6 cm available when harvesting the CSA at its origin from the  subscapular artery. However, increased pedicle lengths mea-  suring 11-14 cm are possible when the subscapular vessels  are divided at their origin from the axillary artery and vein.   The scapula tip is supplied by the angular branch of  the thoracodorsal artery, a highly consistent anatomi-  cal finding. It branches from the thoracodorsal artery  just proximal to a branch supplying serratus anterior or  less commonly at a point distal to this vessel and supplies  muscular branches to the subscapularis muscle before ter-  minally arborizing in the periosteum of the scapula tip  approximately 3 cm from its most caudal point. This ves-  sel is consistently located in the plane between teres major  and latissimus dorsi and once identified can be traced to  its termination at the scapula tip following transection of  teres major.   Sensory supply to the overlying skin is derived from the  dorsal rami of the corresponding spinal nerves; however,  these nerves have not been shown to maintain useful sen-  sation to skin paddles from this donor site.   Several publications investigating the vascular anatomy  of this region have confirmed its predictability and ana-  tomical consistency.    Harvesting of the osteocutaneous scapula flap begins with  patient positioning. Traditionally, intra-operative repo-  sitioning of the patient, at least once into the lateral decu-  bitus position was necessary following tumour ablation.  This unfortunately adds significant operative time as a  two-team approach is not possible and sterile prepara-  tion and re-draping of the donor site is required. However,    intra-operative repositioning can be avoided by placing the  patient in a semi-lateral decubitus position exposing the ipsi-  lateral scapula and supporting the patient with an inflatable  sand bag. The ipsilateral arm is covered to the elbow with a  sterile stocking and the entire upper extremity and posterior  trunk can be sterilized and draped in continuity with the  head and neck allowing access for the ablative component  and harvesting of the scapula flap without violating sterility.    In this lateral position, the assistant can support the arm  exposing the scapula and axilla. Appropriate skin mark-  ings are made including an outline of the scapula and its  spine together with the attaching musculature and triangu-  lar space. A sterile handheld pencil Doppler is used to trace  out the path of the transverse and descending cutaneous  branches of the CSA including the CSA itself as it emerges  from the triangular space. The CSA and its branches are  then outlined on the skin and an appropriate-sized skin  paddle is delineated over the respective cutaneous branch.  Typically, for the osteocutaneous scapula flap the trans-  verse branch is utilized affording greater flexibility of the  skin paddle relative to the bone, whilst the parascapular  flap is based on the descending cutaneous branch.    Harvesting begins by elevation of the skin paddle from  medial to lateral in a suprafascial plane relative to infraspi-  natus and continued until the lateral border of the scapula  is reached. In this plane, one can often see the transverse  branch and follow it to its confluence with the descend-  ing branch and the parent circumflex scapula vessels more  proximally as dissection is carried towards the triangular  space. Once these vessels are confirmed, the teres major is  exposed to its inferior border and transected followed by  division through infraspinatus with bovie down to scap-  ula periosteum. This allows exposure of the lateral scapula  border and the required length of bone can be outlined.  An oscillating saw is then used to complete the bony cuts  with a malleable retractor placed on the deep surface of the  scapula whilst making the superior and inferior lateral cuts  to protect the underlying chest wall. Upon completion of  the bone cuts, the bone segment can be retracted out of the  wound to expose the underlying subscapularis and bipo-  lar cautery is used to divide subscapularis leaving a small  muscle cuff on the undersurface of the bone thus preserv-  ing the muscular and periosteal blood supply to the bone.    Attention is then drawn to completion of the outline of the  skin paddle over the triangular space and dissection down  to the circumflex scapula vascular pedicle under direct    vision. More proximal dissection of the vascular pedicle  continues until the origin of the CSA and CSV from the  subscapular vessels is encountered. The thoracodorsal ves-  sels should become apparent at this point. The bone and skin  paddle are then assessed for perfusion and pedicle division  follows just distal to the takeoff of the thoracodorsal vessels.  Greater pedicle length may be achieved by sacrificing the  thoracodorsal vessels and dividing the pedicle at the origin  of the subscapular vessels from the axillary artery and vein.    Wound closure follows with reattachment of the teres  major to the remaining body of scapula through drill holes  and thick vicryl sutures. A large calibre vacuum suction  drain is placed and the wound margins are approximated  primarily and skin is sutured or stapled. Gauze dressings  are placed over the wound and the flap is transferred to the  head and neck recipient site for insetting after copious irri-  gation of the flap vascular system with heparinized saline.    Harvesting of the parascapular fasciocutaneous flap begins  in a similar fashion to that of the osteocutaneous flap  described above with an exception that this flap is based over  the descending cutaneous branch and does not include bone.   Identification of the cutaneous branch is performed  with handheld pencil Doppler and an appropriate-sized  skin paddle is outlined over this vessel including the point  of emergence of the CSA through the triangular space.   Skin paddle elevation begins caudally and progresses in a  subfascial plane to ensure the descending branch is captured  with the skin flap. As the triangular space is encountered  and confirmed through the identification of the upper bor-  der of teres major, the transverse cutaneous branch should  become apparent at which point it can be divided once the  CSA is visualized. The outline of the skin paddle is then  completed and pedicle dissection in a retrograde direction  follows until the origin of the circumflex scapula pedicle is  identified arising from the subscapular vessels. Pedicle divi-  sion may be performed at this point or more proximally at  the origin of the subscapular vessels from the axillary artery  and vein if greater pedicle length is needed.   The upper extremity and shoulder girdle should be  immobilized in the immediate post-operative period  with a splint similar to patients splinted for clavicle frac-  tures. This reduces patient discomfort and total analgesic  requirements.    Physical therapy is initiated usually after 5 days to pre-  vent shoulder and upper extremity stiffness.   Long-term physical therapy must be instituted in the  ensuing 2-3 weeks to prevent chronic restriction in range  of motion of the shoulder girdle.   General patient mobilization from bed usually occurs  on the third post-operative day but varies based on  individual unit protocols.    Shoulder joint violation. Particular attention must be made  to avoidance of entry into the glenohumeral joint poten-  tially resulting in significant articular injury, haemar-  throsis and long-term joint dysfunction.   Seroma. Meticulous layered wound closure and placement  of large calibre vacuum suction drains and pressure  dressings to minimize dead space often prevents this.  Drains should only be removed when minimal output  is seen.   Long thoracic nerve injury. Injury to this nerve is uncom-  mon and usually occurs with overzealous dissection  deep to teres major and latissimus dorsi where it passes  to innervate serratus anterior resulting in scapula  winging.   Chronic shoulder weakness/dysfunction. Limited shoulder  mobility and range of movement can result from poor  reapproximation of teres major to the remaining  scapula and inadvertent division of teres minor more  cephalad.   Lung injury/pneumothorax. This complication should not  occur and is preventable if protective retractors are  placed deep to the scapula during the performance of  bone cuts.    e The use of handheld pencil Dopplers markedly  improves the localization of the transverse and  descending cutaneous branches thus maximizing  perfusion to the harvested skin paddle.   e Where bilateral neck dissection is not warranted  patient positioning in a lateral position at the begin-  ning of the case provides adequate exposure for neck  dissection and tumour ablation followed by scapula  harvest without the need for multiple intra-operative  patient repositioning thus significantly reducing total  operative time.   e Significant increases in pedicle length may be achieved  by proximal pedicle dissection to the origin of the  subscapular vessels from their corresponding axillary  artery and vein.   e Timely institution of physical therapy following the  acute post-operative period minimizes shoulder dys-  function and limitations in movement.    Brown J, Bekiroglu F and Shaw R. Indications for the scap-  ular free flap in reconstructions of the head and neck.  Br J Oral Maxillofac Surg. 2010; 48(5): 331-337.   Coleman 3rd JJ and Sultan MR. The bipedicled osteocu-  taneous scapula flap: A new subscapular system  free flap. J Plast Reconstr Aesthet Surg. 1991; 87(4):  682-692.   Dos Santos LF. The vascular anatomy and dissection of the  free scapular flap. Plast Reconstr Surg. 1984; 73(4):  599-604.   Gilbert A and Teot L. The free scapular flap. Plast Reconstr  Surg. 1982; 69(4): 601-604.    Miles BA and Gilbert RW. Maxillary reconstruction with  the scapular angle osteomyogenous free flap. Arch  Otolaryngol Head Neck Surg. 2011; 137(11): 1130-1135.   Nassif TM, Vidal L, Bovet JL and Baudet J. The parascapu-  lar flap: A new cutaneous microsurgical free flap.  Plast Reconstr Surg. 1982; 69(4): 591-600.   Seneviratne S, Duong C and Taylor GI. The angular branch  of the thoracodorsal artery and its blood supply to  the inferior angle of the scapula: an anatomical study.  Plast Reconstr Surg. 1999; 104(1): 85-88.   Urken ML, Bridger AG, Zur KB and Genden EM. The  scapular osteofasciocutaneous flap: A 12 year experi-  ence. Arch Otolaryngol Head Neck Surg. 2001; 127(7):  862-869.   Flap harvest - rectus abdominis myocutaneous flap  Flap harvest - DIEP flap    The rectus abdominis free flap is a versatile myocutane-  ous flap based upon the deep inferior epigastric artery and  its associated vena comitans. The flap was first described  by Drever in 1977, as the ‘epigastric island flap’ and later  adapted for breast reconstruction.' Credit is also given  to Mathes and Bostwick for their use in abdominal wall  reconstruction during that same year.’   The flap has been well described for its use in recon-  struction of large volume defects of the head and neck.  Advantages of the flap include ease of harvest, two-team  approach and a long vascular pedicle with a large vessel  diameter. A large skin paddle with adequate bulk can be  provided with minimal donor site morbidity. The flap can  also be harvested based solely upon the perforating ves-  sels traversing the rectus muscle within the periumbilical  region. The deep inferior epigastric muscle-sparing perfo-  rator flap (DIEP) variant, originally described by Koshima  and Soeda in 1989, has continued to increase in popular-  ity due to its theoretic decreased risk of abdominal wall  herniation, bulge and post-operative pain.** The rectus  abdominis free flap still proves to be a valuable reconstruc-  tive tool and should be considered especially in situations  requiring large amounts of soft tissue to be transferred.>°  This chapter discusses both the rectus abdominis myocu-  taneous free flap and the DIEP flap for use in head and  neck reconstruction.    The rectus abdominis flap is a reliable flap that can be used  for reconstruction of large defects of the head and neck.  General advantages include a large caliber artery and  associated vena comitans (2-4 mm), long pedicle length  (8-10 cm), consistent anatomy and a two-team approach.  Nakatsuka et al. reported on their extensive series of 2372  free flaps for head and neck reconstruction over 23 years.  The rectus abdominis flap proved to be the most fre-  quently utilized (n = 784) free flap.° The authors’ expla-  nation for this choice of flap selection was due to its low  rate of flap necrosis and ease of use in reconstruction of  the head and neck. Although donor site morbidities such  as hernia, abdominal wall bulging and pain are generally  considered to be of a low risk, the option to use a muscle  sparing DIEP flap for the avoidance of such complications,  can be utilized.4**° This flap involves harvest of only the  skin and subcutaneous tissue based upon the deep inferior  epigastric artery. Woodworth et al. reported on a series of  11 DIEP flaps used for large volume defects of the head  and neck with the most common sites being either sub-  total glossectomy or skin defects. Leonhardt et al.’ pub-  lished a case series on 10 DIEP flaps for reconstruction of  the maxillofacial region with a defect size ranging from  40-180 cm?. In a systematic review comparing donor site    morbidity of the abdominis myocutaneous flap and the  DIEP flap, Sailon et al. reported that there was no signifi-  cant difference with respect to abdominal bulge with these  two flaps (11% versus 8%, respectively).!° In another very  large series of 1507 breast reconstruction patients compar-  ing the transverse rectus abdominis myocutaneous flap  (TRAM) versus the muscle sparing or DIEP flap the over-  all risk of hernia or muscle bulge was 5.9%.* The authors  also reported that the risk increased with the amount of  rectus fascia harvested and was significantly decreased  with the use of a mesh.    Although computer-assisted reconstruction/3D-modelling  along with improved techniques in free vascularized bone  flaps have allowed for advancements in maxillary recon-  struction, large volume soft-tissue free flaps such as the  rectus abdominis prove useful in extended maxillary/  orbital reconstruction.''"'* The bulky soft-tissue flap is  easy to inset without associated vessel geometric prob-  lems, allowing for adequate defect obturation. This will  provide acceptable facial esthetics and adequate speech  and swallowing function without the need for a pros-  thetic obturator. Pryor et al. reported on a series of 13  patients reconstructed with the rectus abdominis free  flap for such defects. The authors reported that cosmetic  results were acceptable to both patient and surgeon  whilst meeting the goal of successful obturation of the  maxillectomy defect without the need for oral cavity  defect care’’ (see Figure 23.1a through c).    Tumours involving the anterior skull base may require  both resection of hard and soft tissue. The defect cre-  ated will result in a communication between the intra-  cranial space and the paranasal sinuses/nasopharynx.  Goals of skull base reconstruction include the creation  of a watertight dural seal and the separation of the  paranasal sinuses from the neurocranium. This separa-  tion is important to prevent cerebrospinal fluid (CSF)  leak, meningitis, pneumocephalus or brain herniation.  Smaller defects can very often be repaired with local  flaps such as pericranial flaps or autologous bone grafts.  Large defects especially those in combination with  orbital exenteration are best reconstructed with vascu-  larized bulky soft-tissue flaps.    A large amount of tissue is required to restore bulk in  total/subtotal glossectomy defects. This bulk allows for   Figure 23.1 (a) Squamous carcinoma of the orbit and  ethmoid sinuses requiring orbital exenteration and cranio-  facial resection. Communication with the neurocranium  depicted. (b) Squamous carcinoma of the orbit and eth-  moid sinuses requiring orbital exenteration and craniofacial  resection. Orbital defect depicted. (c) Reconstructed cranio-  facial resection/orbital exenteration with a rectus abdominis  free flap.    improved swallow and speech function whilst providing  obliteration of dead space to help prevent an orocutane-  ous fistula. The anterior rectus fascia can also be used  to suspend the floor of mouth by suture to the inferior  border of the mandible.*-? Haddock et al. reported on  a series of eight patients reconstructed with the rectus  abdominis flap for total/subtotal glossectomy defects    in which the muscle/fascia was secured to the lingual  mucosa for suspension of the flap. The authors’ reported  that at 1-year follow-up, all patients tolerated an oral diet  without evidence of aspiration whilst maintaining intel-  ligible speech."    Large defects of the facial skin, cheek and neck can be  reconstructed with the rectus abdominis flap.>> If thin-  ning of the flap is required for a more esthetic facial con-  tour, one can either consider a DIEP flap or immediate  debulking of the subcutaneous tissue whilst taking care  to preserve a cuff of tissue surrounding the perforator.  Secondary contouring procedures for bulky rectus flaps  are also a safe option at a later time interval. The rectus  abdominis flap can also be used for reconstruction of  large scalp defects; however, the large, broad-base, flat  latissimus dorsi muscle only free flap with an overlying  skin graft is generally preferred for this type of defect.’  Although the rectus abdominis flap is considered a bulky  flap that some consider difficult to fold, complex defects  such as full thickness defects involving the skin of the  cheek and oral mucosa have been reconstructed with  this flap. Patel et al. reported on a series of 46 patients  with a complex head and neck defect (external skin and  intra-oral component) successfully reconstructed using  a multi-island vertical rectus abdominis myocutaneous  free flap'® (see Figure 23.2a and b).    The rectus abdominis muscle is a strap-like vertical  muscle, approximately 30 cm in length by 6 cm in width,  originating from the symphysis pubis and inserts into the  5th, 6th and 7th costal cartilages along with the xiphoid  process. The muscle is enveloped by a tough rectus sheath,  formed by the fascia of the three abdominal wall muscles  (external/internal oblique and the transversalis abdomi-  nis muscles) originating at the linea semilunaris. The apo-  neurosis in the midline adjoining the two rectus muscles  is known as the linea alba. The rectus sheath splits into  an anterior and posterior sheath to surround the rec-  tus abdominis muscle. The posterior rectus sheath ends  abruptly at the arcuate line at the level of the anterior supe-  rior iliac spine bilaterally. Below this line, there only exists  an anterior rectus sheath and deep to the rectus muscle is  a thin layer of tissue through which the preperitoneal fat  is easily identified.   The dual vascular supply to the rectus abdomi-  nis muscle is based upon the deep superior and infe-  rior epigastric arteries. Rectus flaps for head and neck  reconstruction are largely based upon the deep infe-  rior epigastric vessels due to increased pedicle length,  larger vessel caliber, anatomic reliability due to skin    Figure 23.2 (a) Cutaneous squamous carcinoma involv-  ing the pre-auricular region, parotid gland and neck. (b) Large  cutaneous defect reconstructed with a deep inferior epigastric  artery (DIEP) perforator flap.   The deep inferior epigastric artery is a large caliber  vessel (3-4 mm diameter) that travels on the deep sur-  face of the rectus abdominis muscle. The vessel splits into  two main branches as it courses the undersurface of the  muscle greater than 50% of the time. From the point that  the artery exits the muscle at the level of the arcuate line  travelling inferiorly for approximately 8-10 cm, it inserts  into the medial aspect of the external iliac artery. Paired  vena comitans accompanying the artery will commonly  form into a single larger caliber vein (greater than 60%)  and enter into the external iliac vein.   The perforators to the skin are most often (80%) sit-  uated in a 3-5 cm area surrounding umbilicus. These  perforators are quite robust (average diameter greater  than 0.5 mm). The perforators identified at the level of  the umbilicus and inferiorly are supplied by the deep  inferior epigastric vessels forming the basis the rectus  abdominis/DIEP flap for head and neck reconstruction  (see Figure 23.3).    Figure 23.3  DIEP flap. Musculocutaneous perforators identified travelling from the pedicle through the rectus muscle and into  the subcutaneous tissue. Perforator dissection towards the pedicle by dividing the rectus abdominis muscle with preservation of the    Innervation to the rectus abdominis muscle and its  overlying skin is supplied by the lower six thoracic ventral  rami and exiting T6-T12 thoracic nerves (7-11th intercos-  tal nerves and subcostal nerve). The nerves travel between  the transversus abdominis and the internal oblique mus-  cle and enter the rectus muscle on the posterior aspect  ultimately piercing the anterior rectus sheath to supply the  overlying skin via the cutaneous branches.”    The skin paddle of the flap can be oriented in a vertical  (VRAM) or transverse (TRAM) orientation to the under-  lying rectus muscle based upon the highly consistent  perforators from the deep inferior epigastric artery sur-  rounding the umbilicus. The flap can be extended in an  oblique fashion from the peri-umbilical area towards the  ipsilateral lower costal margin. Total width of flap har-  vest is generally guided by the ability for primary closure;  however, a skin paddle measuring up to 12 cm x 30 cm  can be harvested (especially in the transverse direction).  Elevation of the skin paddle in the transverse direction  will allow for less muscle to be harvested for a less bulky  flap. Disadvantages of the TRAM orientation include  a shortened pedicle length and the need to preserve the  umbilicus. Although not necessary, the perforators can be  identified using a handheld surface Doppler. During dis-  section only the ipsilateral perforating vessels need to be  preserved to ensure viability of the flap (see Figure 23.4).   Landmarks to be identified include the umbilicus,  xiphoid process, the inferior costal margin, pubic tubercle,  anterior superior iliac spine bilaterally and the iliofemoral  pulse at the level of the inguinal ligament (origin of the  deep inferior epigastric vessels).    After the appropriate landmarks and skin paddle has  been designed, the skin and subcutaneous tissue are in-  cised and dissected from the lateral aspect until the fas-  cia overlying the external oblique muscle is encountered.  Continuing in a medial direction, the linea semilunaris  is identified and as the flap is gently elevated towards the  midline watching carefully for the periumbilical perfora-  tors originating through the rectus muscle and supplying  the overlying skin and subcutaneous tissue. The anterior  rectus sheath is incised laterally to the perforator vessels  in a vertical direction identifying the underlying lateral  border of the rectus muscle. Incision of the anterior rec-  tus sheath is now performed in a transverse direction  ensuring an adequate safe distance both superiorly and  inferiorly from the perforator vessels until the linea alba  is encountered. The skin paddle is now circumferentially  completed on its medial aspect stopping at the linea alba  at the midline. The superficial surface of the rectus mus-  cle is also exposed inferiorly below the level of the skin  paddle and the perforator vessels. Suturing of the subcu-  taneous tissue to the underlying muscle with a resorbable  suture can help to avoid any risk of shearing of the perfo-  rators from the overlying subcutaneous tissue. The rectus  muscle is now divided superiorly identifying the poste-  rior rectus sheath. The distal end of the pedicle will be  encountered superiorly and ligated with silk ties or hemo-  clips. The flap can now be raised in an inferior direction,  keeping the posterior rectus sheath intact. The linea alba  will be incised in the midline, as one continues to iden-  tify the medial border of the rectus muscle, elevating the  myocutaneous flap off of the posterior rectus sheath. Care  must be taken to not enter into the umbilicus and to pro-  tect the ipsilateral peri-umbilical perforators. The pedicle  can now be easily identified on the undersurface of the    A - Transverse rectus abdominis flap design  B - Vertical rectus abdominis flap design  C - Extended oblique rectus abdominis flap design    Figure 23.4 Skin paddle design for the rectus abdominis myocutaneous flap. The x identifies the periumbilical perforators.  A - Transverse rectus design (TRAM). B - Vertical rectus design (VRAM). C - Extended design for increased soft tissue.    rectus muscle. The rectus muscle will now be divided  inferiorly staying above the level of the arcuate line, all  the whilst protecting the pedicle of the deep inferior epi-  gastric artery and its vena comitans. The vascular pedicle  can now be dissected with instrument or gentle finger  dissection as it traverses over the preperitoneal fat/fascia  travelling into the inguinal region to join the external  iliac vessels (see Figure 23.5a and b).   Below the arcuate line, the anterior rectus fascia should  be closed with a non-resorbable suture to avoid the risk of  hernia or abdominal bulge. If there is loss of integrity of  the anterior rectus sheath below the arcuate line, it should  be repaired with a synthetic (i.e. prolene) or resorbable  (i.e. porcine derivative) mesh sutured to the wound mar-  gins. Above this line, the posterior rectus sheath is usually  strong enough so that closure of the anterior sheath is not  necessary especially if it will result in a tight abdominal    wall closure or if one wants to avoid the risk, albeit low  of mesh infection. Any violation of the posterior rectus  sheath with exposure of the peritoneum should be repaired  with a non-resorbable suture once identified.   Closure of the subcutaneous tissue and skin is usually  quite easily done without the need for tissue undermin-  ing. A suction drain should be placed to help minimize  the risk of haematoma or seroma formation (see Figures  23.3 and 23.6).   An alternative technique of harvesting the rectus  abdominis myocutaneous does not involve identification  of the perforator vessels but rather incision of the lateral  and medial aspects of the anterior rectus sheath once it is  initially encountered. There is less risk of perforator ves-  sel shearing with this technique; however, a larger patch  of anterior rectus sheath is required with possible risk of  increased abdominal wall weakness.    (a) Harvest of the rectus abdominis myocu-  taneous free flap. Blue arrow marks: the superficial epigastric  vessels which do not need to be preserved but can also per-  fuse and provide venous flap drainage. Instrument pointing  to the pedicle of the deep inferior epigastric vessels. Black  arrow marks: the distal extent of the posterior rectus sheath.  Line drawn on the abdomen demarcates the arcuate line.  (b) Harvest of the rectus abdominis myocutaneous flap. Vessel  loop around the superficial epigastric vessels.    Flap design and dissection proceed as per the standard  rectus abdominis myocutaneous flap until the perium-  bilical perforator vessels are encountered exiting through  the anterior rectus fascia towards the subcutaneous tis-  sue. The fascia is incised around the perforators, keep-  ing a small cuff of this fascia circumferentially around  the selected perforator for its protection. The remaining  anterior sheath is incised in a vertical fashion exposing the  entire underlying superficial surface of the rectus muscle.  Dissection proceeds carefully unroofing the perforator  vessel through the rectus muscle until the pedicle of the  deep inferior epigastric vessels are encountered. Multiple  perforators can be captured with this technique; how-  ever, generally one large perforator is sufficient to perfuse    the flap. To avoid any twisting or damage to the perfora-  tor vessels, a connecting cuff of muscle can be preserved  between the selected perforators. Once fully exposed on its  lateral surface, the vascular pedicle can be ligated superi-  orly away from the point at which the perforator joins the  pedicle. The remainder of the skin paddle can be elevated  on its medial and inferior aspect with care to identify and  protect the perforator vessels as they are encountered from  this direction. Perforator dissection is completed on the  backside/medial aspect through the rectus muscle until  the pedicle is encountered. Branching vessels into the  muscle can be ligated with hemoclips or bipolar cautery.  Segmental motor nerves encountered deep in the rectus  muscle and deep to the pedicle can be preserved. The vas-  cular pedicle is now dissected inferiorly as in the standard  myocutaneous flap within the preperitoneal fat until the  desired pedicle length is achieved or the origin point at  the external iliac vessels is encountered® (see Figure 23.7).   A layered closure is achieved with the rectus muscle  re-approximated with a resorbable suture and the anterior  rectus fascia closed with a non-resorbable suture.    Standard free flap monitoring should be performed per  specific surgical unit protocol with intensive flap moni-  toring for the first 72 hours following surgery. Methods  of monitoring include assessment of arterial and venous  Doppler signal, flap color, temperature and quality ofbleed-  ing on scratch test. Various methods of anti-coagulation  (ie. aspirin, heparin, dextran) are also surgeon specific;    Figure 23.7 Deep inferior epigastric artery perforator  flap. Two musculocutaneous perfortaors are identified (black  arrow and Doppler probe placed on the second perforator).  A small cuff of muscle is preserved inferiorly protecting the  pedicle.    however, there is very little level I (prospective, random-  ized, blinded controlled-trials) evidence to suggest their  clinical efficacy.!®9   An abdominal binder may be used for added patient  comfort and avoidance of heavy lifting should be followed  for approximately 2 months to avoid the risk of hernia or  wound dehiscence. Although the peritoneum is generally  not violated during harvest of the rectus abdominis flap,  bowel sounds should be assessed prior to starting a diet  due to the risk of ileus. Peri-operative antibiotics should be  administered per standard protocols generally for a period  ranging from 24 to 48 hours post-operatively. Donor site  wound infection is low and ranges from 3% without a  mesh up to 5% with a mesh.”° Drains can be removed early  with risk of seroma and haematoma formation ranging up  to 8%.”! Early mobilization is useful to help prevent risk of    e Previous ventral hernia or significant abdominal sur-  gery involving the ipsilateral side is a contra-indication  to flap harvest.   e Widening of the paired rectus muscles at the midline  (widened linea alba) secondary to previous surgery  or abdominal wall weakness can cause the cutaneous  perforators to appear more laterally positioned. Only  perforating vessels lateral to the linea semilunaris can  be safely ligated.   e DIEP flap can be harvested with a small cuff of muscle  (especially if multiple perforators harvested) to protect  the cutaneous perforators and avoid vessel kinking or  twisting.   e The rectus abdominis flap may be too bulky in the mor-  bidly obese patient.   e Avoid elevating the flap below arcuate line to avoid risk  of abdominal bulge and hernia.    pneumonia and deep venous thrombosis. Post-operative  atelectasis/pulmonary complications can occur as a result  of pain associated from the dissection of the abdominal  wall muscles or asa result of a tight abdominal wall closure.  Lo et al. evaluated 55 patients who underwent head and  neck reconstruction with the rectus abdominis free flap.  The authors recommend the use of a mesh closure if the  anterior rectus sheath was to be completely closed to help  reduce the risk of significant post-operative atelectasis.”    1. Drever JM. The epigastric island flap. Plast Reconstr  Surg. 1977; 59: 343-346.   2. Mathes SJ and Bostwick J. A rectus abdominis  myocutaneous flap to reconstruct abdominal wall  defects. Br J Plast Surg. 1977; 30: 282-283.   3. Koshima I and Soeda S. Inferior epigastric artery  skin flaps without rectus abdominis muscle. Br J  Plast Surg. 1989; 42: 645-648.   4. Chang EI, Chang EI, Soto-Miranda MA, Zhang H,  Nosrati N, Robb GL, et al. Comprehensive analysis of  donor site morbidity in abdominally based free flap  breast reconstruction. Plast Reconstr Surg. 2013; 132:  1383-1391.   5. Nakatsuka T, Harii K, Asato H, Takushima A,  Ebihara S, Kimata Y, et al. Analytic review of 2372  free flap transfers for head and neck reconstruction  following cancer resection. J Reconstr Microsurg.  2003; 19: 363-368.   6. Urken ML, Turk JB, Weinberg H, Vickery C and  Biller HF. The rectus abdominis free flap in head and  neck reconstruction. Otolaryngol Head Neck Surg.  1991; 117: 857-866.   7. Schliephake H, Schmelzeisen R and Neukam FW.  The free revascularized rectus abdominis myocuta-  neous flap for the repair of tumour related defects in  the head and neck area. Br J Oral Maxillofac Surg.  1996; 34; 18-22.   8. Woodworth BA, Gillespie MB, Day T and Kline RM.  Muscle-sparing abdominal free flaps in head and  neck reconstruction. Head Neck. 2006; 28: 802-807.   9. Leonhardt H, Mai R, Pradel W, Markwardt J, Pinzer  T, Spassov A, et al. Free DIEP flap reconstruction of  tumour related defects in head and neck. J Physiol  Pharmacol. 2008; 59: 59-67.   10. Sailon AM, Schachar JS and Levine JP. Free trans-  verse rectus abdominis myocutaneous and deep  inferior epigastric perforator flaps for breast recon-  struction a systematic review of flap complication  rates and donor site morbidity. Ann Plast Surg. 2009;  62: 560-563.   11. Bell RB, Weimer KA, Dierks EJ, Buehler Mand Lubek  JE. Computer planning and intraoperative naviga-  tion for palatomaxillary and mandibular recon-  struction with fibular free flaps. J Oral Maxillofac  Surg. 2011; 69:724-732.    . Pryor SG, Moore EJ and Kasperbauer JL. Orbital  exenteration reconstruction with rectus abdominis  microvascular free flap. Laryngoscope. 2005; 115:  1912-1916.   Gil Z, Abergel A, Leider-Trejo L, Khafif A, Margalit  N, Amir A, et al. Comprehensive algorithm for  anterior skull base reconstruction after oncological  resections. Skull Base. 2007; 17: 25-38.   Haddock NT, DeLacure MD and Saadeh PB.  Functional reconstruction of glossectomy defects  the vertical rectus abdominus myocutaneous neo-  tongue. J Reconstr Microsurg. 2008; 24: 343-350.  OConnell DA, Teng MS, Mendez E and Futran ND.  Microvascular free tissue transfer in reconstruc-  tion of scalp and lateral temporal bone defects.  Craniomaxillofac Trauma Reconstruction. 2011; 4:  179-188.   Patel NP, Matros E and Cordeiro PG. The use of the  multi-island vertical rectus abdominis myocutane-  ous flap in head and neck reconstruction. Ann Plast  Surg. 2012; 69: 403-407.    Boyd JB, Taylor GI and Corlett R. The vascular  territories of the superior epigastric and deep inferior  epigastric systems. Plast Reconstr Surg. 1984; 73: 1-14.  Evans BCD and Evans GRD. Microvascular surgery.  Plast Reconstr Surg. 2007; 119: 18e.   Chen KT, Mardini S$, Chuang DC, Lin CH, Cheng  MH, Lin YT, et al. Timing of presentation of the first  signs of vascular compromise dictates the salvage  outcome of free flap transfers. Plast Reconstr Surg.  2007; 120: 187-195.   Pennington DG and Lam T. Gore-Tex patch repair of  the anterior rectus sheath in free rectus abdominis  muscle and myocutaneous flaps. Plast Reconstr Surg.  1996; 97; 1436-1440.   Miranda BH, Amin K and Chana JS. The drain game  abdominal drains for deep inferior epigastric perfo-  rator breast reconstruction. J Plast Reconstr Aesthet  Surg. 2014; 67: 946-950.   Lo JO, Weber SM, Andersen PE, Gross ND, Gosselin  M and Wax MK. Atelectasis after free rectus trans-  fer and abdominal wall reconstruction. Head Neck.  2008; 30: 1339-1343.   Neurovascular anatomy  Flap design and utilization  Pre-operative assessment  Flap harvesting technique  Suggested readings    © The first musculocutaneous flap described in the medi-  cal text by Tansini in 1896.   © Initially used for the primary reconstruction of the post  mastectomy defect.   ©@ The first use of a pedicled latissimus dorsi flap for recon-  struction in the head and neck area was described by  Quillen in 1978.   ® Watson reported the first successful microvascular  transfer of a free latissimus flap in 1979, and exploited  a wide variety of applications for head and neck  reconstruction.    There has been a subtle resurgence in the utilization of  regional flaps in reconstruction of the head and neck sur-  gical defect, indeed free tissue transfer may not be the  first choice for a range of clinical situations. Indeed as the  range of pathologies which produce defects in the head  and neck evolves, there remains a continued validity for  this versatile myofascial flap.   This is a popular donor site for the transfer of tissue to  the head and neck region because of the following:    © The flap can be raised as a pedicled or free flap.   ©@ The length of the vascular pedicle gives this flap potential  to reconstruct defects anywhere in the head and neck.   ® Bone may be included in the flap, most elegantly by  inclusion of the angular branch artery to the tip of  scapular.    The latissimus dorsi is a large broad flat muscle that cov-  ers the posterior inferior portion of the trunk (Figure 24.1).   It has a broad and crescentic origin from the lower four  ribs; the spinous processes of the lower six thoracic verte-  brae; the thoracolumbar fascia and laterally it also arises  from the fascia that is attached to the iliac crest.   The muscle curves around the lower border of the teres  major, and is twisted upon itself, so that the superior fibers  become at first posterior and then inferior, and the vertical  fibers at first anterior and then superior.   The muscle terminates as quadrilateral tendon, about  7 cm long, which passes in front of the tendon of the teres  major, and is inserted into the bottom of the intertubercular  groove of the humerus; its insertion extends higher on the  humerus than that of the tendon of the pectoralis major.   The lower border of this tendon is united with that of the  teres major, the surfaces of the two being separated near  their insertions by a bursa; another bursa is sometimes    interposed between the muscle and the inferior angle of  the scapula.    The main superior pedicle of the muscle is the thoracodor-  sal artery and vein, which eventually supplies a rich net-  work of musculocutaneous perforators, particularly over  the anterior border of the muscle. It should be noted that  as a type 5 muscle, there are a further two minor vascular  supplies and therefore angiosomes supplied by the poste-  rior intercostal segmental perforators in the mid portion  and the lumber artery segmental perforators in the distal  paraspinal area (Figure 24.2).   The thoracodorsal vessels are terminal branches of the  subscapular artery and vein which arise from the third  part of the axillary vessels. These vessels initially run infe-  riorly through the axilla, and then for a short distance  below the latissimus dorsi muscle before penetrating the  muscle at the vascular hilum. At this point, the vein can  be identified laterally with the artery medial and the tho-  racodorsal nerve being sandwiched between the two. In  its extra-muscular course there are branches to subscap-  ularis, teres major and serratus anterior and the impor-  tant angular branch to the tip of the scapular. Just within  the muscle, the vessels typically bifurcate into transverse  and longitudinal branches. The transverse branch is run-  ning at an average of 3.5 cm below the upper border of the    Figure 24.2 Key branches of the vascular supply to the  latissimus dorsi muscle.    muscle and the longitudinal branch usually 2.0 cm from  the lateral edge. This feature allows the potential develop-  ment of two separate skin paddles.    e The average diameter of the thoracodorsal artery is  2.5 mm, the diameter of the vein is 3.5 mm.   © The length of the pedicle is between 6 and 16 cm.   @ By extending the dissection proximally to the origin  of the subscapular vessels at the axillary artery, the  subscapular artery pedicle can provide a diameter of  6 mm on average. The pedicle length is also extended  by a least 4 cm.    The thoracodorsal nerve supplies the motor innervation  to the latissimus dorsi. It arises from the posterior segment  of the brachial plexus. It enters the axilla from behind the  axillary vessels and then descends with the thoracodorsal  artery and vein to the neurovascular hilum. The thora-  codorsal nerve usually crosses the axillary vessels approxi-  mately 3 cm proximal to the subscapular artery and vein.    The length of the pedicle is generous and even as a ped-  icled flap, most defects of the head and neck area can be  reached after the flap is passed through the axilla and  then between the pectoralis minor and major muscles of  the chest wall. By exteriorizing the pedicle, even posterior  scalp defects may be reconstructed.    Division of the arterial branches to the serratus anterior  prevents inferior tethering of the thoracodorsal pedicle.   Complete isolation of the pedicle by division of the cir-  cumflex scapular branch can be achieved. However, once  this is performed then there is no mechanical method to  stop rotation and kinking of the pedicle as it arises from  the axillary artery. Complete transaction of the tendon of  the latissimus dorsi at the superior insertion provides an  ultimate freedom of rotation.   Fashioning the skin paddle over the distal portion of the  muscle can extend the flap’s reach, but here it should be  noted that, unlike the number of perforators at the anterior  edge of the muscle in the distal territories the density of  musculocutaneous perforators is much reduced and thus  viability of the skin is potentially reduced. Additionally it  should be appreciated that the blood supply to the skin in  this area will have had to cross at least one angiosome via  choke vessels, further compromising the viability of the  distal skin (Figure 24.3).   The total area covered by the latissimus dorsi muscle is  approximately 25 cm x 40 cm. The maximum size of the  skin paddle that can be transferred is naturally determined  by the size of the particular patient. Although the defect  can be skin grafted, rarely is this advised or required.   Through and through defects of the head and neck  involving skin and mucosa can be reconstructed by folding    Figure 24.3 The two skin paddles can be based on  the transverse or vertical limbs of the thoracodorsal artery.  However, the highest density of perforators favours the  anterior edge of the muscle, as indicated.    and de-epithelializing a portion ofa single large latissimus  dorsi musculocutaneous paddle or by using two separate  musculocutaneous paddles based on the transverse and  descending branches as described by Tobin in 1981.   The early 1980s saw much interest in the potential  development of the vascularized bone transfer with the  latissimus dorsi flap and rib. This was based on experi-  mental radio-opaque injection studies of the subscapular  vessels in dogs which suggested retrograde filling of the  posterior intercostal perforators and therefore potential  blood supply to dorsal aspects of the fifth to tenth ribs.  Very few examples exist in the literature of this demand-  ing technique.   The way forward for bone transfer came with the  important clarification of the angular branch of the thora-  codorsal artery by Coleman and Taylor in 1991. This study  defined a separate vascular supply to the caudal tip of the  scapular. This finding not only provided evidence of a sep-  arate vascular supply of the scapular tip for the scapular  flap system, but importantly provides a dependable seg-  ment of bone for use in a thoracodorsal flap setting. Gilbert  has since refined the clinical application of this technique,  using the scapular tip for maxillary reconstruction.   Harii and co-workers have continued to evolve the  use of the latissimus dorsi flap in facial reanimation. The  advantages of the latissimus dorsi for this procedure are  based on the length and calibre of the neurovascular  pedicle and its division into two segments. This allows the  transfer of two separate muscle units. One unit being used  for reanimation of the mouth and the other, for the lower  eyelid. The latissimus dorsi musculocutaneous flap has  also been used for dynamic reconstruction of composite  cheek defects that include the loss of the mimetic muscles  of the midface. In this case, the musculocutaneous unit  is transferred and revascularized and the thoracodorsal  nerve is anastomosed to the ipsilateral facial nerve.   The use of innervated latissimus dorsi flap for the  dynamic reconstruction of the tongue, following glos-  sectomy has been proposed. However, it is accepted that  duplication of the complexity of the tongue’s musculature  in both form and function by a simple muscle flap consist-  ing of fibres running in one direction is limited. Haughey  and Frederickson described the use of the re-innervated  latissimus dorsi musculocutaneous flap for total tongue  reconstruction. The thoracodorsal nerve was anastomosed  to the cut end of the hypoglossal nerve. In this and subse-  quent studies useful tone without purposeful movement  could be demonstrated in the neo-tongue.   Watson and Lendrum reported a one-stage tubed latis-  simus dorsi flap for circumferential pharyngo-esophageal  reconstruction. Watson described several technical con-  siderations in using the latissimus dorsi flap for pha-  ryngeal defects. The authors advised transferring a large  segment of muscle around the circumference of the skin  paddle, this skin paddle is folded upon itself and sutured  together to form a tube, the neopharynx. The muscle was  sutured around the tube and to the surrounding tissues to  provide a second-layer seal (Figure 24.4).    Figure 24.4 The skin paddle is marked to pro-  vide the epithelial layer for pharynx reconstruc-  tion. This is harvested on the complete muscle to  provide optimal skin perforators and a secure sec-  ond layer seal.    Kim in 2003 proposed the Latissimus dorsi perfora-  tor flap. The concept allows harvest of vast areas of trunk  skin, without the necessity of simultaneous muscle har-  vest. The musculocutaneous perforators are dissected free  of the muscle, on their course to the skin. Indeed it has  been suggested that a large skin paddle may be sustained  by the inclusion of a singular perforating vessel group.  This versatile variation of the latissimus dorsi flap is a  popular contemporary solution to the demanding post-  mastectomy defect; this refinement is also ideal in head  and neck reconstruction as it can provide plentiful thin  pliable tissue.    It is useful to assess the patient pre-operatively, and the  muscle can be easily visualized by pushing with the out-  stretched arm against a wall. Note should be made of  previous axillary surgery, as this may have already com-  promised the thoracodorsal vessels. The anterior border  of the latissimus dorsi can be readily palpated in a thin  patient, as it descends out of the posterior axillary fold,  laterally on the trunk. Localization of the arterial supply  with Doppler probes is not necessary.    Typically the patient is usually turned into the lateral decu-  bitus position. The ipsilateral arm is prepared and draped  together with the lateral thorax, shoulder, axilla and back.  The anterior border of the latissimus dorsi is marked on  the patient as a line between the posterior axillary fold and  a point halfway between the anterior superior iliac spine  and the posterior superior iliac spine. On this line, approx-  imately 2 cm below the level of the tip of the scapula is  where the vessels penetrate the muscle and divide into the  horizontal branch, which runs a few centimetres below the  scapula tip, and a more vertically directed branch, which  runs 3-4 cm posterior to the anterior edge of the muscle.  A skin paddle should be centred over one of these main  branches, preferably over the vertical limb which bears the  highest density of skin perforators (Figure 24.5).   The initial incision is made from the axilla along the  marked line or cutaneous paddle. Deeper dissection along  the same line allows the identification the anterior leading  edge of the latissimus dorsi muscle.   Superiorly, the pedicle can be found within the adipose  tissue of the axilla. This then descends on the lateral tho-  racic wall to provide muscular branches and the angular  branch to the scapula before entering the hilum of the latis-  simus dorsi. By retracting the free edge of latissimus dorsi,  the extra-muscular pedicle can be identified by tracing the    Figure 24.5 Anterior border of the latissimus dorsi is  marked on the patient as a line between the posterior axillary  fold and a point halfway between the anterior superior iliac  spine and the posterior superior iliac spine.    last extra-muscular branch to the serratus anterior back  to the main vascular pedicle. It is important to note that  typically, the branch to the angle of the scapula also arises  at this same level (Figure 24.6). After careful recognition  of the pedicle, these opposing branches are ligated and  secured so that significant cranial mobilization of the flap  can continue. Depending on the requirements of the flap,  the whole or part of the muscle is harvested by dissection  from the chest wall and surrounding muscles.   Cutting the muscle to determine the paddle size can be  assisted by the use of a GIA linear stapler. The device pro-  duces a clean, bloodless edge, which is easily suture in the  receipiant site (Figure 24.7).   Complete mobilization of the latissimus dorsi requires  transection of the tendinous insertion to the humerus.  This manoeuvre should be performed with caution whilst  protecting the vascular pedicle and keeping it under direct  vision.   Passage of the pedicled flap requires preparation of a  tunnel between the pectoralis major and minor muscles.  The lateral edge of these muscles is identified in the deep  part of the anterior axilla through the superior aspect of  the incision.   A carefully placed neck dissection incision can facilitate  delivery of the pedicle in to the neck, alternatively an inci-  sion parallel and inferior to the clavicle may be required to  access the pedicle through the tunnel. Naturally a passage  through pectoralis major, at the muscular insertion at the    Figure 24.6 By retracting the free edge of latissimus dorsi,  the extra-muscular pedicle can be identified by tracing the  last extra-muscular branch to the serratus anterior back to the  main vessel.    clavicle is required, it is critical that space for the vascular  pedicle should be generous (Figure 24.8).   Carefully, the latissimus dorsi flap is passed through the  tunnel whilst maintaining the pedicles’ orientation and  being certain not to twist or kink the pedicle.   Primary closure of the donor site can usually be accom-  plished by widely undermining the adjacent skin edges. A  number of deep tension sutures may be required to stabi-  lize the wound closure. This careful layered closure should  be accompanied by adequate suction drainage.    Figure 24.7 Gastrointestinal anastomosis (GIA) linear stapling  device to cut and control bleeding from the muscle.    Figure 24.8 With the pedicle isolated and the muscle and  skin flap elevated, the flap is ready for delivery to the neck.    e The latissimus dorsi flap can be used either as a pedi-  cled flap or as a free flap.   e The pedicle is very long and the flap will reach the orbit  if necessary.   e The pedicle can be used to protect the carotid artery in  irradiated necks.   e Amajor disadvantage is that the patient must be turned  whilst the flap is harvested.    Bach CA, Wagner I, Lachiver X, Guth A, Baglin AC and  Chabolle E The free thoracodorsal artery perfora-  tor flap in head and neck reconstruction. Eur Ann  Otorhinolaryngol Head Neck Dis. 2012; 129(3):  167-171.   Clark JR, Vesely M and Gilbert R. Scapular angle osteo-  myogenous flap in postmaxillectomy reconstruction:  Defect, reconstruction, shoulder function, and har-  vest technique. Head Neck. 2008; 30(1): 10-20.   Coleman JJ, 3rd and Sultan MR. The bipedicled osteocu-  taneous scapula flap: A new subscapular system free  flap. Plast Reconstr Surg. 1991; 87(4): 682-692.   Fowler NM and Futran ND. Achievements in scalp recon-  struction. Curr Opin Otolaryngol Head Neck Surg.  2014; 22(2): 127-130.   Haughey BH. Tongue reconstruction: Concepts and prac-  tice. Laryngoscope. 1993; 103(10): 1132-1141.   Haughey BH and Fredrickson JM. The latissimus dorsi  donor site. Current use in head and neck reconstruc-  tion. Arch Otolaryngol Head Neck Surg. 1991; 117(10):  1129-1134.   Kim JT. Latissimus dorsi perforator flap. Clin Plas Surg.  2003; 30(3): 403-431.   Lee KT and Mun GH. A systematic review of functional  donor-site morbidity after latissimus dorsi muscle  transfer. Plastic Reconstru Surg. 2014; 134(2): 303-314.    Mathes S and Nahai F. Reconstructive Surgery, Principles,  Anatomy, and Technique. New York, NY: Churchill  Livingstone; 1997.   Maxwell GP, Stueber K and Hoopes JE. A free latissi-  mus dorsi myocutaneous flap: Case report. Plastic  Reconstru Surg. 1978; 62(3): 462-466.   Miles BA and Gilbert RW. Maxillary reconstruction  with the scapular angle osteomyogenous free flap.  Archives Otolaryngol Head Neck Surg. 2011; 137(11):  1130-1135.   Quillen CG. Latissimus dorsi myocutaneous flaps in head  and neck reconstruction. Plastic Reconstructive  Surgery. 1979; 63(5): 664-670.   Rigby MH and Hayden RE. Regional flaps: A move to sim-  pler reconstructive options in the head and neck.  Curr Opin Otolaryngol Head Neck Surgery. 2014;  22(5): 401-406.   Ryan RF, Krementz ET and Cardona-Loya O. One-stage  cervical esophageal and pharyngeal reconstruction  for a fourth primary cancer. Plastic and Reconstru  Surg. 1981; 67(2): 224-249.   Tobin GR, Moberg AW, DuBou RH, Weiner LJ and Bland  KI. The split latissimus dorsi myocutaneous flap. Ann  Plas Surg. 1981; 7(4): 272-280.   Urken ML, Cheney ML and Sullivan MJ., et al. Atlas  of Regional and Free Flaps for Head and Neck  Reconstruction. New York, NY: Raven Press; 1995.   Watson JS, Craig RD and Orton CI. The free latissimus  dorsi myocutaneous flap. Plast Reconstru Surg. 1979;  64(3): 299-305.   Watson JS and Lendrum J. One stage pharyngeal recon-  struction using a compound latissimus dorsi island  flap. Br J Plast Surg. 1981; 34(1): 87-90.   Wolff K-D, Hélzle R. Raising of Microvascular Flaps: A  Systematic Approach. Berlin-Heidelberg, Germany:  Springer.   Yoo J, Dowthwaite SA, Fung K, Franklin J and Nichols A. A  new angle to mandibular reconstruction: The scapu-  lar tip free flap. Head Neck. 2013; 35(7): 980-986.    The anterolateral thigh flap is a perforator flap  (Figure 25.1). A perforator flap is a flap of skin or sub-  cutaneous tissue which is based on the dissection of a  perforating vessel. A perforating vessel or, in short, a  perforator, is a vessel that has its origin in one of the  axial vessels of the body. It passes through certain struc-  tural elements of the body besides interstitial connec-  tive tissue and fat before reaching the subcutaneous  fat layer. As a perforator flap, the anterolateral thigh  flap is relatively simple to raise and in most hands has  been reported as an extremely reliable flap for a vari-  ety of defects. If the flap pedicle is harvested at its junc-  tion with the profunda vessels, the artery is typically 4  mm in diameter and the vein 6 mm in diameter, and  it is extremely long. The lateral cutaneous nerve can be  incorporated for either motor or sensory nerve recon-  struction. Like most perforator flaps it has the advantage  of not removing a bulk of muscle and of the skin being  closed primarily. It can be raised as a free myocutane-  ous flap and, provided a large enough flap is raised, the  distribution of perforators can be ignored. Although in a  Western population, the added bulk is seldom necessary  this is occasionally a useful option.    The anterolateral thigh flap is indicated for the coverage of  any soft tissue defect of the head and neck including tubed    flaps for laryngeal reconstruction and as an obturator flap  for maxillary defects. Although popularized in the Far  East as the first choice or default flap for intraoral recon-  struction, the apparent increase in flap thickness exhibited  in Caucasian—-Western populations, particularly females,  can make this flap less than ideal for many defects, and its  use should be avoided for patients with a BMI higher than  30. Despite the possibility that a flap may be 5 cm thick,  this is a very useful flap for larger intraoral defects. The  flap thickness may be an advantage in replacing a compos-  ite parotid resection, total glossectomy where loss of bulk  due to muscle atrophy is not a problem, and in maxillary  obturation. According to some authors, fairly radical flap  thinning can be undertaken, circumventing the thick-  ness problem, perhaps aided by the use of the operating  microscope. However, although some flap thinning can  be easily undertaken at the margins of the flap, reduction  of the entire flap to say 50% would not be recommended,  particularly to surgeons new to this technique. Muscle can  be incorporated where a two-layer closure is required, like  for fistulas.    The size and thickness of the proposed defect should be  estimated and will indicate whether this flap should be  used. The thickness of the flap can be assessed by sim-  ply squeezing the skin and subcutaneous tissue in the  area of the thigh to be harvested between the thumb and  forefingers. If another flap such as the radial forearm    Figure 25.1 Anatomy of anterolateral thigh flap based on  descending branch of lateral circumflex femoral artery. LAT,  lateral; INF, inferior.    flap could be used, to some extent the patient should be  offered the choice between the alternative flaps. Even  though closed primarily, the donor site scar and thigh  dimpling that occur after healing is not ideal and the  patient may prefer the defect in the forearm caused by  the radial forearm flap. A line is drawn between the  anterior superior iliac spine and the lateral border of the  patella (Figure 25.2). At a point midway along this line  a 4 cm circle is drawn. Perforating vessels are searched  for using a 10 MHz handheld Doppler probe, the most  common site to find a perforator is in the inferolateral  section (Figure 25.3).   Nearly all patients have usable perforators (96%) and a  handheld Doppler has a positive predictive value of only  65%, so this is only a guide and should not be a reason for  abandoning the flap. Either leg can be used for any defect  so the leg that has the loudest perforators should be used.  However, all patients should be warned that an alternative  flap might have to be utilized.    The patient should be supine without the aid of any sand-  bags or splinting of the leg. This permits synchronous  harvesting of the flap with the head and neck resection.  Though not essential, ideally all monitoring lines should  be placed in the other leg.    Figure 25.2 Anterolateral thigh flap marked out. Note  inferolateral segment of 4 cm radius circle is most likely to  contain perforator(s).    Figure 25.3 After Doppler mapping, this circle that will be  included in the flap has been moved 4 cm away from the ante-  rior superior iliac spine, at top left of picture.    The incision is placed along a line drawn between anterior  superior iliac spine and the lateral border of the patella  (Figure 25.2) unless it crosses where a perforator can be  heard on the Doppler (in which case the line should be  moved to give at least 1 cm clear skin between the signal  and the flap margin). Ifa sensate flap is required, the lateral  femoral cutaneous nerve can be harvested. Conveniently,  this runs along the line joining the anterior superior iliac  spine to the lateral border of the patella and is found to  lie in the deep subcutaneous tissue just above the fascia.  No further flap marking is carried out to permit reloca-  tion when the perforator(s) are visualized much later. The  incision should be angled at 45° laterally to protect any  nearby perforator(s) and is deepened to incise the deep  fascia to expose the underlying rectus femoris or vastus  lateralis muscle. Though the pedicle is short it may still  be useful. The transverse branch of the lateral circumflex  femoral artery gives rise to perforators to form the tensor  fascia lata flap. The pedicle is situated at the superior end  of the line joining the anterior superior iliac spine to the  lateral border of the patella and lies between the tensor  fascia lata and rectus femoris muscle. Perforators may be  located in a similar fashion by dissecting below the fascia  in a medial to lateral direction. Again this will tend to  offer a bulky flap with a shorter pedicle than the antero-  lateral thigh flap.   It is recommended to first trace out the perforators by  careful dissection to the main pedicle rather than dissect  them out completely as the latter manoeuvre is more eas-  ily performed once the entire pedicle can be visualized.  Side branches from the perforators should be coagulated  with a bipolar diathermy or ligated with small metal clips,  particularly if close to the perforator. Perforators are fol-  lowed through muscle and/or fascia until the main ped-  icle (descending branch of the lateral circumflex femoral  artery) is reached within the groove between rectus femo-  ris and vastus lateralis muscles.   It is not recommended to locate the descending branch  of the lateral circumflex femoral artery by dissecting down  into the groove between the rectus femoris and vastus  lateralis and then follow branching lateral perforators in a  lateral direction towards the skin, as most of these perfo-  rators will end in muscle.    Starting medial to the descending branch of the lateral cir-  cumflex artery, in a lateral direction a sheet of vastus late-  ralis muscle can be raised. The muscle is usually 1.5-2.5  cm thick and 6-10 cm in width. Although sheets of muscle  greater than 10 cm in length almost inevitably have at least  one perforator smaller lengths of muscle can be raised  by identifying muscular perforators coming of laterally  from the pedicle into the muscle. The muscle sheet can  be dissected with the skin paddle on top or more distally  (Figure 25.4).    Figure 25.4 Picture shows the anterolateral thigh (ALT)  flap muscle marked out more distally than skin. The muscle  paddle can be raised like this or coincident with the skin pad-  dle depending on where the two tissues are required.    Figure 25.5 Exposure of the pedicle: descending super-  ficial circumflex femoral artery and vena comitantes with  perforator in the foreground.    The artery and its venae comitantes are followed from the  junction with the perforator(s) to the junction with the  profunda femoris artery and vein if the entire length of  the pedicle is required (Figure 25.5). During this dissec-  tion, it is helpful to self-retain the muscle by placing large  sutures from its underbelly to the lateral skin. Once the  junction has been identified, the full dissecting out of the  pedicle and perforators can take place in a proximal to  distal direction. If the entire length is not required then  it is not necessary to dissect out the entire descending  lateral circumflex vessel, however, the artery and venae  comitantes may be much smaller (at around 2 mm) before  both transverse and ascending vessels join so it may  be preferable to accommodate a lengthy pedicle in the  neck rather than have an ideal length with small vessels.  During this dissection many branching arteries and veins  will be encountered and will require ligation. This may  include the ascending and transverse lateral circumflex  vessels (Figure 25.6). Branches of the femoral nerve run  underneath the pedicle and will have to be dissected out  carefully. This becomes more problematic as the diameter  of both the pedicle and nerves become smaller, and it may  be preferable to sacrifice a small nerve branch which will  have little, if any, impact on motor function rather than    damage the pedicle or perforator(s). During the dissec-  tion of the musculocutaneous perforators, by leaving a  5 mm cuff of muscle around these perforators, the dissec-  tion is made less hazardous and the perforators are made  more robust.    Once the main pedicle and perforator(s) have been fully  dissected out, the skin flap can now be designed. If two  perforators are present then, unless the flap is very large,  it will encompass both ends of its length. If there is just  one perforator or there are two and the surgeon has a spe-  cific requirement, the position of the paddle can be varied  according to need. The further down the thigh, the thin-  ner the tissue becomes (Figure 25.7), but if it is planned  to anastomose at the large termination part of the pedicle  this will produce a very long pedicle.   According to some authors, flap thickness in  Caucasians is 4 cm in the upper thigh, 3 cm in the mid-  thigh and 2 cm in the lower thigh. The tissue is much  thicker as a result of fat deposition in the superior thigh,  but the pedicle is often an ideal or manageable length for  most oral reconstructions and the increased bulk may  be desirable. A compromise may be reached to end up  with a slightly thicker flap than necessary, with a slight  pedicle length excess but with very large vessels to use in  an anastomosis.   To ensure that the ‘backcut’ flap incision does not vio-  late the perforator(s) it is recommended to pass a small  needle from the fascia towards and out of the skin at a  point situated a minimum of 1 cm from the pedicle below  the fascia where the perforators can be visualized. The flap  can then be marked around this, and the flap raised and  isolated from all but its blood supply to permit evaluation  of the viability of the flap.    There should be clear evidence of bleeding subcutaneous  flap tissue at this time. If two perforators have been raised,  the viability of either perforator can be assessed using a  microvascular clamp on the pedicles (Figure 25.8).   This manoeuvre is essential if the flap is to be divided and  used as two separate or chimeric flaps. During the inter-  val between the completed elevation of the flap and pedicle  division, the flap should be sutured to one of the wound  margins with the pedicle under no tension. This will pre-  vent the flap accidentally falling off the leg downwards,  which might produce a force sufficient to tear the pedicle.    This is straightforward and the same as for any other flap,  the vessels in the thigh should be transfixed if harvesting  at the profunda junction. The flap should be irrigated with  heparinized saline. If clotted blood becomes dry in the  perforators, it will be difficult to get them running again.  If there is only one perforator before the pedicle is divided,  a stitch should be run from part of the perforator (prefer-  ably the muscle) cuff to a flap margin to prevent torsion or  kinking of the perforator.    This can be commenced as soon as the flap has been com-  pletely raised and a large part of the closure can be carried    out prior to pedicle division. If closure is not to be carried  out immediately, three sutures (2/0 or larger) should be  used to close the donor site temporarily, as swelling will  otherwise make closure very difficult.   After diathermizing any bleeding points, closure should  commence with repair of any muscle that has been divided  to permit perforator dissection. A resorbable 3/0 stitch is  recommended. Closure of the fascia and subcutaneous tis-  sue should then be carried out using a 2/0 resorbable suture.  If the pedicle has not been divided, the superior part of the  wound can be left open, to be closed after pedicle division.  The skin can be closed with either non-resorbable sutures  or clips. It is not recommended to insert a drain in the leg,  although a tight crepe bandage is desirable. Flaps of up to 10  cm width can be closed primarily but nylon tension sutures  will probably have to be used to achieve this. A very pleas-  ing cosmetic result can be expected after the skin has healed  (Figure 25.16)    Flap insetting may be made difficult if it is too bulky for the  defect (Figure 25.9). Certainly trimming the fat, particularly  at the margins of the flap, is helpful in this scenario. If the  flap is tight as it is inset, it is recommended to orientate it  with a minimum number of sutures (say four) and then pro-  ceed to anastomosis (Figure 25.10). The flap is then allowed  to run before insetting. If the flap is to be tubed, the deep  fascia can be closed around the skin layer as a double closure.    The skin is easily monitored and a Doppler probe can be  placed on the site of the perforator in the flap as before  it was raised; this is easily achieved for flaps used for  skin replacement but more problematic for intraoral  flaps, although this is easier with a detachable internal    monitoring probe. Otherwise, monitoring the pedicle  in the neck is usually adequate. If the blood flow is to be  evaluated using a needle prick, blood flow may be slower  than that seen in other flaps. After radiotherapy or at least  1 month, the flap can be safely thinned if it is too bulky.    Damage to the fine perforators is the obvious and cata-  strophic complication. Fortunately, this is most likely to  occur in the very early stages of the flap, when it can be  abandoned for an alternative. Where there are two perfo-  rators (Figure 25.11) twisting is not a problem but twisting  a single perforator is a hazard that should be avoidable by  placing the safety stitch (Figure 25.12) as described in the  section ‘Complications intraoperative’.    In the author’s experience, this is an extremely reliable flap  (Figures 25.13 through 25.15), but vigilance for arterial and  venous failure is clearly essential. Even partial flap necrosis  is rare. Gait problems may require months to resolve if a  large number of femoral nerve branches have been sacri-  ficed. Thigh numbness may result, but is likely to be of little  significance to the patient.    Burd A and Pang P. The antero-lateral thigh (ALT) flap: A  pragmatic approach. Br J Plast Surg. 2003; 56: 837-839.   Celik N, Wei FC, Lin CH, Cheng MH, Chen HC, and Jeng  SF et al. Technique and strategy in anterolateral thigh  perforator flap surgery. An analysis based on 15 com-  plete and partial failures in 439 cases. PlastReconstru  Surg. 2002; 109: 2211.   Coskunferat OK and Ozkan O. Free tensor fascia lata per-  forator flap as a backup procedure for head and neck  reconstruction. AnnPlast Surg. 2006; 57: 159-163.   Demirkan F, Chen HC, Wei FC, Chen HH, Jung SG, Hau  SP. et al. The versatile anterolateral thigh flap: A  musculocutaneous flap in disguise in head and neck  reconstruction. Br J Plast Surg. 2000; 53:30-36.   Kimura N and Satoh K. Consideration of a thin flap as an  entity and clinical applications of the thin anterolat-  eral thigh flap. PlastReconstru Surg. 1996; 97: 985-992.   Mardini S, Tsai FC and Wei FC. The thigh as a model for  free styleflaps. Clin Plast Surg. 2003; 30: 473-480.   Ross GL, Dunn R, Kirkpatrick J, Koshy CE, Alkureishi LW,  Bennett N. et al. To thin or not to thin: The use of the  anterolateral thigh flap in the reconstruction of intra-  oraldefect. Br J Plast Surg. 2003; 6: 409-413.   Song YG, Chen GZ and Song Y. The free thigh flap: A new  free flap concept based on the septocutaneous artery.  Br JPlast Surg. 1984; 37: 149-159.    Wu CW, Valerio IL, Huang JJ, Chang KP and Cheng MH.  Refinement of the myocutaneous anterolateral thigh  flap for reconstruction of frontonasal fistula defects.  Head Neck. 2015. [Epub ahead of print]   Yu PU. Characteristics of the anterolateral thigh flap in a  western population and its application in head and  neck reconstruction. Head Neck. 2004; 26: 759-769.    Yu P and Youssef A. Efficacy of the handheld Doppler in  preoperative identification of the cutaneous perfo-  rators in the anterolateral thigh flap. Plast Reconstru  Surg. 2006; 118: 928-933.    The gracilis flap is most frequently used in free neuro-  muscular tissue transfer for facial reanimation after long-  standing facial paralysis. The low profile of the muscle and  the organization in small innervated segments make this  flap particularly suitable for the reconstruction of mimic  muscles. Gracilis muscle free flaps are, however, also used  as innervated muscle segments for tongue reconstruction  and for skull base repair as muscle-only flaps. The skin  overlying the muscle has been reported to be unreliable,  but myocutaneous gracilis free flaps have been success-  fully transferred as transverse upper gracilis (TUG) flaps  for breast reconstruction."® Moreover, the muscle is exten-  sively used as a pedicled flap for reconstructive procedures  in the perineal area.    The gracilis muscle is a flat and thin adductor muscle of  the thigh. It originates from the ramus of the pubic bone  and inserts at the medial tibial tuberosity below the knee.  The gracilis muscle is a type II muscle according to the  classification of Mathes and Nahai with its dominant vas-  cular supply arising from the adductor artery and vein  which branch off of the profunda femoris artery and vein.  The vascular pedicle commonly has two comitans veins  and enters the gracilis muscle 8-10 cm distal to the pubic  tubercle. Minor vascular pedicles arise from the superficial  femoral artery (distal) and the medial circumflex artery  (proximal). The motor nerve supply comes through the  anterior branch of the obturator nerve and enters the mus-  cle approximately 2 cm proximal to the vascular pedicle.    The patient is positioned supine with the hip of his donor  leg flexed, abducted and rotated outwards and his knee  moderately flexed so that the foot rests on the operation  table at the height of the opposite lower leg (Figure 26.1).  This position is secured by support against the calf and the  thigh, preventing the knee from stretching and thigh from  rotating backwards and inwards. Care must be taken to  provide adequate padding for the calf in order to prevent  pressure ulcers on the skin overlying the tibia. The leg and  the pubic hair should be shaved preoperatively, and the  site should be draped in a way that the inner half of the  thigh and the landmarks (medial tibial tuberosity and the  pubic tubercle) are exposed and can be clearly palpated.  The surgeon is positioned on the side of the operation table  opposite to the donor leg.    A straight line is drawn between the pubic tubercle and  the tibial tuberosity. In an upright position, this would  delineate the anterior margin of the gracilis muscle. In a  horizontal position in relaxation, the muscle drops down  and the anterior margin is located approximately 15 mm  posterior to the straight line, where it should be marked  with an additional line. The incision through the skin  and subcutaneous fat tissue is carried out along this line  approximately 20 cm in length starting below the pubic  tubercle. The incision goes through the superficial fascia  down to the fascia lata.    The gracilis muscle midbelly is identified after inci-  sion of the overlying fascia and clearly distinguished  from the sartorius muscle, which is located anterior  to the gracilis in the surgical position of the leg in the  mid thigh, and from the adductor longus muscle that is  located immediately anterior to the gracilis muscle in  the proximal thigh (Figure 26.2). Separation of the skin  and the subcutaneous fat tissue from the lateral aspect  of the muscle can help to identify the gracilis from the  small anterior—posterior dimension. The intermuscular  septum between the adductor longus and the gracilis  muscle is carefully divided superficially, and small ves-  sels that may enter the anterior margin of the muscle can  be coagulated and divided.    The vascular pedicle runs in the intermuscular septum  between the adductor longus and the adductor magnus  before entering the gracilis muscle (Figure 26.3). It is first  identified when carefully dividing the adductor longus  from the gracilis muscle at the anterior margin of the graci-  lis by blunt dissection whilst reflecting the gracilis muscle.  In this position the vessels are running across the surface of  the adductor magnus muscle that becomes visible between  the adductor longus and the gracilis muscle (Figure 26.4).  After identification of the artery and the two comitans  veins, the motor nerve supply is dissected and exposed by  continuing the dissection slightly more proximal, where  the anterior obturator nerve can be identified from its  oblique course across the surface of the adductor magnus  muscle. The nerve enters the gracilis muscle approximately  20 mm proximal to the entry of the vascular pedicle.    Before entering the gracilis muscle, the vascular pedicle  gives off small branches to the adductor longus muscle  (Figure 26.3). These branches have to be ligated to get access  to the full pedicle length. During this procedure it is help-  ful to pull up the adductor longus muscle with two small  retractors placed proximally and distally to the vascular  pedicle. Fine scissors and forceps are necessary to accom-  plish blunt release of the tiny branches from the adductor  longus muscle surface. After elevation of the branches,  haemostat clips are used for ligation. Electrocautery of the    Figure 26.2 Spatial relationship of the gracilis muscle at mid thigh and proximal thigh.    Figu re 26.4 Identification of the vascular pedicle between adductor longus and gracilis, lying on the adductor magnus.    small vessels is not recommended in order to avoid ther-  mal damage to the main pedicle. After separation of the  branches, the adductor longus muscle can be pulled fully  upwards giving way to the dissection along the pedicle to  the profunda femoris vessels (Figure 26.5). There may as  well be branches that run off into the underlying adductor  magnus muscle. They have to be identified and ligated by  carefully elevating the vascular pedicle from the muscle  surface before the pedicle is separated from the profunda  femoris vessels. During ligation of the pedicle, care must be  taken not to compromise blood flow in the profunda fem-  oris vessels. Therefore, a minimum distance of 5 mm from  the junction between the pedicle and the profunda femoris  artery and vein should be observed when the pedicle is cut.  After completion of the dissection of the adductor artery  and vein, a pedicle length of approximately 6 cm should be  available. The diameter of the vessels can be expected to be  between 2 and 2.5 mm on average.    Dissection of the obturator nerve and  definition of the graft size    The obturator nerve that has been previously identified is  easily followed along its course proximally by blunt dis-  section until a length of approximately 8 cm is achieved.  A nerve stimulator is used to define neuromuscular units.  If very small muscle segments are planned, dissection of  the nerve under the microscope can be carried out, and  individual neuromuscular units can be identified after    stimulation of individual fascicles (Figure 26.6). The nerve  usually contains three fascicles although there may be up  to seven present. The anterior half of the muscle belly is  commonly innervated by one fascicle; the posterior half is  supplied by the remaining ones with some overlap in the  midline. The width of the muscle segment that is used for  facial reanimation commonly occupies half of the width  of the muscle belly, so that the anterior half of the muscle  is divided for harvesting (Figure 26.7). In the proximal  half, the muscle fibres run parallel which makes division  in a longitudinal direction easy. The length of the muscle  required has to be identified beforehand during preopera-  tive planning and the dissection of the recipient site in  the cheek (see Chapter 29). Usually a length of approxi-  mately 8 cm is needed. To avoid inadvertent damage to the  neurovascular pedicle during release and circumcision of  the deeper muscle portions a small retractor is inserted  underneath the pedicle close to its entry into the muscle  and gently pulled upwards. During final separation and  mobilization, the epimysium is preserved on the surface of    the muscle to provide a sliding layer for easier movement  of the muscle during contraction after transfer. Before the  pedicle is divided, adequate perfusion of the muscle seg-  ment is checked.   After complete separation, the function of the obtu-  rator nerve segment included in the graft should also be  checked with the nerve stimulator after placing the graft  on a moist surgical towel on the patient. The graft is then  stored in moist surgical towels until definite graft fixation  and microvascular anastomosis are performed.    Meticulous control of bleeding from the trans-sectioned  muscle tissue is performed by electrocautery. The anterior  margin of the remaining parts of the gracilis muscle is  attached to the fascia of the adductor longus muscle to sta-  bilize the gracilis muscle and restore easy function of the  adductor muscles. A 10-gauge suction drainage is placed  on the reconstructed fascia, and the wound is closed in  layers. The leg is bandaged with decreasing pressure from  distal to proximal, or a pressure stocking is applied to  avoid postoperative thrombosis.   Routine postoperative prevention of thrombosis is  applied by administration of fractionated heparin (e.g.,  enoxaparin). The operated leg should be positioned in a  slightly elevated position for a couple of days until com-  plete mobilization of the patient is achieved. Postoperative  mobilization with the help of a physical therapist can be  performed from the first postoperative day as the muscle  function of the adductor group remains grossly unaf-  fected by the removal of the small gracilis segment and its  nerve supply. If no substantial bleeding occurs, the suction  drainage can be removed on the second postoperative day.    In general, harvesting of the gracilis muscle has very low  morbidity, and complications are rarely encountered asso-  ciated with this procedure.    © Damage to the pedicle may occur during the release  of the branches to the adductor longus and adductor  magnus muscles. The use of the microscope during dis-  section and the use of clips rather than electrocautery  during ligation are helpful in avoiding this problem.   ©@ Damage to the profunda femoris vessels may occur dur-  ing separation and ligation of the pedicle. In particular,  the profunda femoris veins are prone to compromised  blood flow and subsequent thrombosis. This can be  avoided by observing an adequate distance of 5 mm  pedicle length during ligation and separation of the    pedicle from the profunda femoris vessels and by using  clips rather than sutures for ligation.   © Nerve damage is unlikely to occur as the dissected seg-  ment of the obturator nerve is short and interference  with other nerves is not encountered.    ®@ Haemorrhage: Postoperative bleeding is unlikely  to occur as the site of harvest does not contain  high-volume flow vessels, and the dissection is carried  out only along intermuscular septa without dividing or  cutting vessels with relevant blood flow that could be  violated inadvertently and overlooked during wound  closure. Nevertheless, improperly seated ligation clips  after separation of the pedicle from the profunda femo-  ris vessels can become detached and cause substantial  haemorrhage. Thus, great care is required during this  step of the dissection to make sure that ligations of the  adductor vessels are reliable.   ® Secondary bleeding from the transected muscle may  occur if haemostasis has been inadequate. The careful  use of electrocautery after identification of individual  intramuscular branches under the microscope before  wound closure minimizes this risk.   e Thrombosis: Thrombosis is also unlikely to occur if  routine heparin prophylaxis is administered and early  mobilization is accomplished. The saphenous vein that  drains the superficial venous system is located above the  site of harvest. This vein is commonly not encountered  during dissection and thus can be easily preserved. Deep  venous thrombosis may occur if ligation clips or sutures  compromise the blood flow in the profunda femoris  veins, which can be avoided by observing an adequate  distance to the vein during ligation as described above.    The dissection of the flap is very straightforward, with little  chances to go grossly wrong. Nevertheless, a few things can  ease the surgical work and improve the results.    e During flap dissection, the division of the branches that  go off into the adductor longus is a crucial point. Use  high magnification to make sure that this is done care-  fully, and take your time. Use clips or microcautery.   e As the pedicle is rather short, use as much length as  you can get; however, keep in mind to preserve a 5-mm  cuff for ligation to avoid thrombosis of the femoris pro-  funda vein.   e When defining the muscle volume, take care not to  obtain too much tissue. Careful nerve testing and  definition of functional muscle units will improve  the result in terms of cosmetics, as unsightly bulging  of the grafted muscle during contraction is avoided.  Trimming of the muscle after transfer is always more  difficult and carries the risk of removing the wrong  muscle units.    Arnez ZM, Pogorolec D, Planinsek F and Ahcan U. Breast  reconstruction by the free gracilis (TUG) flap. Br J  Plast Surg. 2004; 57: 20-26.   Hari K, Ohmori K and Torii S. Free gracilis muscle transplan-  tation with microvascular anastomosis for the treatment  of facial paralysis. Plast Reconstr Surg. 1976; 57: 133-135.   Manktelow RT. Microvascular Reconstruction. New York,  NY: Springer; 1986. p. 37.    Mathes SJ and Nahai F. Classification of the vascular ter-  ritory of muscles: Experimental and clinical correla-  tion. Plast Reconstr Surg. 1981; 76: 177.   Sullivan MJ and Urken ML. Gracilis. In Urken ML, Cheney  ML, Sullivan MJ and Biller HF (eds.), Atlas of Regional  and Free Flaps for Head and Neck Reconstruction.  New York, NY: Raven Press; 1995. pp. 139-148.   Yousif N, Matloub H, Kabachalam R, Grunert B and  Sanger J. The transverse gracilis musculocutaneous  flap. Ann Plast Surg. 1992; 29: 482-490.    The fibula is a long slender triangular-shaped bone that  is said to have two functions: ankle joint stability and  microvascular reconstruction of bony defects. It is mainly  composed of cortical bone, giving it great stability. The  advantages of the fibula are that it offers an abundant supply  of tubed bi-cortical bone, which is useful for reconstruc-  tion of long segmental defects across the midline - 25 cm  or more of bone can be harvested. There is usually little  morbidity at the donor site, and it is highly reliable with a  95% success rate (when used, the skin paddle component  is reported to be less reliable). It is also possible to har-  vest the fibula simultaneously with the tumour resection  as no change in the patient’s position is required. Bone  height is the main potential disadvantage, especially when  reconstructing the dentate mandible. To overcome this  problem, the osteotomized fibula can be folded back onto  itself whilst maintaining intact soft tissue and periosteum  on one side (‘double barrelling’). Distraction osteogenesis,  followed by implant placement, can also give a very good  result (Figure 27.1). It is usual to leave the flap for several  months before distraction, to allow bony union with the  recipient bed and enable the fixation plates to be removed.    The first vascularized fibula flap transfer was used for  ulnar reconstruction by Ueba in 1974 (series of cases pub-  lished in 1983). Taylor et al. subsequently reported free    fibula transfer for two tibial defects in 1975.? As the flap  was increasingly used, modifications were made, such as  including large parts of the soleus muscle and skin paddles.  Although these first fibula transfers were performed with-  out a skin paddle, Chen and Yan were the first to report an  osteo-cutaneous fibula flap in 1983.3 Hidalgo reported the  use of the vascularized fibula in mandibular reconstruc-  tion in 1989, and this opened a new field in maxillofacial  reconstructive surgery.*   The fibula is the longest bone flap available, and it can  be transferred as a bone flap or in combination with a skin  island for soft tissue coverage if required. Therefore it has  a broad spectrum of indications ranging from bony recon-  struction of the extremities to partial or total mandibular  reconstruction including closure of perforating defects of  the oral cavity. The disadvantage of the skin paddle is that  it cannot be rotated separately from the bone (as compared  to a scapula flap).    An understanding of the relevant anatomy of the fibula  and the arrangement of muscles, compartments and  vascular supply of the lower limb below the knee is vital  (Figure 27.2).   The lateral compartment of the lower leg (lateral to the  fibula) is formed by peroneus longus and brevis muscles  (the latter muscle arising from the fibula more distally). In the  anterior compartment, extensor hallucis longus (EHL) and    Figure 27.2 Cross-section of the mid calf. The inter-  osseous membrane and anterior/posterior crural septae have  been highlighted in bold (nerves have not been shown).    extensor digitorum longus are attached to the anterior sur-  face of the fibula. The large tibialis anterior muscle is found  near the tibia. Separating the anterior and posterior com-  partments is the anterior inter-osseus membrane - a white  fibrous band that is attached to both fibula and tibia. The  anterior tibial artery and deep tibial nerve can be found run-  ning close to this membrane. In the posterior compartment,  lying between tibialis posterior and flexor hallucis longus  (FHL) muscles (and close to the deep surface of the fibula) are  the peroneal vessels. The soleus and gastrocnemius form the  muscle bulk of the posterior compartment. Finally, the ante-  rior crural septum runs between peroneus longus and brevis  and EHL, whereas the posterior crural septum runs between  the peroneus longus and FHL - the latter septum is usually  used to reach the fibula during the dissection.    ® The fibula is supplied by periosteal branches of the pero-  neal artery, and by an endosteal vessel which directly  enters the bone at the middle third/distal third junc-  tion.’ The peroneal artery arises from the posterior    tibial artery, and runs between the chevron-shaped  fibres of tibialis posterior and FHL, running close to  the fibula, along its deep surface. The vascular pedicle is  relatively short (approximately 6 cm), but it can be made  longer by harvesting the fibula more proximally than  that required for the reconstruction — following detach-  ment of the flap, the pedicle is dissected free from this  excess bone, which is subsequently discarded.   Between two and six cutaneous perforator vessels  emerge from the peroneal artery. They pass posterior to  the fibula and may be myocutaneous (perforating FHL  and/or soleus) or septocutaneous. A paddle of skin can  be harvested with the main bone flap. There is anatomi-  cal variation in location, course, size and number of  these cutaneous perforators according to anatomical  studies and various clinical reports. Different survival  rates of the skin island have been reported and vari-  ous proposals have been made to improve its reliabil-  ity. Yu et al.° performed a live study on 80 consecutive  fibula flaps looking at perforator patterns. They found  two discrete groups of perforators located proximally  and distally. If the fibula was divided into quarters, the  clinically useful perforators (distal) were located over  the third quarter. In 51% of cases, there were two or  more perforators approximately 1.5 cm posterior to the  line connecting the fibula head to the lateral malleolus.  Surprisingly, they also found that over 90% of the per-  forators were septocutaneous. The most reliable region  for harvesting the skin paddle was found to be 8-12 cm  above the ankle - an area corresponding to the third  quarter of the fibula.° To facilitate identification of the  cutaneous perforators, pre-operative mapping using a  handheld Doppler probe is advisable. The perforators  can also be seen on pre-operative imaging.   There are a number of important anatomical varia-  tions of the lower limb arterial supply, which need  to be known (Figure 27.3). The normal arterial sup-  ply is found in 88%. Although some information can  be obtained by a standard vascular examination and  duplex assessment, accurate assessment of the patient’s  lower limb vasculature can only be provided by conven-  tional angiography or magnetic resonance angiography  (MRA). The latter is becoming widely used, especially  because it avoids arterial puncture and its associated  complications.’ In the authors’ opinion, such vascular  assessment is mandatory before harvesting a fibula flap  to exclude congenital peroneal artery anomalies. These  include a dominant peroneal artery (0.2% of patients)  or congenital absence of the peroneal vessels (less than  0.1%). Because many of these congenital and acquired  peroneal artery anomalies are unilateral, it is advisable  to obtain bilateral leg imaging before harvesting a fibula  flap. Both of the authors have encountered a variation  of the abnormally long tibio-peroneal trunk. In one  case, the peroneal artery joined the fibula some 26 cm  from the fibula head (Figure 27.4).* However, not all sur-  geons routinely request these tests, with some relying  instead on duplex scanning alone.’    (a) (b) (c) (d) (e) (f)  Normal Absent Absent Peroneal Absent Long    (88%) anterior posterior artery peroneal _tibio-peroneal  tibial tibial magna (<0.1%) — trunk  (3.8%) (1.6%) (0.2%) (0.1%)    ® It should be noted that in the authors’ experience there  can bea discrepancy in the length of the pedicle depend-  ing on which leg is chosen. This is due to variations in  the length of the tibio-peroneal trunk. This is shown  in Figure 27.5 where the right lower limb has a shorter  tibio-peroneal trunk giving almost 5 cm longer pedicle.   © Peripheral vascular disease occurs quite frequently in  head and neck cancer patients, and the peroneal artery  typically serves as an important collateral blood supply  to the foot. Clearly, if there is significant atheroma in the  lower limb vessels, and/or an anatomical variant with  one or more vessels missing, it is better not to carry out  a fibula free flap. Foot loss following this procedure has  been reported in the literature!    In maxillofacial surgery, the fibula flap is mainly used  for primary or secondary reconstruction of extensive    Figure 27.5 Computed tomography angiogram showing  the longer tibio-peroneal trunk on the left side, resulting in a  shorter pedicle length.    mandibular bone defects. When greater depth of bone is  required in large mandibular defects, it may be possible  to fold the bone back on itself (double barreling), or per-  form interval distraction osteogenesis. The flap can also  be used for congenital malformations, and some have rec-  ommended its use in pre-prosthetic surgery. It has many  other uses outside the head and neck region.   It should be mentioned that the fibula anatomy can  allow us to raise solely a soft tissue flap based on the same  pedicle. This can be very useful especially if one wants to  avoid the complications concerning the donor site of the  radial forearm. The anterolateral thigh flap has been sug-  gested as an alternative to the radial forearm flap, but this  can be difficult if the patient is not thin and can lead to  quite a bulky flap. Wolff et al. published their series of 30  peroneal perforator flaps which details the procedure.”    With the advent of computer-assisted design and  computer-assisted manufacture (CAD-CAM) technol-  ogy and rapid prototyping modelling (RPM), surgical  planning for fibula flaps has evolved to a very precise pro-  cedure. The advantages have been well documented to  improve outcomes and save operative time (Figure 27.6).  Manufacture of three-dimensional (3D) models allows  the ablative surgeon, with the assistance of the maxil-  lofacial technician, to perform model surgery to assess  the shape and size of the defect. This then gives the sur-  geon a chance to plan for complex shapes such as a man-  dibular resection involving body, angle and ramus or the  anterior mandible (Figures 27.7 and 27.8). Knowing the  shape of the defect allows for reconstructive plates to be  pre-bent, which saves time at operation and improves  accuracy at restoring form. The plates can be made with  locators so as to reproduce their placement from the lab    Figure 27.6 Computer-assisted design and computer-  assisted manufacture model with pre-bent plate.    Figure 27.8 Assessment of location of osteotomy cuts  required to correctly shape the fibula (clear acrylic).   From a reconstructive point of view, the same technol-  ogy can be used to reproduce the donor fibula. The fibula    can then be assessed for the quality of bone to help pro-  duce stents to guide osteotomy cuts and even implant  placement (Figure 27.9).    The fully anaesthetized patient is placed on their back, and  the leg is flexed at both the hip and knee joint and brought  into a prone position for better access to the lateral and  posterior aspect of the calf. We have described a simple  triangular-shaped padded device that when placed under  the knee, greatly facilitates this position.!! It can be easily  constructed by a competent dental technician as follows:    1. The entire lower extremity is prepared with antiseptic  solution, and the foot is enclosed in a sterile drape. Both  authors do not routinely use a tourniquet for flap har-  vest. If a tourniquet is preferred, this should be inflated  to over 300 mmHg, and should be released after a maxi-  mum of 2 hours to prevent re-perfusion injury. The  fibula head and lateral malleolus (as constant anatomi-  cal landmarks) are identified and marked. A line drawn  between the two is the surface marking of the posterior  inter-crural septum (one of the approaches to the lateral  fibula - the other being via the anterior crural septum).   2. For a bone-only fibula graft, a skin incision is made along  this line, in the middle to distal one-third of the pal-  pable bone. Superiorly, the incision should not pass too  close to the fibula head, for risk of subsequent damage to  the common peroneal nerve. Inferiorly, at least 6-7 cm  of bone should be left to maintain ankle joint stability  (Figure 27.10). When a skin paddle is required, the initial  linear incision can be modified and placed more anteri-  orly than the line marked in Step 1. Once the skin flaps  have been raised and the perforator(s) identified emerg-  ing from the posterior surface of the fibula (Figure 27.11),  the skin paddle can be marked and raised centred on  these perforators.'? As previously mentioned, a Doppler  probe can also be used to mark the perforator sites.   3. The skin and subcutaneous fat is raised from the under-  lying muscle fascia using sharp dissection. The poste-  rior crural septum will come into view, appearing as a  white line directly over the lateral aspect of the fibula.  Posteriorly soleus is identified, and peroneus longus and  brevis with their longitudinally running muscle fibres  are retracted anteriorly. The septum can then be fol-  lowed onto the bone.    Figure 27.11 Two perforators can be seen emerging pos-  terior to the fibula (arrowed).    4. Peroneus longus and brevis are detached from the lat-  eral surface of the fibula using sharp dissection. The  dissection passes anteriorly, along the whole length of  the incision in a broad front, with detachment of the  anterior crural septum, extensor digitorum longus and  EHL. The safest way to do this is with sharp dissection,  staying close to the bone but leaving a small cuff of mus-  cle attached to it.   5. A thick white membrane (the inter-osseus membrane)  will be encountered next (Figure 27.12). The anterior  tibial artery and vein and the deep peroneal nerve are  sometimes visible lying between this membrane and  the underside of the tibialis anterior muscle. This vas-  cular pedicle is retracted and the membrane is incised  along its length using a pair of sharp scissors which are  opened and slid along the membrane from proximal to  distal (or vice versa) at a distance of about 1 cm from the  fibula.   6. Attention should now be paid to the fibula bone cuts.  The periosteum at the proposed bone cuts is incised. An  instrument (such as a Macdonalds or Howarth’s retrac-  tor) is gently passed around the deep surface of the    fibula in a sub-periosteal plane to protect the underlying  pedicle. The bone cuts (both proximal and distal) are  performed with an oscillating saw. Some surgeons com-  plete the cuts with an osteotome. The fibula should now  be carefully retracted laterally using bone clamps. This  procedure gives greater access to the peroneal vessels.  When a longer pedicle is required, the amount of bone  harvested can be increased by making a more proximal  bone cut. The pedicle can be dissected free from this  bone (and the latter discarded by making a further bone  cut at the required length) once the flap is detached.    shaped fibres of tibialis posterior (Figure 27.13). The next  stage depends on operator preference. Most surgeons  will dissect through tibialis posterior at the distal bone  cut site, using sharp and blunt dissection and staying  close to the fibula (it is usual to leave 1 cm or so of tibia-  lis posterior attached to the fibula). The peroneal vessels  (artery and two accompanying veins) will readily come  into view (Figure 27.14), and can be ligated and divided,  thereby allowing the bone to be further retracted later-  ally. Others prefer to expose the length of the pedicle  by dissecting along the length of tibialis posterior using  sharp and blunt dissection. The advantage of the former  method (and that preferred by the authors) is that the  peroneal artery can be identified early, and followed up  the fibula, in a manner not dissimilar to following the  facial nerve during a parotidectomy - the overlying tibi-  alis posterior can be lifted off the pedicle and safely cut.    . If skin is required, the skin incision around the paddle    is now completed (see Step 2). It is sensible to include a  cuff of both FHL and soleus when completing this part  of the dissection to include as many perforating muscu-  lar branches as possible.° The laterally retracted fibula  flap can be moved from side to side, to ensure that this  is done from both sides (laterally and medially), thereby  reducing any chance of damage to either the main  pedicle (Figure 27.15) or these perforators. As the skin  and muscle paddle are released, it is wise to temporar-  ily suture the paddle to the muscle cuff attached to the  fibula to reduce the chance of shearing.    9. As more of tibialis posterior is released, the flap can  be retracted further laterally (Figure 27.16), revealing  FHL and the posterior inter-muscular septum. The  FHL is released from the fibula, taking care to ensure  that the pedicle is not damaged during this procedure.  Several perforating vessels arise from the peroneal  artery and enter FHL, and if care is taken, these can be  identified and dealt with before they are cut! The poste-  rior tibial vessels are found more medially and should  be left undisturbed.   10. Finally, any remaining muscle attachments are released  from the fibula. Once the flap has been raised, it can be  ‘rested’ in a heparinized saline-soaked gauze swap and  temporarily placed back in the wound with the pedicle    still running until it is needed for the reconstruction.  When finally tying off the artery, a transfixation  suture as well as conventional ligation ensures that  the divided vessel will not inadvertently start bleeding  post-operatively!   If osteotomies are needed to allow the fibula to satis-  factorily fit the defect, these can be performed from  the lateral aspect of the bone after the pedicle has been  divided. Before these osteotomy cuts are made, the soft  tissues and periosteum at the proposed bone cuts are  carefully stripped off using sharp dissection and subse-  quently protected using a periosteal retractor. The cuts  can be made with an oscillating saw on a sterile table,  and completed with an osteotome. With the advent of    modern imaging and software, it is possible to accu-  rately plan the osteotomy cuts in three dimensions, and  to perform these cuts whilst the flap is still attached on  the peroneal pedicle.’ The flap is secured at the recipi-  ent site using the surgeons’ choice of fixation (either a  reconstruction plate or multiple 2-mm mini-plates). As  already mentioned, the pedicle is sharply dissected off  any excess bone to increase its length.   The wound is closed in layers by carefully suturing  muscle groups together. A suction drain is also placed.  When a skin paddle has been harvested, the defect is  closed with either a full- or split-thickness skin graft.  The latter can be taken from the thigh of the same leg,  preferably using a powered dermatome.   Patients should mobilize early, initially with par-  tial weight bearing. Ankle and foot movements are  encouraged. Skin grafts should be managed in the  conventional way. When patients are slow to mobilize,  low molecular weight heparin prophylaxis should be  considered.    Careful pre-operative assessment with imaging is rec-  ommended (either angiography or MRA).   Surgical landmarks: Mark the fibula head and lateral  malleolus and draw a line between them. Leave at least  7 cm of bone proximally and distally to maintain ankle  joint stability and prevent damage to the common  peroneal nerve.   Always dissect on a broad front, and leave a small cuff  of muscle attached to the bone.   Identify cutaneous perforators early if a skin paddle is  to be used (they emerge posterior to the fibula).   Place a retractor sub-periosteally during proximal and  distal bone cuts to prevent pedicle damage.   The pedicle is always lateral to the tibial nerve in the  posterior compartment.   Proximal venae comitantes can be quite voluminous  and fragile, so dissection should proceed with caution.  Include a generous muscle cuff (FHL and soleus) when  askin paddle is raised.    The authors would kindly like to thank Mark Richards,  Salisbury Hospital, for providing Figures 27.7 through 27.9    Ueba Y and Fujikawa S. Nine year follow-up of a vas-  cularised fibula graft in neurofibromatosis: A case  report and literature review. Orthop Trauma Surg.  1983; 26: 595-600.    application of the osteocutaneous flap of fibula.  Microsurgery. 1983; 4: 11-16.    . Hidalgo DA. Fibula free flap: A new method of man-    and Tsai TM. The osteocutaneous fibula flap:  An anatomic study. J Reconstr Microsurg. 1992; 8:  215-223.    . Yu P, Chang E and Hanasono M. Design of a reli-    able skin paddle for the fibula osteocutaneous flap:  Perforator anatomy revisited. Plast Reconstr Surg.  2011; 128: 440-446.    DB and Carlos RC. Preoperative MR angiography in  free fibula flap transfer for head and neck cancer:  Clinical application and influence on surgical deci-  sion making. Am J Roentgenol. 2007; 188: 268-274.    Brennan PA. An unreported variation of the course  of peroneal artery during fibula flap harvest. Br  J Oral Maxillofac Surg. 2007; 45: 588-589.    vascular assessment of the lower limb for harvest of  a fibular flap: The views of vascular surgeons in the  United Kingdom. Br J Oral Maxillofac Surg. 2004; 42:  307-310.   Wolff K, Bauer F, Wylie J, Stimmer H, Hélzle F and  Kesting M. Peroneal perforator flap for intraoral  reconstruction. Br J Oral Maxillofac Surg. 2012; 50:  25-29.   Anand R, Brennan PA, Panchbhavi V and Ilankovan  V. Stabilising the leg to harvest a fibular flap: A  new device. Br J Oral Maxillofac Surg. 2002; 40:  438-439.   Baker NJ. Modification of the skin incision to allow  versatility in placement of the skin paddle when rais-  inga fibular osteocutaneous flap. Br J Oral Maxillofac  Surg. 2005; 43: 535-536.   Eckardt A and Swennen G. Virtual planning of com-  posite mandibular reconstruction with free fibula  bone graft. J Craniofac Surg. 2005; 16: 1137-1140.    Of all the free vascularized bone containing flaps, the vas-  cularized iliac crest graft undoubtedly provides the best  bone stock for orofacial reconstruction, supplying tissue to  reconstruct the facial skeleton accurately, with ample bone  for the placement of dental implants. Although a bone-  only flap has been described which heals by epithelization,  most flaps are probably raised to include some or all of the  internal oblique muscle without skin. Although it is usually  rather bulky, skin can be included, and even raised with the  exclusion of muscle as a perforator flap.   The blood supply is from the deep circumflex iliac artery  (DCIA) and venous drainage is from its venae comitantes.  The pedicle is fairly short and fragile but the artery and  particularly the vein are of adequate diameter of 2-4 and  2-7 mm, respectively. In most cases, there is a single artery  and vein coming off the external iliac artery which usually  divides within 1 cm into a deep branch supplying the ilium  and lower transversalis, and an ascending branch supplying  the muscles of the abdominal wall. Three approaches to the  deep circumflex vessels may be utilized. The first approach  is subinguinal. The femoral vessels are isolated below the  inguinal ligament, and the deep circumflex iliac vessels are  identified by upward retraction of the inguinal ligament.  The transinguinal approach involves identification and  retraction of either the spermatic cord or the round liga-  ment and dissection through the transverses abdominus to  expose the external iliac vessels. However, Taylor who first  described this flap in 1979 noted the variability in the loca-  tion of the large ascending muscular branch and warned    that because of its size it was a potential point of confusion  when trying to locate the DCIA. It is mainly for this rea-  son that the superior approach using location of the distal  pedicle on the under surface of the internal oblique muscle  is the one preferred by the author.   The donor site can almost always be closed primarily, and  if careful attention is paid to closure of the deeper tissues,  there should be little long-term morbidity, even if the ante-  rior superior iliac spine (ASIS) is harvested.    The flap is used for reconstruction of segmental mandibu-  lar defects in dentate patients, particularly anterior defects,  and for reconstruction of maxillary defects that extend out-  side the maxillary alveolus (Figures 28.10 through 28.13).  Where a cutaneous defect exists, the flap can be used to cover  skin defects resulting from both maxillary and mandibular  pathology. Additionally, where a large partial glossectomy has  been carried out en bloc with an anterior mandible defect,  the skin paddle can be used as a tongue resting on the inter-  nal oblique used as the floor of mouth. In either mandibular  or maxillary reconstruction, the ipsilateral hip should be used.  In the mandible, this can provide an ideal lower border angle  or symphysis. In the case of midline defects, the flap should  be raised ipsilaterally to the side where the pedicle is to be  anastomosed.   Using the ipsilateral side in the maxilla gives optimal  pedicle orientation and bone-to-bone apposition. The flap is  contraindicated where there has been a previous iliac crest    graft, an inguinal hernia repair or abdominal incision for  an operation such as appendicectomy. Patients with gait  problems are not good candidates for this procedure in  either limb. Obesity is only a consideration where a skin  paddle is to be taken. In most cases of mandibular recon-  struction, the contralateral side can be harvested instead,  though some contouring may be lost at the lower border of  the mandible.    The area around the iliac crest should be checked for  visible scars in case this was missed in the history. There  is a large thickness of subcutaneous fat in this area, and  in many patients this will render the skin unsuitable  for reconstruction. If a skin paddle is to be harvested,  the use of a handheld Doppler is advocated to locate the  perforators. There is a fairly consistent perforator 5 cm  lateral and 2.5 cm above the ASIS and other perforators  may be found laterally at a similar distance above the  iliac crest. A template can be used to aid in bone harvest,  and this should ensure accurate fast bone harvest.  This should be constructed pre-operatively, with the  aid of a three-dimensional computer tomography (3D  CT) of the jaw which can be converted into a model  and template. The patient should be warned of post-  operative pain and discomfort, numbness at the front  of the thigh and that gait is likely to be abnormal for at  least 3 months.    With the patient supine, a large sandbag is placed beneath  the hip, and skin preparation should be across the midline  medially, at a lower level than the greater trochanter infe-  riorly, laterally past the post-axillary line and superiorly  just above the costal margin. A sigmoidal line is drawn  from the pubic symphysis, along the superior border of the  iliac crest which should be palpated, to the posterior axil-  lary line. If a skin paddle is to be harvested, it should be  marked out following perforator location with a Doppler  probe (Figure 28.1).    Along the length of the incision, the skin and fat are  incised through Scarpa’s and Camper’s fasciae to the  external oblique muscle whose fibres run in a downwards  and forwards direction; this should obviously run around  the skin paddle if one is to be raised. The muscle should be  incised in the direction of its fibres to the underlying inter-  nal oblique muscle which has a very distinctive down-  wards and slightly backwards orientation (Figure 28.2).    Figure 28.1 Skin markings or flap with skin paddle, the  X marks the Doppler signal point. The lower line would be  appropriate for a myo-osseous flap (left side).    If a skin paddle is to be raised, the perforators should be  identified, and a cuff of external oblique muscle should be  left around the perforators.   osseocutaneous flap devoid of muscle where the muscle  layers are opened to permit tracing the pedicle to the  ascending or main branch of the DCIA (Figures 28.3 and  28.4). This technique will not be discussed further; only  surgeons with extensive experience of vascularized iliac  crest grafts should carry out this procedure which has  been well described by Kimata.!    The external oblique muscle should be incised along the  whole length of the crest, and this incision should be  extended medially, its lower border the inguinal ligament.    Figure 28.3 Undersurface of internal oblique showing  ascending branches and deep circumflex iliac artery in a right-  sided flap.    The muscle should then be elevated superiorly detaching it  from the underlying internal oblique muscle.    Once the internal oblique muscle has been exposed com-  mensurate with the amount to be harvested, the portion  required should be marked out with ink. In mandibular  reconstruction, the iliac crest is best utilized as the lower  border, and the estimate for the amount of muscle to be  harvested should include that required to run from ‘the  lower border’ into the buccal sulcus. It is recommended  to harvest at least 4 cm of muscle from the upper border  of the iliac crest. In the rare event that there is only an  ascending branch of the DCIA, the flap will have to rely  on this vessel.   The incision through the internal oblique muscle  should commence at the superolateral aspect of the  muscle and should extend below the transversalis fascia  onto this muscle. The internal oblique and transversalis    fascia should be raised by sharp dissection. Meticulous  haemostasis to the many perforating vessels which run  through the two muscles is required using bipolar dia-  thermy. Dissection should proceed in an inferolateral  direction as this will release the assistant from the tire-  some job of pulling a large bulk of skin fat and external  oblique muscle upwards.    The ascending branch will soon be visualized, and as dis-  section proceeds, this will become larger. At this stage,  dissection should proceed inferiorly to expose a possible  ‘lower ascending branch’, as there is frequently branch-  ing of the ascending branch. As the dissection proceeds  inferiorly, the DCIA itself will be encountered. This may  be above or below the iliacus muscle as it inserts into the  ilium but a small 1 cm or less cuff of muscle should be left  around the vessel to safeguard it. The author realizes that  other descriptions involve not locating the DCIA along-  side the ilium but harvesting 2 cm of iliacus to preserve  it. In the author’s experience, this is the minimum muscle  required for a safe ‘blind approach’.   Dissection should now proceed medially and the inter-  nal oblique muscle incised superomedially laterally to  aid this. There should at least be a small length of muscle  left above the ascending branch but more muscle may  be required, and the only limitation is the extent of the  muscle at the costal margin superiorly and rectus sheath  medially, although a cuff of muscle should always be left  to aid in repair. It is tempting to harvest as little inter-  nal oblique muscle as possible, but it should be remem-  bered that in reconstructing high dentate mandibles 4 cm  of muscle may be lost just to bring the muscle into the  mouth.   As the dissection proceeds medially to the ilium, the  overlying internal and external oblique muscles will need  to be incised to the medial end of the ilioinguinal ligament.   Attention must be paid to vessels branching off the ped-  icle which if violated will bleed causing a loss of pedicle  visualization (Figure 28.5). These are best ligated with  metal clips rather than using diathermy, to protect the  pedicle. About 2 cm from the external iliac vessels, the  ascending branches will join the pedicle, and at about this  point, the vein which is 2-3 mm in diameter will start to  dilate as it curves upwards and medially to course over  the DCIA and external iliac artery before joining with the  external iliac vein at a diameter of 4-8 mm. This requires  meticulous dissection as the veins can be quite thin walled,  and the wide vein with the 1.5-2 cm length over the artery  that can be achieved may be crucial as the defect may not  be ready for the flap. It is recommended to delay this dis-  section until the time has been reached for pedicle division  and delivery of the flap.   Although the anatomy of the pedicle is fairly constant,  there is some variability. The ascending and main deep  circumflex vessels may join the iliac vessels separately,    Figure 28.5 Junction of pedicle and external iliac vessels  (right side).    giving duplicate pedicles. Although it may be possible to  run the flap on one set of vessels, ideally all these vessels  which are usually less than 2 mm in diameter should all  be anastomosed. Occasionally, only the ascending branch  will originate from the external iliac artery with the main  DCIA originating from the internal iliac artery. The ped-  icle should now be traced backwards towards the ilium  separating the pedicle from the underlying psoas muscle.  At a point 2-3 cm medial to the ASIS, the lateral cutane-  ous nerve of the thigh will be identified and the pedicle  should be dissected off this structure. It is however, advo-  cated that those with early or little experience of this flap  should sacrifice this nerve if they are in any doubt about  the pedicle being at risk.    The point at which bone harvest should commence along  the length of the ilium depends on three factors:    1. Quantity of bone required: this flap will reach the con-  tralateral ramus with total ipsilateral reconstruction,  but the entire length of the ilium that can be harvested  with the muscle and pedicle will be required.   2. Part of the mandible to be reconstructed: the anterior  crest is an ideal shape for mandibular angle reconstruc-  tion. The anterior mandible does not require the ante-  rior crest, and by taking the bone 3 cm lateral to the  ASIS, this will be 3 cm extra pedicle length.   3. If the maxilla is to be reconstructed the requirement for  bone length is not usually great, but the requirement  for pedicle length may be critical. Therefore the bone  harvest should commence as far away laterally from the  ASIS as possible.    If the anterior crest is to be harvested after detaching  the inguinal ligament, the gluteus medius muscle should    Figure 28.6 Osteotomy cuts in left-sided flap. This has  been made to preserve the anterior superior iliac spine and  inguinal ligament. Note that the two incomplete osteotomy  cuts that will be greenstick fractured later.    be stripped from the outer aspect of the ilium to match  the template. If the anterior crest is not to be harvested,  the periosteum should be stripped from the inner aspect  of the ilium to where the medial bone cut is to be made.  It is important to leave the gluteus medius attached to  the outer aspect, otherwise the anterior crest can become  avascular and may dehisce through the wound. The bone  is cut with a saw, and the medial and lateral beginning and  end cuts should be made with a small copper retractor or  periosteal elevator, protecting the underlying periosteum  and pedicle. The template even if just constructed intra-  operatively should give an idea of where any ‘intra-flap’  osteotomy cuts are located, and it is the author’s prefer-  ence to make these cuts in situ as the bone is held rigid  here. These osteotomy cuts should not perforate the inner  cortex, this can be greenstick fractured later to preserve  the periosteum (Figure 28.6). The horizontal cut can now  be made with a retractor situated medially to protect the  peritoneum. Once the osteotomy cuts have been made,  an osteotome should be used gently to mobilize the bony  flap, which should be carefully handled out of the pelvis  (Figure 28.7).    Any obvious bleeding should be attended to; only bipo-  lar diathermy can now be used on the flap, as all current  from a monopolar diathermy may be transmitted by the  narrow pedicle only with the possibility of thermal dam-  age. Bone wax should be placed over the trabecular bone  of the donor site. Once it has been ascertained that the  flap including the bone is bleeding, attention should be  drawn to the donor site, most of which can be closed  before detaching the pedicle. Bone wax should be placed  over the trabecular bone. The abdomen should then be    closed in layers. To aid this, a series of holes are made  approximately 1 cm apart along the inner and outer cor-  tex of the bony defect in the ilium.   It is recommended to use 1 or 1/0 nylon sutures and  temporarily hold them with artery clips until all the  sutures have been placed before tying the knots. A piece  of non-resorbable mesh should be trimmed to the size of  the internal oblique defect. This is sutured to the outer  cortex of the ilium and the internal oblique muscle with a  round-bodied needle, 1 or 1/0 nylon suture with the knots  being tied immediately (Figures 28.8 and 28.9). A suction  drain with a minimum intra-luminal diameter of 3 mm  should be placed over this layer and an epidural catheter  teased through one of the sutured muscle layers. Both of  these devices should be secured to the skin with a suture  immediately after introduction. Closure of the muscle  layers medial to the ilium has to be delayed until pedicle  division.    Final dissection of the proximal pedicle should be under-  taken and the artery and vein divided and ligated. The flap  should be carefully handled to avoid twisting the pedicle.  The lumen of the artery is identified, and a small nylon  cannula is introduced into it to permit flushing of the flap  with 20-50 mL of heparinized saline.   The muscle medial to the donor site is closed in layers.  The inguinal ligament if detached is sutured to the ilium,  and the external oblique muscle is closed to itself medially  and to the gluteus medius muscle laterally. Even if a large  skin flap has been harvested direct skin and subcutaneous  tissue closure is assured.    Insetting and anastomosis  The bony component of the flap should be adjusted with a    saw if required, rotary instruments are not recommended  in case the pedicle is snagged and torn. The bone should be    Figure 28.8 The transversalis and parts of the iliacus  are sutured into these holes with a round body needled 1  or 1/0 nylon suture. It is recommended to temporarily hold  the sutures with an artery clip until all the sutures have been  placed before tying the knots.    Figure 28.9 A piece of prolene mesh or similar material is  trimmed to the size of the defect in internal oblique.    fixed with the appropriate screws and plates. In contrast to  the fibula, the iliac bone is contoured using opening oste-  otomies with simple splitting of the bone prior to spread-  ing the bone around the cut. This will increase the bone  length. Cancellous bone chips can be used to fill the resul-  tant bone gap. The muscle and skin should just be tacked    in place to orientate the pedicle, and the anastomosis car-  ried out at this stage.   In the author’s personal experience, the vein is best  anastomosed first. This allows no interruption of flow  through the artery once this anastomosis is complete. At  5 minutes before the artery is allowed to run, 5000 units  of heparin are administered intravenously; this is not the  usual practice of the author for any other flap. The DCIA is  a relatively small vessel and before it was the author’s prac-  tice to use heparin, many flaps would start to run before  stopping after 10-20 minutes. It may be that the heparin  prevents fibrin degradation products in the previously  ischaemic tissue setting off the clotting cascade when fresh  blood enters the vessels, and to date this technique has  allowed 40 consecutive DCIA-based flaps to run perfectly  following clamp removal.   After the flap is running, the internal oblique muscle is  sutured into the intra-oral defect. Some muscle trimming  may be required, but although the flap may appear very  bulky at this stage, it is likely to shrink back in a matter of  weeks and certainly after radiotherapy. If there is a skin  flap, this can now be inset (Figure 28.11).    If there is a skin paddle, the artery can be easily moni-  tored with a handheld Doppler probe and assessed for  pallor, although it is possible that the state of this flap  based on a small perforator may appear less perfused  and less drained than the muscle and bone. A handheld  Doppler can assess arterial flow of the pedicle within  the neck. For venous monitoring, the colour of the flap,  which will obviously appear dark if engorged, is use-  ful. Stabbing the muscle may be useful; bright red blood  should flow rapidly, and if individual muscle fibres can  be seen, it probably signifies the flap is not working. The  muscle should ideally have a ‘glazed toffee apple appear-  ance’. A Doppler probe sutured around the flap side of    Maxillary reconstruction. Note: multiple  osteotomies and internal oblique muscle prior to suturing into  position.    the venous anastomosis may also be helpful. None of  these methods are 100% reliable, and it is fair to say this  is a difficult flap to monitor. The muscle component of  this flap should be epithelized by 72 hours. Local anaes-  thetic can be infused through the epidural catheter to aid  in analgesia (Figures 28.12 and 28.13).    ® Damage to the small delicate pedicle is always possible.  This is most likely to occur to the main deep circumflex  iliac (DCI) vein behind the medial portion of the ilium  where it can be buried in the iliacus muscle.   ® Violation of the thin transversalis muscle to produce  herniation of pre-peritoneal fat is always a possibility  but can be closed.   ® Snagging of the pedicle with a rotary instrument is  possible and potentially disastrous; use of these instru-  ments should be minimized in this operation.    © Loss of flap perfusion and venous drainage are particu-  lar problems in maxillary reconstruction.   ® Partial necrosis of the internal oblique muscle may  occur but is not usually a problem as granulation over  vital bone will absolve this.   © Partial bone necrosis can be more of a problem and is of  course more likely to occur with small distal segments  of osteotomized bone.   © Seromas may occur probably as a result of damage to  the external iliac lymphatics.   © Post-operative infection particularly associated with  the internal oblique mesh can be very troublesome  and may even require removal of the mesh. It is advis-  able to handle this material carefully and apply topical    antiseptics to the mesh bed and mesh itself to reduce  this.   ® Incisional hernia is always possible if the layers of the  donor site are not closed with care.   ©@ Numbness to the anterior thigh due to damage to the  lateral cutaneous nerve may be troublesome to some  patients.   ® Gait problems may last 6 months or even longer espe-  cially in the elderly.    e Always ensure enough muscle is harvested in mandibu-  lar defects. Distal bone fragments can sometimes have  a precarious blood supply. A thick covering of richly  supplied muscle will hence sometimes be invaluable.   e Where pedicle length is likely to be an issue (usually  maxillary cases) use the smallest amount of bone har-  vested as far back along the iliac crest as possible, to  lengthen the pedicle.   ¢ Do not underestimate the time, complex nature and  importance of carefully closing the donor site defect.  In some quarters, this flap has acquired a reputation for  medium- and long-term morbidity, both of which can  nearly always be avoided by attention to detail.    1. Kimata Y. Deep circumflex iliac perforator flap. Clin  Plast Surg. 2003; 30: 433-438.    Brown JS. Deep circumflex iliac artery free flap with inter-  nal oblique muscle as a new method of immediate  reconstruction of maxillectomy defect. Head Neck.  1996; 18: 412-421.   Forrest C, Boyd B, Manktelow R, Zuker R and Bowen V.  The free vascularised iliac crest tissue transfer: Donor  site complications associated with 82 cases. Br J Plast  Surg. 1992; 45: 89-93.   Ghassemi A, Ghassemi M, Modabber A, Knobe M, Fritz U,  Riediger D, et al. Functional long-term results after  the harvest of vascularised iliac bone grafts bicorti-  cally with the anterior superior iliac spine included.  Br J Oral Maxillofac Surg. 2013; 51: 47-50.   Kimata Y, Uchiyama K, Sakuraba M, Ebihara S, Hayashi R,  Asakage T, et al. Deep circumflex iliac perforator flap  with iliac crest for mandibular reconstruction. Br J  Plast Surg. 2001; 54: 487-490.   Lyons AJ, James R and Collyer J. Free vascularised iliac  crest graft: An audit of 26 consecutive cases. Br J Oral  Maxillofac Surg. 2005; 43: 210-214.    Sarukawa S, Noguchi T, Oh-iwa I, Sunaga A, Uda H, Urken ML, Vickery C, Weinberg A, Buchbinder D and  Kusama M, et al. Bare bone graft with vascula- Biller HE The internal oblique-iliac crest osseo-  rised iliac crest for mandibular reconstruction. myocutaneous microvascular free flap in head and  J Craniomaxillofac Surg. 2012; 40: 61-66. neck reconstruction. J Reconstr Microsurg. 1989; 5:   Shpitzer T, Neligan PC, Gullane PJ, Boyd BJ, Gur E, Rotstein 203-214.    LE, et al. The free iliac crest and fibula flaps in vascu-  larized oromandibular reconstruction: Comparison  and long term evaluation. Head Neck. 1999; 21:  639-647.    Facial reanimation is indicated in cases of acquired  long-standing facial paralysis or in congenital disor-  ders associated with a decrease in facial muscle activ-  ity such as the Mobius syndrome, congenital unilateral  lower lip palsy (CULLP) or even hemifacial microsomia.  Acquired long-standing facial paralysis most frequently  results from neurosurgical or otolaryngological inter-  ventions for intracranial tumours as central palsy but  may as well occur after ablation of malignant parotid  tumours as peripheral palsy. After long-standing paral-  ysis, a transfer of nerve grafts alone is insufficient to  restore facial movement as functional muscle tissue has  almost disappeared.   Facial reanimation encompasses surgical measures that  support or restore facial movement in cases of facial nerve  palsies. In contrast to static reconstructions such as sus-  pension plasties to raise the oral commissure or lateral  canthopexy to alleviate the sequelae of orbicularis oculi  muscle palsy, these procedures allow for active movement  of facial muscles either by supporting existing muscu-  lar activity or by transferring neuromuscular units from  adjacent or distant sites to the deficient area. As voluntary  and involuntary facial movement is accomplished by 18  separate muscles that are unique in their way to produce  individual facial expression, even dynamic functional  reconstruction using revascularized transfer of neuro-  muscular units does not always restore symmetry in uni-  lateral facial palsy.   There are three areas in which muscle function can be  restored through dynamic facial reanimation: the eyelids    for eye closure and protection of the globe, elevation of the  oral commissure to achieve oral continence and lower lip  depression to complete facial expression. Eyelid closure  is often approached statically by metal implants into the  upper eyelid to support lid closure. Dynamic function  with blink restoration of can be accomplished by pedicled  transfer of frontalis or temporalis muscle as well as free  neuromuscular transfer. Dynamic reanimation of oral  commissure movement is achieved by pedicled temporalis  muscle insertion but more often using free neuromuscular  transfer, mostly gracilis muscle subunits. Restoration of  depressor function can be restored by transfer of digastric  or platysma segments.   This chapter focusses on the most common neuro-  muscular transfer in facial reanimation, the free transfer  of subunits of the gracilis muscle for reanimation of oral  commissure movement.    Symmetric innervation of the transferred muscle segment  is crucial for a successful reconstruction. This does not  only relate to voluntary movement but even more to spon-  taneous emotional expression. As the facial nerve is the  only cranial nerve that spontaneously produces impulses  during facial expression, it is considered as the source of  choice for neurotization. The hypoglossal nerve and the  motor nerve supply to the masseter muscle have also been  used as source of innervation to a muscle graft, but could    not achieve the degree of symmetry that the facial nerve  provides.   In cases of peripheral nerve palsy, the ipsilateral facial  nerve stump could be used. However, as the individual fas-  cicles of the nerve are assigned to different facial regions,  appropriate selective neurotization through one of these  fascicles is difficult without the possibility to check for  their original assignment and avoid synkinetic movement  of the ‘wrong’ contralateral muscles. Therefore, in periph-  eral and even more in central facial nerve palsy, the contra-  lateral facial nerve is the preferred source of innervation.  Nerve impulses from the contralateral side are conducted  to the paretic side through a cross-face nerve graft. Thus,  free neuromuscular tissue transfer for facial reanimation  is a two-step procedure with the first step being the cross-  face nerve graft from the opposite side and the second step  performing the muscle transfer 9-12 months after nerve  grafting.    1. Graft procurement: The sural nerve is commonly used as  donor nerve for the cross-face nerve graft as it provides  adequate length to crossover to the opposite side of the  face. The nerve runs down the leg on the postero-lateral  aspect of the calf where it passes to the lateral side of  the foot approximately 2 cm posterior to the ankle. Here  it is easily exposed from a small horizontal incision of  1-2 cm length. After identification of the nerve trunk,  a second transverse incision some 4-5 cm proximal is  placed on the calf slightly more posterior than the first  one. The nerve is identified and connection with the  exposed nerve segment further distal is established by  subcutaneous dissection. The same is carried out again  4-5 cm more proximally. The nerve is then divided  below the most distal incision and removed in a proxi-  mal direction. Care must be taken to avoid tearing of  the branches, which have to be identified by subcuta-  neous dissection and separated from the main trunk.  In this way, a nerve segment of 10-12 cm length can be  obtained. The small incisions are closed and a moder-  ate compression dressing with decreasing pressure from  distal to proximal is applied.   2. Facial nerve preparation: The sural nerve graft is con-  nected to one or two branches of the facial nerve on the  opposite side and that provides impulses to the area  that is supposed to be reconstructed on the paralyzed  side. In this way, symmetric innervation and facial  expression are intended. Commonly, the muscles that  elevate the oral commissure receive motor nerve supply  from the buccal branches of the facial nerve. This part  of the nerve contains multiple branches that are con-  nected to each other, so that division of one or two small  branches does not compromise facial nerve function on    the non-paralyzed side of the face. In order to allow for   using electrical testing, general anaesthesia has to be  administered without muscle relaxation.   a. ‘The patient should have his endotracheal ventila-  tion tube inserted through the nose. His head has to  be positioned and draped in a way that allows turn-  ing of the head and provides access to both parotid  areas as well as visual control of peri-oral and peri-  orbital muscles.   b. Exposure of the facial nerve branches starts from a  pre-auricular incision after elevation of the facial skin  superficially to the parotid fascia (Figure 29.1). Good  visualization is mandatory for safe exposure and reli-  able identification of the individual nerve branches as  well as microsurgical coaptation between the branches  and the sural nerve graft later on. Thus, if required, the  incision is extended superiorly across the hair line and  inferiorly around the mandibular angle into the sub-  mandibular area. Despite a rather long incision line,  the resulting scar is less conspicuous than the vertical  cheek incisions that are recommended otherwise for  direct access to the nerve branches.   c. When the anterior edge of the parotid gland is  reached, dissection is continued along the fascia into  the fat tissue where the branches leave the gland.  As the branches are below 1 mm in diameter, this  part of the operation requires careful dissection  with repeated use of the nerve stimulator to iden-  tify the precise function of the individual branches  (Figure 29.2). Redundance of innervation is manda-  tory for those functions that are accomplished by  the branches selected for coaptation with the cross-  face nerve graft to avoid loss of function on the non-  paretic side. Thin rubber slings are used to mark these  branches and the dissection is carried on in the sub-  cutaneous plane anteriorly to the nasolabial crease.    d. The pathway for the nerve graft to the opposite side  of the face runs through a subcutaneous tunnel in  the upper lip. This tunnel is prepared from bilateral  curved incisions at the alar base and a contralateral  pre-auricular incision. The former ones are used  for subcutaneous dissection from midline to the  nasolabial fold (Figure 29.3). The latter incision is  placed in a facelift like fashion and the parotid area  is exposed by extracapsular dissection after eleva-  tion of a facial skin flap. When the subcutaneous  tunnel is finished a thin and curved long forceps  is inserted from the paretic to the non-paretic side.    Figure 29.2 Dissection of small branches of the facial  nerve exiting the gland at the anterior margin. Nerve testing  to prove redundance of nerve supply in the buccal and zygo-  matic region.    Bilateral curved incision  around alar base for  tunneling of the upper lip    Figure 29.3  Pre-auricular incision and subcutaneous dis-  section to the upper lip, continued to the contralateral side by  bilateral bow-shaped incisions at the nasal alar base.    The proximal end of the nerve graft is grasped and  guided through the tunnel to the paralyzed side. In  this way, it is ensured that coaptation of the facial  nerve branches is not inadvertently done to fascicles  that run into side branches that have been divided or  torn during harvest. The nerve is placed high in the  upper lip immediately underneath the collumella  and the alar base in order to avoid interference with  the dissection during muscle transfer later on.   e. Interfascicular nerve coaptation between the  selected facial nerve branches and the sural nerve  graft is done under the microscope using 11-0  sutures. It will not be possible to connect all fascicles  of the nerve graft to the small facial nerve branches,  but it is important to make sure that the fascicles  of the facial nerve branches are securely connected  to individual fascicles of the sural nerve graft.  The end of the nerve graft on the paralyzed side is  fixed to the parotid fascia by a non-resorbable 3-0  suture that can be easily identified and dissected  9-12 months later during muscle transfer. Suction  drainage with a 10-gauge drain on either side and  skin closure in layers complete the operation. It is  important to ensure that the drain is not located  in the vicinity of to the coapted nerve branches to  avoid inadvertent damage during drain removal.    Planning: After a minimum wait of 9 months, the muscle  transfer can be planned for restoration of oral commissure  movement and/or eye closure. In order to achieve a symmet-  ric smile, it is important pre-operatively to do the following:    ® Define the desired position of the modiolus at rest with  the patient sitting in an upright position.   © Identify the vector and the extent of movement of the  commissure during smiling.    The commissure and the nasolabial crease are marked  on both sides with a waterproof pen on the immediate pre-  operative day. The difference between the actual and the  planned position of the commissure at rest is registered on  the paralyzed side with a ruler. The extent of movement of  the commissure during smile on the non-paralyzed side is  also measured directly using the ruler and the direction  of movement is marked on the skin with an arrow. These  marks will have to be renewed after facial skin disinfection  and draping immediately before the operation starts. The  required length of the muscle graft can be estimated from  the distance between the zygomatic bone prominence and  the position of the modiolus at rest.    The facial skin on the paralyzed side is elevated from the  pre-auricular incision, which is extended to the subman-  dibular area. Subcutaneous dissection is carried on to the  lower border of the mandible where the facial vessels are    identified and exposed to be used as recipient vessels for  the muscle graft. The end of the cross-face nerve graft  that had been fixed to the parotid fascia is released and  adequate regeneration is confirmed clinically by a posi-  tive Tinel’s sign and histologically after removal of a small  portion of the nerve for frozen section analysis. Elevation  of the skin is continued medially until the oral commis-  sure and the malar prominence are reached. This exposes  the paralyzed zygomaticus muscles, the action of which is  supposed to be replaced by the muscle graft (Figure 29.4a).   The tissue underlying the commissure is grasped with  a forceps and pulled gently in a cranial direction towards  the zygoma while the formation of creases and the change  in the shape of the commissure is observed (Figure 29.4b).    Figure 29.4 (a) Exposure of the zygomaticus muscle and  identification of the modiolus. (b) Traction to the commissure  to define the ‘smile pattern’.    The traction points will have to be modified slightly and the  procedure repeated until a satisfactory smile shape results.  This traction point is secured with a permanent suture that  is left open. Commonly, one or two more traction points  are needed to produce a movement and shape that mimics  that of the normal side. These are explored while the central  point in the commissure is ‘activated’ by pulling the suture.  In this way, additional points are identified and secured  with sutures. The additional points are commonly found  slightly more medial to the commissure in the upper lip and  below the central point in lateral portion of the lower lip.   Insertion of the muscle graft: The muscle is harvested  according to the procedure described in Chapter 26. The  graft is placed on the recipient side with the point of entry  of the vascular pedicle and the nerve on the undersur-  face of the muscle. The muscle length should be roughly  adapted according to the distance between the commis-  sure in a simulated position at rest and the malar promi-  nence. This is advisable to avoid asymmetric positioning  of the neurovascular pedicle that may occur if the muscle  is shortened after one end has already been fixed. Usually  a length of 6-7 cm is used in this position.   The graft end that faces the commissure is divided into  two or three portions depending on the number of trac-  tion points identified (Figure 29.5). The muscle ends are  attached separately to the upper lip commissure and if  required to the lower lip. Fixation to these points is done  with 2-0 or 3-0 resorbable mattress sutures. Excess muscle  volume at the points of fixation is reduced by excision of  muscle fibres from the centre of the graft ends in order  to preserve the epimysium for secure fixation. The stay  sutures that have been fixed to the traction points are acti-  vated to elevate the commissure to a position that is sym-  metric to the position at rest on the normal side according  to the pre-operative measurements. They are transcutane-  ously fixed over lead buttons above the malar prominence    Figure 29.5 The graft end is divided into three parts  before it is fixed to the oral commissure.    (Figure 29.6). The upper end of the muscle is securely fixed  to the periosteum of the zygoma by multiple mattress  sutures in the direction of the vector defined by the stay  sutures. The muscle length should be adapted in a way that  there is slight tension on the muscle.   Vascular anastomoses of the graft vessels with the facial  vessels are done under the microscope using 9-0 or 10-0  sutures depending on the diameter of the graft vessels.    Occasionally, spasm of the facial artery occurs, which can  be released by carefully applying papaverine to the end of  the facial artery. Interfascicular coaptation of fascicles of  the muscle’s motor nerve to the cross-face nerve graft is  done using 11-0 sutures. Coaptation should be close to the  muscle to allow as early re-innervation by regenerating  axons from the cross-face nerve graft as rapidly as possible.   Before wound closure, the stay sutures should be  checked to make sure that the new position of the com-  missure is held by the sutures and not by the muscle. A  10-gauge suction drain is placed in the submandibular  area and the tip of the drain is kept away from the facial  vessels to avoid damage during removal.    Post-operative care of the donor leg is described in  Chapter 26. The suction drainage is routinely removed  on the second post-operative day. Patients are asked not  to activate their facial muscles on the normal side of the  face to avoid tension and dislocation on the reconstructed  side. The stay sutures are left for 3-4 weeks to allow for  consolidation of the connection between the grafted mus-  cle tissues in the points of fixation. Four weeks after the  operation, transcutaneous electrical stimulation of the  grafted muscle is started to avoid muscle atrophy during  nerve regeneration (Figure 29.7a and b).    (a) Long-standing facial paralysis at rest (left) and during activation (right). (6) Three months after repair (gracilis    Complications are rare with respect to bleeding or wound  break down. A major complication is the inability of  the muscle graft to take on action. This only becomes  evident some 25-30 weeks after the muscle transfer.  Electromyography at this time can prove existing or miss-  ing voluntarily muscle contractions. Failure to show signs  of activity may be due to insufficient vascularization or  missing re-innervation. Insufficient vascularization has to  be excluded by a meticulous technique of microvascular  anastomosis as monitoring of the graft after wound clo-  sure is impossible. Reliable graft perfusion through pat-  ent anastomoses has to be proven by a positive Acland test  and clear signs of muscle perfusion before wound closure.  Failure to re-innervate the muscle may occur if the cross-  face nerve graft has too few actively regenerating axons.  This has to be excluded during muscle transfer by a posi-  tive Tinel’s sign and histologically by frozen sections.    Success in facial reanimation by neuromuscular tissue  transfer is very much based on symmetry of facial expres-  sion. In order to achieve this, a few things should be kept in  mind during the surgical procedures.    e A crucial point is a functioning nerve supply. Thus,  coaptation of the cross-face nerve graft to the facial  nerve on the non-paretic side must be done with great-  est possible care in that the fascicles of the selected  branches are reliably connected to fascicles at the distal  end of the nerve graft.   e The nerve graft should be long enough to reach the  pre-auricular incision line to allow for a tensionless  coaptation with the graft nerve, which in turn should  be as short as possible to shorten neurotization time.   e The muscle graft should be positioned in an almost  vertical fashion from the modiolus to the malar promi-  nence to ensure vertical movement of the commissure  during activation.   e The position of the commissure at rest must be safely  secured by the stay sutures and the lead buttons and  the grafted muscle should be under moderate tension  in this position. A slight overcorrection will compensate  for the tendency of sagging of the soft tissues after  removal. Correction of the position of the commissure  later on by activation of the stay sutures is barely toler-  ated by the patients.    Hari K, Ohmori K and Torii S. Free gracilis muscle trans-  plantation with micorvascular anastomosis for the  treatment of facial paralysis. Plast Reconstr Surg. 1976;  57: 133-135.   Kempe LG. Topical organization of the distal potion of the  facial nerve. J Neurosurg. 1980; 52: 671.   Manktelow RT. Microvascular Reconstruction. New York,  NY: Springer; 1986. p. 128.   Nduka C, Hallam MC and Labbe D. Refinements in smile  reanimation: 10-year experience with the lengthening  temporalis myoplasty. J Plast Reconstr Aesthet Surg.  2012; 65: 851-856.   O’Brien B, Franlin JD and Morrison WA. Cross-facial nerve  grafts and microneurovascular free muscle transfer  for long established facial palsy. Br J Plast Surg. 1980;  33: 202-212.   Terzis JK and Noah ME. Analysis of 100 cases of free-mus-  cle transplantation for facial paralysis. Plast Reconstr  Surg. 1997; 99: 1905-1921.   Terzis JK and Karypidis D. Blink restoration in adult facial  paralysis. Plast Reconstr Surg. 2010; 126: 126-138.   Ueda K, Harii K and Yamada A. Free neurovascular muscle  transplantation for the treatment of facial paraly-  sis using the hypoglossal nerve as a recipient motor  source. Plast Reconstr Surg. 1994; 94: 808-817.    LASER is an acronym for Light Amplification by  Stimulated Emission of Radiation. The laser light is a type  of electromagnetic (EM) radiation and is derived from the  optical part of the EM spectrum. Radiation is considered  energy in transit and its propagation can be influenced  by changes in the energizing source. The laser light trav-  els in waves, which have characteristic wavelengths and  frequency.    The physics of laser is a complex topic; Albert Einstein  published the theoretical basis of laser in 1917, but a func-  tioning laser light was only produced in 1960 by Theodore  Maiman. In brief, atoms consist of a positively charged  nucleus and negatively charged electrons, which orbit in  precise energy levels. At rest these electrons remain at  the lowest energy level (ground state) and when energy is  added, are elevated to an excited state. The excited state  is unstable and the atoms return to the ground state by  emission of a photon (spontaneous emission), which can  be in any direction.   A laser beam on the other hand, which is generated  by a device, consists of photons which are of the same  wavelength (monochromatic), coherent (all components  of the waveform are in phase) and collimated (very little  beam divergence). The basic laser generator consists of  three components: (1) an active or lasing medium, (2)    an optical chamber or resonator and (3) an energizing  source (Figure 30.1).   When energy is pumped into the lasing medium, it is  absorbed by the individual atoms in the medium, which  are elevated to an excited state (stimulated absorption). The  photons released as these atoms try to revert to a ground  state, collides with other excited atoms which are forced to  emit an identical photon (stimulated emission), which are  of the same wavelength, direction and phase. The stimu-  lated photons produced are reflected back and forth by  parallel mirrors in the optical chamber and the number of  photons amplified by each reflection (amplification). When  more atoms achieve an excited state - ‘population inver-  sion’ occurs. The front of the output mirror is designed to  be partially reflective and allows a small percentage of the  energy to be emitted as a laser beam. This beam is fur-  ther passed through a series of focusing lens to reduce its  diameter and increase its intensity and energy to make it  suitable for clinical applications.   The differing types of laser now available are deter-  mined by the active (lasing) medium producing the beam  (Table 30.1). The lasers used in maxillofacial surgery are  often delivered to the tissues via optical cables or through  mirrors in an articulated arm and is dependent on the  wavelength and power of the laser beam. Carbon dioxide  (CO,) laser is traditionally delivered with an articulated  arm and others such as neodymium:yttrium-aluminium-  garnet (Nd:YAG) and potassium-titanyl-phosphate (KTP)  are delivered by fibre optic cables.    The effect of laser on the tissue is principally depen-  dant on its wavelength, power and delivery sequence  in addition to the particular characteristics of the tis-  sues. The outcome of these interactions is due to thermal    (coagulation, vaporization, carbonization and ignition)  and non-thermal (photomechanical, photochemical and  photoablative) events. Photothermal effects are due to the  production of heat from the absorption of laser energy;  photochemical effects are due to changes in the chemical  composition of the tissue resulting from the absorption  of laser light and photomechanical effects results from  the target area being mechanically destroyed by laser  absorption.   Selective photothermolysis' is the ability to achieve  temperature-mediated localized injury to the target tis-  sue through a specific chromophore, while minimizing  damage to the surrounding tissue and is dependant on  the use of a laser with an appropriate wavelength, energy  fluence and pulse duration. Thermal relaxation time is  defined as the time required for a given heated tissue to  lose 50% of its heat through diffusion and therefore sig-  nificant thermal diffusion (thermal damage) can be mini-  mized if the duration of the laser pulse is shorter than  the thermal relaxation time of the target tissue. The laser  beam can be delivered as a continuous wave, pulsed wave  (nanoseconds to seconds) or Q-switched (very fast pulses  10~° seconds).   Therefore, for proper selective thermolysis to occur,  the target tissue (through its chromophores) must pos-  sess greater optical absorption than the non-targeted  surrounding tissue and the laser of choice must have  pulse duration shorter than the thermal relaxation time  of the target tissue. Further, the power, focus and dura-  tion that the beam dwells in a particular spot also influ-  ence the tissue effects (focused beam — incision, defocused  beam - vaporize at high power, coagulate at low power).  The wavelengths, target chromophores and principle uses  of the commonly used lasers in maxillofacial surgery are  highlighted in Table 30.2.   In general, there is very little inflammation associated with  laser wounds with resultant decrease in pain and scarring.  This is thought to be due to the denaturation of proteins,  including the inflammatory mediators, with subsequent  underestimation by the body of the damage caused by the    Laser type Wavelength (nm) Target chromophore Clinical uses  co, 10,600 Water Cutting, vaporization, skin resurfacing, scar  revision  Er:YAG 2,940 Water Skin resurfacing, scar revision  Nd:YAG 1,064 Oxyhaemoglobin, melanin, black, | Vascular lesions (venous malformations),  yellow, red, orange pigment tattoos, pigmented lesions, hair removal  Alexandrite 755 Melanin, black, blue, green Tattoos, hair removal, pigmented lesions  pigment  Ruby 694 Melanin, black, blue, green Tattoos, hair removal, pigmented lesions  pigment  Pulsed dye laser (PDL) 577-595 Oxyhaemoglobin, melanin, yellow, Vascular lesions (capillary, venous  red, orange pigment malformations), pigmented lesions,  tattoos, scar revision  KTP 532 Oxyhaemoglobin Vascular lesions (venous malformations)    laser. The denatured collagen is also partly responsible for the  heamostasis obtained following CO, laser wounds, though  this is restricted to vessels less than 0.5 mm in diameter.    Wavelength: Its selection is principally influenced by the  target chromophere and the intended depth of penetra-  tion (determined by the location of the target chromo-  phere). The shorter the wavelength, the more superficial  the penetration and longer the wavelength, the deeper  the penetration.   Power and spot size: Power and spot size determines power  density and influences the energy and heat delivered to  the target tissue. For a given power output, decreasing the  spot size will increase the energy delivered to a unit target  area (like a magnifying glass concentrating sunlight on  a target). Decreasing the spot size will, however, reduce  the depth of penetration of the laser. As a general rule,  when the spot size is halved, the energy output will have  to be doubled to create an effect at the same treatment  depth. The principal determinant of treatment depth is  the wavelength, regardless of power or spot size.   Pulse width: It is the delivery/exposure time of the laser to  the target tissue. Its selection is influenced by the vol-  ume and thermal relaxation time of the target tissue.  The ideal pulse width is half the thermal relaxation time  of the target tissue.   Cooling: Laser therapy aims to maximize and restrict ther-  mal damage to the target chromophore, while minimiz-  ing damage to the superficial epidermis. Selective cooling  of the superficial skin layers can reduce the undesirable  thermal injury. The two commonly used cooling modali-  ties are sapphire plate contact cooling and cryogen spray  cooling systems. The contact system works by recirculat-  ing chilled water (4°C) around a transparent medium that  is kept in direct contact with the target tissue for less than  2 seconds and removed manually. The selective epider-  mal cooling or dynamic cooling uses the Freon substitute  (cryogen) as the conductive medium and is delivered in  spurts of spray directed over the treated area of a fixed  diameter. The droplet temperature is variable, but usually  set clinically between 45°C and 55°C.    Lasers are safe if used appropriately, though the risks to  patient and the staff can be significant if used improperly.  The safety of lasers is classified according to its effect on  the skin or cornea and is based on the maximum per-  missible exposure (MPE) levels. Class I is the safest and  Class IV is the highest and most dangerous; medical lasers  are Class IV. The clinician using the laser is responsible  for the safety of the patient and the staff. Local policies    should, however, be in place to allow use of lasers by only  trained clinicians, in a safe laser environment staffed by a  trained support team. These operational aspects are often  overseen by laser protection supervisors and laser protec-  tion advisors in the hospital.   The clinician should demonstrate appropriate training,  understanding and experience with lasers in addition to  being aware of the local safety guidelines. The supporting  team, which usually includes a senior nurse prepares the  theatre, checks and starts up the laser and assists with the  setting during its use. The key to laser machine is often  kept by this person, who keeps it with their house key to  ensure that it is not left near the laser machine. The num-  ber of keys in circulation is also strictly controlled.   Safe environment involves the creation of a laser light-  tight envelope to the theatre in addition to provision of  a regularly serviced and inspected laser machine. The  access should be limited to essential personnel instructed  in laser safety and doors should be locked and all win-  dows and ventilation pathways covered with shutters.  Clear warning with illuminated signs should highlight  that a laser procedure is in progress and local safety rules  apply. These signs are usually interlocked with the elec-  trical supply of the laser machine and illuminate auto-  matically when the power is switched on. Some hospitals  have interlocks on the doors, which inhibit laser emis-  sion if the door is opened and interrupts clinical pro-  cedures. In these instances, it would be sensible to have  additional door locks to prevent interlocks cutting the  laser emission.    All the staff in the theatre including the surgeon should  wear eye protection designed for the particular laser in  use. These are designed to provide protection from acci-  dental exposure and are not intended to allow direct view-  ing of the laser beam.   It is essential that the hand piece is not waved around  carelessly, when the laser is switched on. When active, it  should only be aimed at the operation site and all other  times should be switched to the safe standby mode. The  support staff in charge of the machine should always keep  an eye on the clinician and should switch to standby mode  if the laser is being pointed away from the operative site.  Mirrors and highly polished surfaces should be excluded  from the operative site.   The key areas of patient safety in maxillofacial surgery  relate to the airway, eyes and sites adjacent to the target.  Though it is rare for explosive gases to be used in anesthe-  sia; nowadays, it is good practice to discuss this with the  anesthetist. There are, however, inflammable combination  of agents such as nitrous oxide and oxygen used regularly  and it is vitally important that the laser beam does not pen-  etrate the lumen of the airway or endotracheal tube, with  a significant risk of a catastrophic airway fire. There are  specially designed armoured laser resistant endotacheal    tubes available, which are often placed per orally. This can  restrict access for treatment in the mouth, and in these  instances, a nasal tube can be used with additional protec-  tion with a metal foil till the nose and saline soaked gauze  throat and post-nasal pack to protect the tube in this area.  It is important to be particularly aware of the possibility of  perforating the palate and entering the nasal airway and  causing damage to the nasal tube in this region. In the  same way, a cleft palate is a potential risk and an armoured  oral tube would be a better option.   Eye protection is vitally important and depends on  the particular procedure being undertaken. Lead corneal  protectors are used for procedures involving the eyelids  and periorbital areas, whereas special laser safety glasses  are used for other procedures. The areas surrounding  the operative site are protected by a thick layer of saline-  soaked gamgee, in which a small hole can be cut to allow  access to the target site.   Laser plumes contain dust, hazardous chemicals and  biological agents (bacteria, viral DNA), which can cause  potential harm. A laser grade smoke evacuation sys-  tem (high flow, two-stage filtration, filtration efficiency  >99.99%, down to a particle size of 0.05 um) is therefore  essential for scavenging, in addition to wearing surgical  masks and gloves.    The common clinical uses of laser are highlighted in  Table 30.2 and specific applications are described in detail  in other chapters in this book. When a CO, laser is used,  it is important to check on each occasion that the He-Ne  visible light indicator laser and the invisible CO, beam  coincide. This is done by aiming the He-Ne laser at a tar-  get spot on a wooden spatula and firing the CO, laser and  comparing the target spot with the burn spot. Do not rest  your spatula on your lap when you do this.   The CO, and erbium lasers are often used for cutaneous  resurfacing and the recent advent of computerized pattern  generator and scanning capabilities have allowed for large  areas to be treated rapidly and safely. CO, laser resurfac-  ing has been associated with the reactivation of herpes    simplex virus (HSV) causing delayed re-epithelialization  and scarring. Antiviral prophylaxis (famciclovir, valacy-  clovir) should be instituted in this group of patients.    Fractional photothermolysis (Fraxel) works by producing  thermal damage to microscopic zones of the epidermis  and dermis and therefore it is postulated that following  fraxel skin resurfacing, the surrounding normal skin  will help in faster healing and less “down time’ between  treatments.   Intense pulsed light (IPL) is not a laser, but a non-  coherent, multi-wavelength light source, in which appro-  priate filters are placed to produce light with wavelengths  ranging from 590 to 1200 nm. It is primarily used for hair  removal, pigmentary disorders and non-ablative skin  tightening.    e Always refer to the local protocols for the use of lasers.  e Careful protection of the patient, operator and other  staff is essential.    1. Anderson RR and Parrish JA. Selective photother-  molysis: Precise microsurgery by selective absorp-  tion of pulsed radiation. Science. 1983; 220(4596):  524-527.    Farkas JP, Hoopman JE and Kenkel JM. Five parameters  you must understand to master control of your  laser/light-based devices. Aesthet Surg J. 2013; 33(7):  1059-1064.   Historical overview of computer-assisted reconstruction of the facial skeleton 293  Diagnosis and analysis 293  Planning and simulation 294  Computer-assisted reconstruction of the midface 296  Computer-assisted reconstruction of the mandible 301  Validation and quality control 308  Summary 308  Suggested readings 310    Computer-assisted surgery of the head and neck dates  back to the end of the last century. Three-dimensional (3D)  printing with stereolithography was introduced in the  1980s. Since the 1990s, this technique has been increas-  ingly used together with novel techniques for the visu-  alization of 3D computed tomography (CT) data sets for  creating patient-specific models for surgical planning and  simulation. This approach, however, was both complex and  expensive. The introduction of frameless stereotaxy, or in  other words intra-operative navigation systems, gave deci-  sive impetus to computer-assisted surgery. Neurosurgeons  were the first to use this advanced technology. As early as  the mid-1990s, oral and maxillofacial surgeons too rec-  ognized the advantages that this novel technique offered  and ever since have increasingly used it in their specialty.  High costs, initial system inaccuracies and especially the  absence of appropriate and easy-to-use software for plan-  ning and simulating complex reconstructions were the  reasons why this technique was initially used mainly on  a case-by-case basis for navigation-assisted tumour resec-  tion, for planning and performing osteotomies and for den-  tal implant placement. Further milestones in the workflow  of computer-assisted reconstruction of the facial skeleton    were reached when appropriate planning and simulation  software was developed and implemented at the beginning  of this millennium and further improved over the follow-  ing 10 years. Further progress has been made in data set  segmentation and the automatic segmentation of CT data  sets, which involves the division of data sets into surgically  relevant segments for the generation of virtual templates  for facial skeleton reconstruction. In addition, the surface  tessellation language (STL) file format allows external  objects such as preformed implants to be imported into  software platforms. As a result of these advances, naviga-  tion is now routinely used in the clinical setting for the  computer-assisted reconstruction of the facial skeleton.  The implementation of intra-operative 3D imaging and the  prefabrication of patient-specific implants, which includes  the production of resection, bone-cutting and position-  ing guides, has further increased the surgeon’s options  in reconstructing the facial skeleton with computer assis-  tance. All these aspects are included in the workflow of  computer-assisted reconstruction of the facial skeleton  (Figure 31.1).    Diagnosis precedes the computer-assisted reconstruction of  the facial skeleton and is based on clinical findings and 3D  imaging since the usefulness of conventional 2D radiographs    is considerably limited as a result of superimposition. With  the exception of panoramic radiographs, which provide  a good overview of major anatomical structures and are  therefore still useful, 2D images of the facial region (images  of the paranasal sinuses, posterior—anterior or lateral images  of the skull etc.) are no longer required.   CT, magnetic resonance imaging (MRI) and cone-  beam computed tomography (CBCT) are high-resolution  imaging modalities that provide 3D morphologi-  cal information. Since the reconstruction of the facial  skeleton requires the visualization of bone structures  in great detail, CT and CBCT are currently the only  imaging modalities that provide a resolution that is  high enough to meet the requirements of facial bone  reconstruction.   MRI is particularly suitable for imaging soft tissues  and is therefore useful for detecting soft-tissue processes  such as soft-tissue tumours or soft-tissue inflamma-  tion and for planning the surgical management of these  conditions.   A comparison of CT and CBCT reveals that both  modalities provide excellent resolution of bone structures  and that the effective radiation dose delivered to a patient  during a CT examination is generally higher than that  resulting from a CBCT scan.   In spite of this, CT must be regarded as the gold stan-  dard for primary diagnosis preceding facial skeleton  reconstruction and should be preferred to CBCT as the  standard imaging modality for the assessment of bone  structures since it provides not only excellent resolution  of bone structures but, unlike CBCT, also allows soft-  tissue structures to be evaluated, especially with the use    + 3Dimaging  Planning and simulation  + Virtual reconstruction  + Patient-specific 3D model  + Surgical guides  + Patient-specific implants    Surgical procedure  + Intraoperative navigation  + Surgical guides  + Patient-specific implants    Validation and quality control  + Intra-operative and post-operative 3D imaging  + Fusion of pre-operative, intra-operative and    Figure 31.1 Workflow of computer-assisted reconstruc-  tion of the facial skeleton.    of contrast media. Retrobulbar haemorrhage can usually  not be identified by CBCT alone. Although CT is asso-  ciated with a higher effective radiation dose, it should  be preferred to CBCT especially for the diagnosis and  reconstruction planning of tumour diseases, extensive  inflammation and severe malformation since these con-  ditions require the assessment of both bone and soft  tissues.   A combination of CT and positron emission tomogra-  phy (PET), which is also known as PET-CT, offers further  advantages in the diagnosis of tumour diseases. When an  appropriate scanning protocol is used and the CT data set is  reconstructed with a maximum slice thickness of 1.0 mm,  PET-CT images can be used not only for diagnostic pur-  poses but also for planning bone reconstructions so that  no additional radiographs are required.   As a rule, not only axial but also coronal and sagittal  reconstructions should be generated in order to obtain  multiplanar views. Data sets should be reconstructed with  a slice thickness not exceeding 2 mm. Nevertheless, a slice  thickness of 1 mm or less is recommended since impor-  tant details may otherwise be visualized with insufficient  resolution and accuracy may be compromised by the seg-  mentation of virtually generated 3D objects (orbit, zygo-  matic bone, mandible etc.) and the interpolation of slices.  This can, in particular adversely, affect the accuracy of  fit of patient-specific implants and patient-specific surgi-  cal guides and can thus have negative effects on the entire  reconstruction.    Virtual computer-assisted planning and simulation of  a facial reconstruction is performed on the basis of pre-  operative 3D data sets to increase the predictability of  the desired outcome and the safety of the surgical pro-  cedure. Reconstruction is planned using appropriate  planning software that allows any number and many dif-  ferent types of simulations to be performed without a loss  of information and allows 2D and 3D images to be dis-  played in any plane. Different data sets can be combined  by semi-automatic fusion and can then be used for a  precise pre-operative analysis of images from different  imaging modalities and for reliable intra-operative and  post-operative quality control.   The objective of surgical planning is to create a vir-  tual model that matches the desired outcome of surgery.  Planning software that has been developed for this pur-  pose allows for threshold-based segmentation and/or even  atlas-based automatic segmentation during the process of  creating such a virtual model. In addition, it should enable  users to mirror parts of a data set and to freely move, rotate  and modify the generated virtual models in a rapid and  easy way.   STL data sets of 3D bodies (dental implants, tita-  nium mesh structures etc.) can be imported into plan-  ning software so that standard implants, anatomically    preformed implants and patient-specific implants can  be virtually positioned in the patient data set pre-  operatively and their shape, size and fit can be assessed  (Figure 31.2).   STL data sets can be exported so that virtually generated  models or reconstructions can be produced by a 3D printer  and thus allow patient-specific models to be created. Such  models can be used to adapt and pre-operatively bend  patient-specific titanium implants such as mandibular    reconstruction plates or titanium mesh for midface recon-  struction (Figure 31.3).   The next step of computer-assisted facial skeleton recon-  struction is to process virtual reconstruction STL data sets  using computer-aided design (CAD) software for planning  patient-specific implants and to directly produce these  implants using computer-aided manufacturing (CAM)  techniques (Figure 31.4). This process does not require the  fabrication of models.    Figure 31.2. Virtual orbital wall reconstruction using iPlan CMF 3.0 (BrainLAB®). The blue object (top right) is a virtual (anatomi-  cal preformed) titanium mesh (DePuy Synthes®). The green contour shows the virtual template for the planned reconstruction. The  template was created by automatic segmentation and mirroring of the unaffected side.    Figure 31.3 (a) Patient-specific standard implants preformed using three-dimensional (3D) models. Patient-specific mandibular  model with a manually preformed mandibular reconstruction plate. (b) Virtually reconstructed patient-specific skull model with  manually preformed titanium mesh for the secondary reconstruction of the facial skeleton.    Figure 31.4 Patient-specific computer-aided design (CAD)/computer-aided manufacturing (CAM)-fabricated implants.  (a) Computerized numerical control (CNC)-milled patient-specific mandibular reconstruction plate for mandibular reconstruction  with a plate and a fibula flap and a simulation model made of polyamide (DePuy Synthes®). (b) Patient-specific titanium implant  made by selective laser melting (SLM) for the reconstruction of the facial skeleton and the braincase (KLS Martin®).    During the surgical procedure, surgeons have the difficult  task of transferring the result of virtual computer-assisted  planning to the surgical site as accurately as possible. For  this purpose, they can use or combine a variety of different  methods, depending on the complexity of the task.    Today, intra-operative navigation is an integral part of  computer-assisted facial skeleton reconstruction.   Modern infrared-based navigation systems use opti-  cal instruments to emit light waves produced by light-  emitting diodes (LEDs) that are mounted on the system’s  camera (indirect systems). These light waves are reflected  back to the camera of the navigation system by reflective  spheres attached to the instrument (Figure 31.5). The light  waves that are reflected by the instrument and detected by  the camera system are used to calculate the precise loca-  tion of the instrument in space, which is then optically  displayed on the screen of the navigation system.   At the beginning of the surgical procedure, the patient  on the operating table must be ‘fused’ with the image data  set that is displayed on the screen. This process is known  as referencing and is based on reference points that must  be clearly identifiable and reproducible both on the patient  and in the image data set.   Furthermore, the patient’s position must be perma-  nently registered since patient movements during surgery  cannot be prevented or may even be necessary during  the procedure. This is best accomplished by using a star-  shaped reference array that is attached to the patient’s head    Figure 31.5 Intra-operative setup of an indirect navigation  system ([a], camera with integrated LEDs; [b] screen; *, pointer  with two reflective spheres; +, reference array with three  reflective spheres attached to the calvaria). The yellow lines  represent the light waves that are emitted by the camera sys-  tem and reflected back to the camera system by the reflective  spheres of the referencing system (patient tracking). The red  lines represent the light waves that are emitted by the camera  system and reflected back to the camera system by the reflec-  tive spheres of the pointer (instrument tracking).    and allows the navigation system to register all patient  movements without limiting head mobility. When a ref-  erence array is used, the LEDs that are mounted on the  camera of the navigation system emit light waves that are  reflected back by the reference array affixed to the patient’s  head. These waves are detected by the camera and pro-  cessed by the navigation system (Figure 31.5).   Other fixation methods such as a head strap are asso-  ciated with a loss of accuracy. Alternatively, the reference  array can be secured to a Mayfield clamp. This technique    provides accuracy similar to that of direct skull fixation  but does not offer intra-operative mobility of the patient’s  head.   The accuracy of infrared-based navigation systems is  influenced by several factors. The widest range of inac-  curacies is associated with the referencing method used.  Surgical applications require a standard accuracy of  2 mm. Such a level of accuracy can be reliably achieved  by bone-anchored registration points such as screw mark-  ers (mini-screws) that are inserted prior to the acquisition  of the planning data set. The insertion of mini-screws in  the region of the anterior calvaria, for example, can be  recommended for this purpose (Figure 31.6a). An alterna-  tive non-invasive approach is the use of a maxillary splint  and mini-screws (Figure 31.6b) which are attached to the  splint by polymerization. Reliability can be increased by  combining this method with bone-anchored registration  points. As a rule, when reference points are selected or  placed, their centre should be located in the surgical field.  In addition, accuracy can be improved by using widely  spread reference points.   Further methods of registration include the use of ana-  tomical bone landmarks, skin surface matching and skin  fiducials, which are registration points that are glued to the  patient’s skin. Anatomical landmarks have the disadvan-  tage that a sufficient number of landmarks must be identi-  fiable in an accurate and reproducible manner during the  surgical procedure. The use of skin surface matching or  skin fiducials too is associated with difficulties. One major  disadvantage is that imaging must be repeated in the event  of changes to the soft-tissue envelope, which, for example,  occur when swelling develops or subsides or when surgery  is performed. For this reason, these registration tech-  niques are not suitable for facial skeleton reconstruction.   Once the aforementioned technical requirements are  met, the position of the pointer or tip of the pointer can  be visualized in the data set on the screen of the naviga-  tion system. This enables surgeons to verify the realign-  ment of bone fragments and the position and fit of inserted  implants during surgery and to make any necessary    changes without patient exposure to ionizing radiation. In  this process, the virtual reconstruction that has been made  during the planning phase serves as an intra-operative  template that helps surgeons align bone fragments and/or  place implants.    Following the completion of a reconstruction procedure,  surgical outcome is validated in three dimensions. If pos-  sible, such a validation should be performed during the  surgical procedure immediately after reconstruction. This  applies in particular to midface and orbital reconstruc-  tions and, where appropriate, to the reduction and fixation  of mandibular condyle fractures.   This allows necessary modifications such as incorrect  positions of bone fragments and implants to be made dur-  ing the surgical procedure.   In general, ultrasonography, MRI, CT and CBCT are  imaging modalities that can be used during surgery.   Intra-operative imaging for facial skeleton reconstruc-  tion, however, must meet a number of special require-  ments as follows:    © Sufficient resolution, especially for imaging the thin  bone structures of the midface and orbits and the  inserted implants   © Export of Digital Imaging and Communications in  Medicine (DICOM) data for the fusion of intra-opera-  tive images with pre-operative images or pre-operative  planning   @ Data storage on the Picture Archiving and  Communication System (PACS) of the medical facil-  ity for meeting the requirement of archiving intra-  operative image data sets    Figure 31.6. Referencing for intra-operative navigation. (a) Invasive referencing with mini-screws inserted into the calvaria under  local anaesthesia before computed tomography (CT). Sites of incision are marked by black arrows. (b) Non-invasive referencing using  a maxillary splint and four titanium mini-screws (arrows) fixed to the splint by polymerization.    CBCT offers a number of advantages that make this  modality superior to others in meeting the aforementioned  requirements. CBCT systems are available as mobile,  ceiling-suspended or floor-mounted 3D C-arm systems  for use in the operating room (Figures 31.7 and 37.8) or as  small compact CBCT systems for intra-operative use (e.g.  Xoran® x-CAT).   The systems consist of a motor-driven isocentric C-arm  that is rotated 180° around the patient. They produce  image series for multiplanar imaging in the axial, coro-  nal and sagittal planes and thus allow hard tissues to be  imaged during surgery. Soft tissues, however, cannot be    assessed. The radiation dose depends on the system used,  and in particular on tube output, image repetition rate and  exposure time. Although there are no comparative studies  in the literature, the dose of radiation that is applied dur-  ing a single rotation of the C-arm can be assumed to be  lower than that from a comparable conventional CT scan  of the facial skeleton.   The images that are produced by these systems are of  such quality that additional post-operative imaging is usu-  ally not required. The use of a mobile 3D C-arm can thus  be regarded as the current standard intra-operative imag-  ing modality in facial skeleton reconstruction.    Figure 31.7 Mobile 3D C-arm systems. (a) Vario (FD) 3D with a flat panel detector (black arrow) (Ziehm®). (b) Arcadis Orbic 3D  with an x-ray image intensifier and a tracking device for intra-operative navigation (black arrow) (Siemens®).    Figure 31.8 Fixed 3D C-arm systems. (a) Ceiling-suspended 3D C-arm system (Allura Xper FD series, Philips®). (b) Hybrid operating  room with a system that combines a floor-mounted robotic arm and a C-arm imaging system (Artis Zeego, Siemens®).    for example, applies to the transcutaneous reduction of the  zygomatic bone and zygomatic arch using a traction hook.  Following a stab incision, the hook is inserted below the zygo-  matic bone or zygomatic arch for closed reduction of the frac-  ture. Immediately after the surgical intervention, reduction is  verified using a 3D C-arm in the operating room. If necessary,  reduction can be directly corrected and unstable fractures  can be managed by open reduction and fixation (Figure 31.9).    Computer-assisted surgery with intra-operative imaging  allows surgeons to increasingly use or to revive the use of  minimally invasive techniques without decreasing the pre-  dictability of the outcome of reduction procedures. This,    Closed zygomatic bone/zygomatic arch reduction using intra-operative 3D C-arm imaging. After closed zygomatic  arch reduction (d), the 3D C-arm (a) rotates 180° around the patient’s head. (b) Multiplanar (right) data set representation and 3D  reconstruction allow for an accurate intra-operative analysis of the reduction of a lateral midface fracture and an assessment of the  need for orbital wall treatment after zygomatic bone and zygomatic arch reduction. (c) Pre-operative CT shows a depressed fracture  of the left zygomatic arch. (d) Reduction by traction hook after transcutaneous stab incision. The bony contours of the zygomatic  bone and zygomatic arch as well as the locations of stab incisions for traction-hook reduction are marked. (e) Following traction-hook  reduction, intra-operative imaging shows the anatomically correct position of bone fragments in the region of the zygomatic arch.    Fractures of the zygomatico-orbital complex are associ-  ated not only with zygomatic bone fractures but often also  with displaced fractures in the region of the orbital floor.  In such cases, the question is what degree of orbital floor  displacement requires surgical reconstruction in addition  to a reduction of the zygomatic bone fracture. Surgical  reconstruction involves an intra-orbital procedure with  increased morbidity. For this reason, a surgical recon-  struction of the orbital floor should only be performed if  absolutely necessary. Since the zygomatic bone forms part  of the orbital floor, a reduction of the zygomatic bone -  including a closed reduction of the orbital floor - is suf-  ficient in many cases. After zygomatic bone reduction  and especially after a closed reduction, it is still unclear  during surgery whether zygomatic bone reduction has  also resulted in a sufficient reduction of the orbital floor  or whether additional orbital reconstruction is required.  Intra-operative 3D imaging allows surgeons to rapidly  assess the condition of the orbit and to avoid unnecessary  explorations and orbital reconstructions (Figure 31.10).    Fractures of the orbital walls (medial wall or orbital floor)  should receive delayed primary care within the first 2  weeks and after resolution of the swelling. Especially,  orbital wall fractures with involvement of the junction  between the posterior orbital floor and the medial orbital  wall and blow-out fractures of the orbital wall are associ-  ated with an increased risk of malposition of reconstruc-  tion material. This is attributable to the complex and  difficult preparation procedure and usually limited vis-  ibility with haemorrhage and protrusion of orbital tissue.  A biologically inadequate reconstruction of the orbit or  entrapment of orbital tissue can lead to persistent globe  displacement that may result in enophthalmos or exoph-  thalmos and/or can lead to functional deficits such as  diplopia or strabismus. Compared with primary recon-  structions, secondary reconstructions are associated with  a higher complication rate and do not always lead to the  desired functional outcome despite anatomically adequate  repair. For this reason, primary reconstruction should be  preferred. Among the materials used for reconstruction,    Fusion of pre-operative CT scans and intra-operative 3D C-arm images after the reduction of a zygomatico-orbital  complex fracture. (a and b) Pre-operative CT scans of a displaced fracture of the orbital floor (white arrows). (c and d) Intrao-perative  images after zygomatic bone reduction and fixation on the zygomatico-alveolar crest (black arrow). The images show an ana-  tomically correct position of the orbital floor (white arrows). There is no need for open exploration and further management of the    alloplastic materials such as titanium mesh are increas-  ingly preferred to autologous bone grafts since they can be  adapted to the patient’s anatomy, they are non-absorbable  and therefore offer more predictable results; they cause  less donor site morbidity.   For this reason, the first step in the management of  complex orbital wall fractures is virtual reconstruction by  automatic segmentation of the CT data set into anatomi-  cal and surgical structures (iPlan CMF 3.0, BrainLAB®,  Feldkirchen, Germany) (Figure 31.11a). Before surgery, a  virtual template for orbital reconstruction can be created  either by mirroring the unaffected side in the case of uni-  lateral fractures or by using free-form segments in the case  of bilateral fractures with subsequent alignment of seg-  mentation (Figure 31.11b). Anatomically preformed tita-  nium implants (DePuy/Synthes®, Zuchwil, Switzerland)  or patient-specific titanium implants manufactured by  selective laser melting (SLM) (KLS Martin®, Tuttlingen,  Germany) can be virtually placed before surgery in order  to assess the accuracy of fit (Figures 31.11b and 31.12c¢,d).  A navigation system can then be used to verify the align-  ment of bone fragments after reduction and the position  and shape of the inserted implants. The tip of the pointer  is placed on the implant or bone and the position of the  pointer tip shows the current position of the structure of  interest (Figure 31.11c). This enables surgeons to verify  reduction as well as the position and accuracy of fit of  implants and to make any necessary corrections. Intra-  operative 3D imaging is then performed as a final assess-  ment of the procedure. Details of radiological images are  sufficient to allow reconstruction results to be accurately  validated on the basis of intra-operative data sets that  are fused with pre-operative data sets and simulations  (Figures 31.1ld and 12e,f). Whereas previously orbital  floor and medial orbital wall reconstructions required a  coronal incision, the combined use of patient-specific or  anatomically preformed implants, intra-operative naviga-  tion and imaging now enables surgeons to perform even  extensive reconstructions of the orbital floor and medial  orbital wall via a transconjunctival approach and thus to  avoid visible scars.    Secondary reconstructions are extremely challenging  for surgeons because of the presence of soft-tissue atro-  phy and scarring. The complex anatomy of the orbit  and the peri-orbital region often complicate functional  and aesthetic reconstruction with autologous bone.  Reconstruction using alloplastic materials (preferably  titanium) is much easier since these materials can be  combined with autologous bone grafts (e.g. calvarial  bone) or vascularized soft-tissue or bone flaps. Computer-  assisted simulation and planning (Figure 31.13a through  13c) allows bone reconstructions to be virtually planned  in detail before surgery and to be exported as an STL data  set (iPlan CMF 3.0, BrainLAB®, Feldkirchen, Germany).  A patient-specific 3D plastic model can then be printed  on the basis of the STL data set (Figure 31.13d) and    patient-specific reconstruction can be prepared using  standard implants and standard mesh structures (Figure  31.13e). Alternatively or additionally, such patient-specific  implants can also be manufactured industrially using  polyether ether ketone (PEEK), ceramics or titanium  (Figure 31.13f). These pre-operatively manufactured  implants are placed intra-operatively using a pointer-  based navigation system (Figure 31.13g). 3D imaging  allows the position of an implant to be verified during  surgery (Figure 31.13h) and after surgery (Figure 31.13i).    The human mandible plays a key role in masticating food,  swallowing and speaking and supports the tongue, which  keeps the airways clear. In addition, it is important for the  harmonious appearance of the face. In diseases of the oral  cavity such as carcinomas, osteoradionecrosis, osteomy-  elitis or medication-related necrosis of the lower jaw, the  surgical removal of a portion of the mandible, and thus  a loss of mandibular continuity are inevitable in many  cases. The rehabilitation of the mandibular contour, the  restoration of occlusion, and the correct position of the  condyles in the glenoid fossae are crucial for providing  the patient with adequate masticatory function and an  aesthetically satisfying result. Two methods are primar-  ily used to reconstruct mandibular continuity defects: (1)  alloplastic mandibular reconstruction using mandibular  reconstruction plates and secondary bone reconstruc-  tion of the defect zone after a relapse-free interval and  (2) primary mandibular bone reconstruction following  resection in combination with reconstruction plates or  miniplates.   Patient-specific implants are used for computer-assisted  mandibular reconstruction. They can be combined with  patient-specific resection, cutting and positioning guides.   When patient-specific implants or reconstruction plates  are used, it is difficult for surgeons to position them on  the mandible according to planning. Without the use of  surgical guides, it is also often impossible to adequately  osteotomize microvascular bone segments and to fixate  them to a plate as planned. Patient-specific surgical guides  thus play the role of an interface between the virtual and  the real world. For this reason, their design and accuracy  are of crucial importance for an exact transfer of virtual  reconstruction to the patient.   Apart from the basic distinction between primary allo-  plastic and primary bone reconstruction, the following  types of procedures can be distinguished:    © The simplest procedure involves the use of a standard  implant that is manually bent in accordance with a  patient-specific model and fixated to the mandible in a  standard surgical procedure.    Computer-assisted primary reconstruction of the left orbit using an anatomically preformed implant. (a) Multiplanar  view of the virtual planning and creation of a template for orbital wall reconstruction by means of automatic segmentation of the  unaffected right orbit using iPlan CMF 3.0 (BrainLAB®) (green contour lines). (b) Multiplanar view of the virtual reconstruction of the  left orbit by means of mirroring the segmentation of the unaffected side (green contour lines) and virtual placement of an anatomi-  cally preformed orbital implant (red contour lines). The virtual placement of the anatomically preformed titanium implant allows sur-  geons to verify the size and accuracy of fit of the orbital implant. During surgery, implant placement (red contour lines) is performed  according to the virtual reconstruction of the orbit (green contour lines) or the virtual placement of the implant. (c) Multiplanar view  of the navigation-assisted placement of an anatomically preformed orbital implant (c: top left) (DePuySynthes®). The green contour  line shows the virtual reconstruction of the orbit (analogous to the green contour line in [b] and [d]). During the surgical procedure,  the red contour line displays the surface of the orbital implant inserted on the basis of implant surface data provided by the naviga-  tion tool. The orange contour line shows the virtually planned orbital implant on the screen of the navigation system (analogous  to the red contour line in [b] and [d]). Multiplanar view of intra-operative 3D imaging with superimposition of virtual planning. The  green contour line represents the virtual reconstruction (analogous to [b] and [c]) and the red contour line shows the virtually placed  orbital implant (analogous to [b]). The image shows good fit of the radio-opaque implant in accordance with virtual planning.    Figure 31.12 Computer-assisted primary reconstruction of the left orbit with a patient-specific implant manufactured by SLM  (KLS Martin®). (a) Multiplanar view of the virtual planning and creation of a template for orbital wall reconstruction by means of auto-  matic segmentation and mirroring of the unaffected left orbit using iPlan CMF 3.0 (BrainLAB®) (green contour lines). (b) Virtual tem-  plate of the right orbit for the simulation and determination of the size of the patient-specific implant (yellow dots). (c) Multiplanar  view of the virtual reconstruction with a virtually placed patient-specific implant that was imported into the left orbit as an STL data  set after industrial planning (red contour line). Virtual implant placement allows the accuracy of fit to be verified before the implant  is manufactured. During surgery, implant placement (red contour lines) is performed according to the virtual reconstruction of the  orbit (green contour lines) or the virtual placement of the implant. (d) CAD of the patient-specific implant. The implant corresponds  to the implant that was virtually placed as an STL data set in [c]. (e) Multiplanar view of intra-operative 3D imaging. The top left  image shows the patient-specific implant after placement. (f) Multiplanar view of intra-operative 3D imaging with superimposition  of virtual planning. The yellow contour line shows the virtual reconstruction (analogous to [a], [b] and [c]). The image shows good fit  of the radio-opaque implant in accordance with virtual planning.    Figure 31.13 Computer-assisted secondary reconstruction of the midface. (a) Multiplanar representation of an inadequately  managed comminuted fracture of the left midfacial region and post-operative craniotomy for brain abscess. (b) Multiplanar view  of the virtual planning and creation of a template for midfacial reconstruction by automatic segmentation of the unaffected right  side (yellow contour lines). (c) Multiplanar view of the virtual reconstruction by mirroring the unaffected side after bone segmenta-  tion using iPlan CMF 3.0 (BrainLAB®) (yellow contour lines). (d) Transfer of a virtual reconstruction into an STL data set that is used  to create a 3D printed patient-specific plastic model. The 3D reconstruction model is used to form patient-specific implants from  standard implants. (e) An additional patient-specific PEEK implant industrially manufactured for repairing a calvarial defect. (f) Intra-  operative view after re-osteotomy of the left zygomatic bone and zygomatic arch complex and placement of patient-specific  implants. (g) Multiplanar view of intra-operative navigation for an assessment of fracture reduction and the position of titanium  implants. The pink contour line represents the surface of the inserted titanium implants. The green contour line shows the virtual  template that was pre-operatively planned for the reconstruction procedure. (h) Multiplanar view of intra-operative 3D imaging  with superimposition of virtual planning (green contour line). The reconstruction conforms well to the virtual template. (i) 3D view  of a post-operative control CT.    e A more complex procedure involves the use of a stan-  dard implant that is manually bent in accordance with  a patient-specific model and combined with manually  manufactured positioning keys.    Both procedures can be used together with resection and  cutting guides that enable surgeons to perform man-  dibular resection and harvest bone segments accurately  according to planning. Resection and cutting guides can    be manufactured either manually or by using CAD/CAM  techniques in a manner analogous to virtual computer-  assisted planning.    e An even more complex procedure of computer-  assisted reconstruction involves the combination  of a patient-specific CAD/CAM mandibular recon-  struction plate and CAD/CAM resection and cutting  guides.    Mandibular reconstruction using patient-specific  preformed standard mandibular reconstruction plates  Pre-operative CT data sets allow patient-specific 3D  models to be printed. These models can be used to pre-  operatively bend a standard implant and thus to create a  patient-specific implant. Whereas intra-operative naviga-  tion allows, for example, titanium mesh structures to be  transferred to the midface, the orbits or the calvaria in a  relatively accurate manner, fixation plates for mandibular  reconstruction require the use of guides for plate posi-  tioning. This applies in particular to cases in which the  standard technique for the fixation of mandibular recon-  struction plates cannot be used anymore.   The procedure here referred to as the standard  technique involves bending a reconstruction plate to the  outer contour of the mandible before mandibular resec-  tion. The plate can be bent either intra-operatively or  pre-operatively using a patient-specific mandibular model.  Once the plate has been bent and positioned, it is fixated  onto the mandible with a minimum of four screws, two  of which are placed distal and the other two proximal to    the mandibular segment to be removed. The position of  the plate on the mandible is thus determined. The plate is  removed and segmental resection is performed. Following  resection, the plate is placed again on the mandible and  fixated to the two remaining mandibular segments using  the predefined screw holes. The use of locking plate sys-  tems allows the 3D structure of the mandible to be almost  completely restored.   This standard method, however, has limitations and  cannot be used if the outer cortex of the mandible is  involved in the pathological process, if a secondary pro-  cedure is performed after segmental resection and the  associated loss of mandibular continuity, and/or if a  microvascular bone graft (e.g. fibula, iliac crest, scapula)  is used for reconstruction. The standard method also can-  not be used if the surgeon favours a plate shape that does  not correspond to the outer contour of the mandible. This  is the case, for example, if a plate is to be located more  posterior in the mental region than the original outer  contour in order to avoid an overly prominent chin or if  a plate is to be located more medial in the lateral man-  dible than the original contour in order to allow a dental  implant to be placed later at a prosthetically appropriate  position (Figure 31.14a).    Figure 31.14 Patient-specific mandibular reconstruction plate with transfer keys and standard plates prebent on the basis of  the patient models. (a) mandibular reconstruction plate prebent on the basis of a patient-specific model and fixed with screws.  (b) Plastic transfer keys in the region of the right ascending ramus. (c) Intra-operative image showing the reconstruction plate fixed  to the remaining mandibular segments by means of transfer keys. Transfer keys temporarily secured with mini-screws.    A wide variety of techniques, such as the use of an  external fixator, the placement of K-wires and the fixation  of the ramus, have been described and can be applied to  avoid this problem.   Alternatively, positioning guides (transfer keys) can be  made of plastic after the reconstruction plate is bent and  fixed to a patient-specific mandibular model that has been  manually milled into shape (Figures 31.14b,c and 31.15a,b).  These positioning guides allow the position of the plate  that has been planned by means of a model to be repro-  duced with a high degree of precision and thus allow a  high accuracy of reconstruction to be achieved in terms of  the position of the plate on the remaining mandible after  segmental resection. This approach has the advantage that  it does not require the previous (temporary) fixation of the  reconstruction plate and the resection can be performed  with no loss of accuracy. In addition, this allows freely    When CAD/CAM technologies are used to generate  patient-specific implants and surgical guides, an STL data  set is created on the basis of virtual surgical and reconstruc-  tion planning and exported into CAD software. Depending  on what is needed where, patient-specific implants and the  associated surgical guides are generated using CAM tech-  niques. The implants are manufactured either by comput-  erized numerical control (CNC) milling (Figure 31.16),  SLM (Figure 31.17) or electron beam melting (EBM). By  contrast, selective laser sintering (SLS) is the method that  is usually used for creating surgical guides (Figure 31.18).    Patient-specific mandibular reconstruction plate with transfer keys in form of drilling guides and standard plates  prebent on the basis of the patient models. (a) Plastic transfer keys in the region of the left ascending ramus in form of a drilling  guide. (b) Intra-operative image showing transfer keys temporarily secured with mini-screws and the drill guide is inserted in the key  to drill the hole in accordance to the model position. (c) Intra-operative image showing the reconstruction plate fixed to the remain-    Figure 31.16 (a) CNCmilled patient-specific mandibular reconstruction plate (DePuy Synthes®) for alloplastic mandibular  reconstruction with a fibula flap. (b) CAD finished implant.    Figure 31.17 (a) Patient-specific mandibular reconstruction plate made by SLM (KLS Martin®) for alloplastic mandibular  reconstruction. (b) CAD finished implant.    Figure 31.18 Surgical guides made from sterilizable polyamide by selective laser sintering (Materialise®). (x) Patient-specific  resection guides with drill sleeves for pre-drilling the screw holes on the basis of the patient-specific mandibular reconstruction  plate. (¢) Cutting guide for mandibular reconstruction with a fibula flap. The cutting guide also has drill sleeves identifying the screw  holes for fixing the mandibular reconstruction plate. CAD finished guides.    These technologies allow workpieces to be manufac-  tured with submillimetre precision.   One difficulty with these techniques is the accurate  positioning of implants or guides at the surgical site. The  presence of soft tissue, limited visibility or the absence of  anatomical landmarks can complicate the positioning of  implants or guides on the basis of planning and can lead  to differences of a few millimetres between the planned  reconstruction and the surgical result.   During pre-operative computer-assisted planning, a  surgeon defines the margins of resection and determines  the details of the planned reconstruction. In a next step,  the desired size of a patient-specific mandibular recon-  struction plate as well as the desired number, positions and  angles of screw holes are individually planned according to  anatomical and surgical requirements. Based on this plan-  ning process, a patient-specific mandibular reconstruction  plate is designed using CAD software. Once the design has  been approved by the surgeon, the plate is manufactured  using CAM techniques.   The margins of resection and the position of the plate  are transferred to the surgical site using guides, which too  are planned with CAD/CAM technology and manufac-  tured from polyamide using selective laser sintering. These  guides are designed based on overall planning. Resection  guides (Figures 31.18 and 31.19d,g) define the planned  margins of bone resection. Information on the positions  of screw holes defining the position of the planned plate  after mandibular resection is encoded in drill sleeves in  the resection guides on the basis of computer planning  and thus transferred to the surgical site. To this end,  sleeves are integrated into the guides, which allow holes  to be pre-drilled for fixation screws (Figure 31.19g,h). This  means that a segmental resection can be performed with-  out prior fixation of the plate to the unresected mandible  because the exact plate position has already been defined  by the screw holes drilled by way of guides. In planned  bone reconstructions involving vascularized or free bone  tissue, cutting guides (Figure 31.19e,h) are also used. After  fixation onto the harvested bone segment, they facili-  tate the segmentation of bone tissue in accordance with  pre-operative computer planning. Here, too, screw hole  positions are determined via drill sleeves in the gutting  guides. Once bone segments have been harvested, they  can thus be screwed to the plate in their planned positions  (Figure 31.19h).   The introduction of CAD/CAM technology for the  design and manufacture of patient-specific mandibular  reconstruction plates, in particular in combination with  surgical guides, has created a broad range of new opportu-  nities for the planning and implementation of mandibular  reconstructions. This applies not only to alloplastic recon-  struction alone but also to reconstruction in combination  with bone grafts or flaps. The insertion of a patient-specific  mandibular reconstruction plate should also be consid-  ered in certain selected cases involving fractures. This  approach offers the important advantage of individual  flexibility with respect to patient-specific requirements.    Compared with conventional techniques, it is also associ-  ated with shorter operative times because there is no need  to bend the plate during the procedure and with consider-  ably easier osteotomy and insertion of bone grafts or flaps.    Whereas intra-operative imaging with a 3D C-arm makes  post-operative imaging after midface reconstruction  unnecessary in many cases, post-operative 3D imaging in  addition to intra-operative imaging may still be required  especially after panfacial and complex reconstructions of  the facial skeleton and mandibular reconstructions.   In these cases, CBCT should theoretically be preferred  to CT because it is associated with a lower effective radia-  tion dose. Clinically, however, care must be taken to ensure  that the field of view of the CBCT system is large enough  to provide the necessary information. Since post-operative  images of both bone and soft tissues may be required, a  suitable imaging modality must be chosen after surgery.  This applies, for example, to entrapped muscle tissue after  orbital wall reconstruction and to the presence of intra-  cerebral free air after a surgical procedure that involves the  posterior wall of the frontal sinus or the region of the skull  base. Despite a higher radiation dose, CT should therefore  be preferred to CBCT in complex cases.   The purpose of intra-operative and post-operative  3D imaging is not only to perform a surgical procedure  under radiological control but also to provide data sets for  computer-assisted fusion with pre-operative image data  sets and especially with pre-operative computer planning.  Image fusion allows differences between pre-operative  planning and surgical outcome to be visualized and, if  required, to be quantitatively evaluated within the scope  of quality assurance.    As a result of advances in 3D imaging, 3D printing, intra-  operative visualization and intra-operative navigation at  the end of the last century and further improvements in  these techniques in recent years, computer-assisted recon-  struction of the facial skeleton has become an integral  part of oral and maxillofacial surgery. In recent years, a  workflow has been established which involves the follow-  ing steps: diagnosis planning and simulation surgical pro-  cedure validation and quality control.   The focus of diagnosis is on 3D imaging especially on  CT and on clinical findings.   Planning and simulation involves the creation of a vir-  tual model of the desired surgical outcome. Apart from the  fusion of different data sets, planning software allows the  virtual models to be segmented in a user-friendly manner  and to be manipulated (e.g. to be mirrored, shifted, rotated  and modified) in an easy way. In addition, STL data sets  can be imported and exported. When STL data sets are    Figure 31.19 Mandibular reconstruction with a patient-specific reconstruction plate and a fibula flap with an intraoral skin  island. (a) Virtual mandibular resection. View of the planned resection (red) and remaining bone segments (blue). (b and c) Virtual  mandibular reconstruction with a four-segment fibula flap. Superimposition of the original mandible (red) and planned reconstruc-  tion (b). (d) CAD of resection guides for mandibular resection. Guides with drill sleeves that identify the planned screw hole posi-  tions. The black arrow indicates the drill sleeves and the blue arrow indicates that area of the guide that helps the surgeon guide a  bone-cutting instrument (saw, osteotome, chisel etc.) (see also g). (e) Virtual fibula osteotomy lines and triangular bone segments  that must be removed in order to obtain the shape of the neomandible consisting of four segments (top). CAD of cutting guides  for harvesting fibula segments (bottom). Guides with drill sleeves that identify the planned screw hole positions (black arrow). The  blue arrow indicates that area of the guide that helps the surgeon guide a bone-cutting instrument (see also h) (bottom). (f) CAD of  the patient-specific mandibular reconstruction plate. Number of screws as well as the position and angle of each screw as predeter-  mined. (g) Resection guide fixed with mini-screws for guiding a saw (blue arrow). Screw holes pre-drilled as planned (black arrow).  (h) Bone-cutting guide fixed to the fibula with mini-screws. Integrated drill sleeves allow screw holes to be pre-drilled as planned  (black arrow). (i) A fibula flap fixed to the patient-specific mandibular reconstruction plate using the pre-drilled screw holes.  (j) Mandibular reconstruction with a fibula flap and a patient-specific mandibular reconstruction plate. Anastomosis of the pedicle  of the fibula flap in the region of the left neck (black arrow). (k) Post-operative panoramic radiography of the reconstruction.    imported, the accuracy of implant fit can be virtually into CAD software are helpful in planning patient-spe-  verified before surgery. When STL data sets are exported, cific implants and in manufacturing them using CAM  patient-specific 3D models and virtual reconstructions techniques.   can be directly printed and can be used for manufacturing During the surgical procedure, planning must be    patient-specific implants. STL data sets that are imported transferred to the surgical site as accurately as possible.    A number of techniques are available for this purpose,  e.g. closed reduction, open reduction with the placement  of anatomically preformed or patient-specific implants in  combination with surgical guides, and the additional use  of navigation and intra-operative imaging.   After reconstructions of the midface, 3D imaging  should be performed even before surgery is completed.  Malpositions can thus be directly corrected and unneces-  sary open reconstructions or explorations - for example of  the orbital walls — can be avoided. Mobile 3D C-arms are  particularly useful for intra-operative 3D imaging.   Patient-specific surgical guides and patient-specific man-  dibular reconstruction plates are used in computer-assisted  mandibular reconstructions. Surgical guides play the role  of an interface between the virtual and the real world and  are thus of crucial importance for an exact transfer of vir-  tual reconstruction to the real surgical scenario.   Validation and quality control require post-procedural  3D imaging. Whereas intra-operative imaging with a 3D  C-arm makes post-operative imaging after midface recon-  struction unnecessary in many cases, post-operative 3D  imaging in addition to intra-operative imaging may still  be required after complex reconstructions of the facial  skeleton and mandible.    Austin RE and Antonyshyn OM. Current applications of  3-d intraoperative navigation in craniomaxillofacial  surgery: A retrospective clinical review. Ann Plast  Surg. 2012; 69: 271-278.   Bell RB and Markiewicz MR. Computer-assisted planning,  stereolithographic modeling, and intraoperative navi-  gation for complex orbital reconstruction: A descrip-  tive study in a preliminary cohort. J Oral Maxillofac  Surg. 2009; 67: 2559-2570.   Gellrich N-C, Schramm A, Hammer B and Schmelzeisen R.  The value of computer-aided planning and intraop-  erative navigation in orbital reconstruction. 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Int J Med Robot. 2009; 5: 111-124.   Schramm A and Wilde EF Die computergestiitzte  Gesichtsschadelrekonstruktion. HNO. 2011; 59:  800-806.   West JB, Fitzpatrick JM, Toms SA, Maurer CR Jr and  Maciunas RJ. Fiducial point placement and the  accuracy of point-based, rigid body registration.  Neurosurgery. 2011; 48: 810-816; Discussion 816-817.   Wilde F, Cornelius C-P and Schramm A. Computer-  assisted mandibular reconstruction with CAD/CAM-  fabricated patient-specific reconstruction plates: A  cadaver feasibility study. Int J Comput Assist Radiol  Surg. 2013b; 8(Suppl 1): 87-88.   Wilde F, Cornelius C-P and Schramm A. Computer-  assisted mandibular reconstruction using a patient-  specific reconstruction plate fabricated with  computer-aided design and manufacturing tech-  niques. Craniomaxillofac Trauma Reconstr. 2014; 7:  158-166.   Wilde EF, Hanken H, Probst EF, Schramm A, Heiland M  and Cornelius C-P. Multicentre study on the use of  patient-specific CAD/CAM reconstruction plates  for mandibular reconstruction. Int J] Comput Assist  Radiol Surg. 2015b; 10: 2035-2051.    Wilde F, Hilbert J, Kamer L, Hammer B, Metzger M,  Schmelzeisen R, et al. The combination of automatic  segmentation, preformed implants, intraopera-  tive imaging in primary orbital wall reconstruction:  Description of a new method. Int J CARS. 2009;  4(Suppl 1): 134.   Wilde E, Lorenz K, Ebner AK, Krauss O, Mascha F and  Schramm A. Intraoperative imaging with a 3D-C-  arm system after zygomatico-orbital complex fracture  reduction. J Oral Maxillofac Surg. 2013a; 71: 894-910.   Wilde FE Plail M, Riese C, Schramm A and Winter K.  Mandible reconstruction with patient-specific pre-bent  reconstruction plates: Comparison of a transfer key  method to the standard method-results of an in vitro  study. Int J Comput Assist Radiol Surg. 2012; 7: 57-63.   Wilde F and Schramm A. Rekonstruktion nach Trauma.  Der MKG-Chirurg. 2013; 6: 154-164.   Wilde F and Schramm A. Intraoperative imaging in orbital  and midface reconstruction. Facial Plast Surg. 2014;  30: 545-553.   Wilde E, Winter K, Kletsch K, Lorenz K and Schramm A.  Mandible reconstruction using patient-specific pre-  bent reconstruction plates: Comparison of standard  and transfer key methods. Int J Comput Assist Radiol  Surg. 2015a; 10: 129-140.   Yu H, Shen SG, Wang X, Zhang L and Zhang S. The indica-  tion and application of computer-assisted navigation  in oral and maxillofacial surgery - Shanghai’s expe-  rience based on 104 cases. J Craniomaxillofac Surg.  2013; 41: 770-774.    Transoral robotic surgery (TORS) is a modern techno-  logical advancement that involves the use of a remote  console operated robot. Its application includes the  removal of difficult access tumours within the oral cav-  ity, oropharynx and supraglottis, thereby avoiding the  use of extensive facial splitting approaches, pull-through  surgical access approaches or radiation therapy. Benefits  of TORS include complete surgical excision and patho-  logic tumour evaluation, decreased hospital length of  stay, avoidance of radiotherapy (or de-escalated dosages)  and associated long-term effects (i.e. osteoradionecrosis,  dysphagia) with improved cosmesis via minimal access  approaches.'* Although its most common application is  for the removal of squamous carcinoma of the oropha-  ryngeal region, surgeons have continued to expand the  scope of this robotic technology to other areas within  the head and neck, including the management of sleep  apnoea, thyroidectomy and neck dissection.*° This  chapter focuses on the use of TORS for the purposes of  the management of tumours within the oral cavity and  oropharynx.    The incidence of oropharyngeal squamous carcinoma  (OSCC) has undergone a significant increase through-  out the world, with links to the human papilloma virus    (HPV).’ Surgery was historically reserved for salvage  treatment often because of the need for extensive facial-  splitting incisions, flap reconstruction and adjuvant  radiotherapy due to initial advanced-stage disease pre-  sentation. As the management of OSCC shifts towards  surgical management for early disease, the use of TORS  will become advantageous. TORS long-term outcomes  data are now available, demonstrating similar long-  term disease free and overall survival as compared to  radiotherapy, while minimizing risks of long-term  radiation side effects such as osteoradionecrosis and  dysphagia.*”-° Weinstein et al. reported on a series of 47  patients who underwent TORS and neck dissection for  OSCC.! Disease-free survival at 2 years was 90% with  38% of patients avoiding adjuvant chemotherapy and  11% of patients avoiding adjuvant chemoradiotherapy.  The incidence of PEG tube dependence was 2.4% at  2 years which is similar to current chemoradiotherapy  treatment rates. Another advantage suggested by TORS  for OSCC includes the ability to accurately patho-  logically stage the tumour, resulting in more accurate  patient-specific treatment (addition of chemotherapy or  de-intensification of therapy). Walvekar et al. reported  on a series in which clinical stage was altered in 40%  of patients.’ Larger resections requiring formal recon-  struction can be managed with local flaps such as with  the buccal fat pad, facial artery myomucosal (FAMM)  or submental island flap. As surgeons have become  more skilled in TORS, vascularized free flaps have  also been inset using a robotic approach (Figure 32.la  through d).*!°    Figure 32.1 (a) Basaloid squamous carcinoma of the tongue base. (b) Tongue base resection defect using transoral robotic  surgery. (c) Submental island artery flap elevated with selective neck dissection levels Il, III and IV. (d) Flap inset.    Approximately 4% of squamous cell carcinomas of the  head and neck will present with metastatic cervical  adenopathy without evidence of the primary source.'>”  Traditionally, these patients would undergo panendos-  copy; random biopsies and palatine tonsillectomy. If the  primary source was not identified, then treatment would  include broad field radiotherapy to the head and neck,  resulting in significant morbidities such as dysphagia.  Positron emission tomography in combination with com-  puterized tomography (PET/CT) prior to panendoscopy  has allowed the surgeon to focus biopsies on suspicious  sites as detected on imaging with improved identification  of the unknown primary. This is obviously important as  it allows the radiotherapist to focus on the primary site  thereby decreasing radiation toxicity. Between 15% and  60% of unknown primary head and neck carcinomas will    occur at the base of tongue. Various series have described  the use of TORS for base of tongue resection to help both  locate and provide definitive surgical therapy simulta-  neously.'"? In a large multicentre trial for the unknown  primary (n = 47), TORS was utilized to resect both the  palatine tonsils and perform a simultaneous tongue base  resection.” The primary tumour was identified in 70% of  cases of which greater than 50% occurred at the tongue  base. Neck dissection was also performed simultaneously  once the primary was identified. The authors also reported  that pre-operative exam and imaging failed to reveal the  primary tumour in 38% of cases.”    TORS technology is being adapted for the use in tongue  base reduction surgery to aid in the management of    obstructive sleep apnoea.*>*? It is often combined with  other surgical therapies such as uvulopalatopharyngo-  plasty (UPPP) with minimal morbidity and improvements  in patient apnoea-hypopnea indicies (AHI) in selected  patients. Vincini et al. reported on a multi-centre trial of  243 cases with significant improvement in AHI, Epworth  Sleepiness Scale and oxygen saturation.   Lin and colleagues suggest that one major predictor of  successful TORS tongue base reduction surgery is in the  absence of lateral velopharyngeal collapse.° Glazer et al.  reported on the safety of TORS surgery for severe OSA  in 166 patients. In their series, only 6% of patients expe-  rienced major complications with one patient becoming  feeding tube dependent due to significant dysphagia.°   © High-definition camera 0° and 30° lenses (8.5 or 12 mm  diameter)   ® Remote operating surgical robot and _ console.  Currently, only the da Vinci Surgical System Model S  or SI (Intuitive Surgical, Sunnyvale, CA) is available for  TORS procedures (Figure 32.2a through d).    The patient is placed supine in the operatory and follow-  ing induction of anaesthesia either a re-inforced naso-  endotracheal tube (laser safe) is placed or tracheostomy  performed. The patient is padded and the tube secured  with the eyes protected with safety goggles. A shoulder  roll also allows for ease of head positioning. Exam under  anaesthesia is performed to re-evaluate the tumour prior  to removal. Both direct visualization and manual palpa-  tion (if possible) are beneficial to aid in surgical planning.    Figure 32.2 (a) Surgical 5-mm diameter operating instruments. (b) Surgical remote operating console. Two consoles are avail-  able to allow for teaching purposes or control of multiple instruments. (c) Feyh-Kastenbauer retractor suspended in position.  (d) Robot in correct position and orientation to begin transoral robotic surgery procedure.    Surgical assistant can view the procedure ona  high definition television monitor.    The mouth is opened with a mouth gag and the retractor  of choice is placed to position the tongue. This will allow  for visualization of the tumour at the tongue base, pos-  terior pharyngeal wall, tonsillar fossa or other selected  location within the oropharynx. Tooth guards should  also be placed to protect the dentition and avoid ventral  tongue injury from mandibular anterior tooth trauma.  A suspension bar can be used to hold the retractor in  position and help suspend the oropharyngeal/laryngeal  structures. Next the robot (draped sterilely) is brought  into position usually from either the left or right side of  the patient starting at the foot of the operating table. The  camera is positioned centrally with the operating arms  in a 30°-45° position on either side of the camera and  lowered into the oral cavity and oropharynx. The sur-  gical assistant is scrubbed in and will help to suction,  retract and change instruments on the various robotic  arms (Figure 32.3). The surgeon is seated at the operating  console and can now perform the surgical tumour extir-  pation. Tumour removal is most often performed with a  monopolar bovie spatula tip. A Maryland dissector can  be used to grasp tissue or provide tension to allow for  ease of tissue cautery (Figure 32.4a and b). A specialized  attachment can manipulate a CO, laser if so desired. The  operating instruments are able to rotate 360° about their  endowrist allowing for complete rotation within a con-  fined space. Frozen section margins can be removed with  a scissor attachment to avoid cautery tissue injury and  difficulties in pathologic assessment. If a simultaneous  neck dissection is to be performed, it can be performed  either prior to robotic surgery or after completion of the  tumour removal.    (a) Removal of a tumour involving the tongue  base and vallecula. (b) Surgical site post-resection of a carci-  noma of the tonsillar fossa.   Robotic surgery (TORS) for the management of oral cavity/  oropharyngeal disease is a costly endeavor (over 1 million  US dollars per robot).'4 It requires the acquisition of special-  ized training skills for both the surgeon and auxillary sup-  port staff. At most institutions training involves practice ina  simulation laboratory followed by proctoring by a surgeon  already qualified in robotic surgery. One must also ask if the  volume of cases will be sufficient to make this technology  cost-effective both financially (important to the facility/  hospital) and to provide maintenance of surgeon skills.   The patient is positioned supine with the neck extended.  Although actual surgical operative time is quite short (gen-  erally less than 30 minutes), robot set-up time can be quite  lengthy especially with an inexperienced operative staff.  One must ensure that the patient is adequately padded to  avoid pressure sores and the eyes are protected to avoid  corneal ulcers or pressure on the globes. The nasoendotra-  cheal tube must also be secured to avoid any pressure on  the nostrils which could result in alar necrosis (Figure 32.5).  One should also apply caution in patients with cervical    spine stenosis or arthritis, as neck extension is needed to  improve visibility and placement of the robotic instruments.   The da Vinci robot (Intuitive Surgical, Sunnyvale, CA) is remote  console operated without haptic or tactile control. Although  the high-definition camera makes it appear as if the opera-  tor is actually touching the tissue, there is no true feedback as  to how much pressure is being applied. In standard surgical  technique, this tactile feedback is very important in tumour  extirpation and protection of adjacent healthy tissue.   A larger mouth opening allows for ease of access and  improved visibility. Relative contraindications to the use  TORS include significant trismus, severe retrognathia and  a heavily restored dentition.*"> Teeth should be protected  with tooth guards both in the maxilla and mandible. The  lower tooth guard will also help to avoid inadvertent lac-  erations to the ventral tongue often caused by mandibular  incisor injury during retractor pressure.   Majority of oropharyngeal TORS procedures can be safely  performed without the need for temporary tracheostomy.  Consideration for tracheostomy should include pre-existing  coagulopathies, significant bleeding, large tumour/need  for flap reconstruction, cardiorespiratory insufficiency/  poor performance status, high aspiration risk (neurologic,  pre-existing dysphagia) and prior head and neck radiation.  If the patient is not to have a tracheostomy serious consid-  eration should be given to delayed extubation, approxi-  mately 24 hours post-procedure, to ensure adequate time  for airway assessment and stability.   Significant tongue edema and airway obstruction can  occur following prolonged application of the mouth/  tongue retractors. To help minimize this, the tongue should  be carefully positioned within the retractor. The retractor  (i.e. Feyh-Kastenbauer) should be used for the minimum  amount of time required for the robotic surgery. It can  also be released periodically throughout the procedure  (i.e. awaiting frozen section results). Moore et al. reported  on a series of 66 patients who underwent TORS for OSCC.  Initially, 17 patients received temporary tracheostomy of  which 98.5% were tracheostomy-free at 2 years follow-up.”   Re-inforced endotracheal tubes and laser safety proto-  cols should always be utilized as to avoid risk of airway fire  or mucosal tissue injury.   Temporary feeding tube can be considered for patients  undergoing TORS procedures for oropharyngeal carci-  noma. Most patients will have their feeding tube either  removed during the peri-operative period. Routine swal-  low evaluation should be performed especially for removal  of carcinoma of the tongue base. Temporary gastrostomy  tube should be considered in patients who will require  adjuvant radiotherapy, flap reconstruction or with pre-  existing dysphagia/poor performance status. Sinclair et al.  reported on a series of TORS-assisted resection for T1 and  T2 OSCC.'"© Ten patients required post-operative gastros-  tomy tube placement with no patient using a tube beyond  1 year. One-third of patients had a continued perceived  dysphagia with adjuvant chemoradiotherapy being a pre-  dictive factor for gastrostomy tube placement.   Ultimately, the purpose of TORS is to achieve negative  pathologic margins with decreased patient morbidity in  terms of both surgical complications and with hopes of  de-intensification of adjuvant therapy orits avoidance entirely.  The patient must understand that the TORS procedure may  either be aborted, converted to an open conventional proce-  dure or adjuvant therapy may be required.   Pre-operative imaging is important to evaluate for extent  of disease within the oropharynx and neck. Magnetic reso-  nance imaging (MRI) will help to provide soft tissue detail  and depth of tumour at the primary site. Significant bleed-  ing may be encountered involving the lingual artery with  tongue base resection. This complication can be best  avoided by identification and ligation of this vessel within  the tongue base or during the neck dissection.   Neck dissection is most often performed simultaneously  during the same procedure prior to the TORS component  of the surgery (management of the primary tumour).*4  Advantages include the ability to manage the lingual artery  or other significant branch of the external carotid artery, sin-  gle anaesthetic procedure and complete pathologic evalu-  ation. If a communication with the neck is encountered,  formal reconstruction can be performed depending on the  size of the communication. Arguments for a staged neck  dissection (generally 1-3 weeks later) include avoidance of  communication with the neck and primary tumour margin  analysis. If the margin returns as positive on final evaluation  it can be reresected at time of the neck dissection.   Further comparative studies are needed to fully under-  stand the efficacy of TORS in the management of oro-  pharyngeal carcinoma. As previously mentioned, current  outcomes data do prove promising. One area of concern  is in the management of the controversial retropharyngeal  lymph nodes. This nodal basin medial to the carotid artery  is reported to occur in approximately 10% of oropharyngeal  carcinomas. They are most often involved in pharyn-  geal wall disease (20%) and lowest in base of tongue SCC  (6% rate of incidence). Positive retropharyngeal nodes are  associated with a poorer prognosis in certain studies.'°"®  These nodes are not dissected in the standard neck dissec-  tion for OSCC but are included in the standard radiation  fields. Thus, as TORS procedures increase for manage-  ment in OSCC disease; will there be an increase in failures  within the neck (retropharyngeal region) especially if fewer  patients receive adjuvant radiotherapy or receive de-inten-  sification of radiotherapy?    Weinstein GS, O’Malley Jr BW, Cohen MA and Quon  H. Transoral robotic surgery for advanced oropharyn-  geal carcinoma. Arch Otolaryngol. 2010; 136: 1079-1085.    FJ, Price DL, et al. Long-term functional and onco-  logic results of transoral robotic surgery for oropha-  ryngeal squamous cell carcinoma. Mayo Clin Proc.  2012; 87: 219-225.    Cohen MA. Selective neck dissection and deinten-  sified postoperative radiation and chemotherapy  for oropharyngeal cancer: A subset analysis of the  University of Pennsylvania transoral robotic surgery  trial. Laryngoscope. 2010; 120: 1749-1755.    surgery for obstructive sleep apnea: Perioperative  management and postoperative complications. JAMA  Otolaryngol Head Neck Surg. 2014; 140: 1207-1212.    . Lin HS, Rowley JA, Folbe AJ, Yoo GH, Badr MS and    Chen W. Transoral robotic surgery for treatment of  obstructive sleep apnea: Factors predicting surgi-  cal response. Laryngoscope. 2014; 125: 1013-1020.  doi:10.1002/lary.24970.    and Quon H. Transoral robotic surgery and human  papillomavirus status: Oncologic results. Head Neck.  2011; 33: 573-580.    D, Johnson JT, et al. Role of surgery in limited (T1-  2, NO-1) cancers of the oropharynx. Laryngoscope.  2008; 118: 2129-2134.   Bonawitz SC and Duvvuri U. Robot-assisted oro-  pharyngeal reconstruction with free tissue transfer.  J Reconstr Microsurg. 2012; 28(7): 485-490.    Mehta V, Johnson P, Tassler A, Kim S, Ferris RL,  Nance M, et al. A new paradigm for the diagnosis  and management of unknown primary tumors of the  head and neck: A role for transoral robotic surgery.  Laryngoscope. 2013; 123: 146-151.   Patel SA, Magnuson JS, Holsenger FC, Karni RJ,  Richmon JP, Gross ND, et al. Robotic surgery for  primary head and neck squamous cell carcinoma of  unknown site. JAMA Otolaryngol Head Neck Surg.  2013; 139: 1203-1211.   Vicini C, Montevecchi F, Campanini A, Dallan I,  Hoff PT, Spector ME, et al. Clinical outcomes and  complications associated with TORS for OSAHS:  A benchmark for evaluating an emerging surgi-  cal technology in a targeted application for benign  disease. ORL J Otorhinolaryngol Relat Spec. 2014;  76: 63-69.   Couch ME and Zanation A. Transoral robotic  surgery disruptive or sustaining innovation?  Arch Otolaryngol Head Neck Surg. 2010; 145:  907-908.   Sinclair CF, McColloch NL, Carroll WR, Rosenthal  EL, Desmond RA and Magnuson JR. Patient per-  ceived and objective functional outcomes following  transoral robotic surgery for early oropharyngeal  carcinoma. Arch Otolaryngol Head Neck Surg. 2011;  137: 1112-1116.   Bussels B, Hermans R, Reijnders A, Dirix P, Nuyts  S and Van den Bogaert W. Retropharyngeal nodes  in squamous cell carcinoma of oropharynx:  Incidence, localization, and implications for tar-  get volume. Int J Radiat Oncol Biol Phys. 2006; 65:  733-738.   Gross ND, Ellingson TW, Wax MK, Cohen JI and  Andersen PE. Impact of retropharyngeal lymph  nodemetastasis in head and neck squamous cell  carcinoma. Arch Otolaryngol Head Neck Surg. 2004;  130(2): 169-173.   Gunn BG, Debnam JM, Fuller CD, Morrison WH,  Frank SJ, Beadle BM, et al. The impact of radio-  graphic retropharyngeal adenopathy in oropharyn-  geal cancer. Cancer. 2013; 119: 3162-3169.    The overall incidence of oral and oropharyngeal cancer is  on the increase. The patho physiology of the disease pro-  cess has changed with an increasing incidence of human  papilloma virus (HPV)-related SCC. There is also the  emerging trend of increased incidence in younger patients.  Treatment strategies have evolved to achieve better out-  comes.' Surgery was the primary treatment of head and  neck tumours. However, with emphasis on quality of life  and advances in chemotherapy and radiotherapy delivery,  there has been a shift in the management of oropharyngeal  SCC. Despite many advances in the diagnosis and treat-  ment, the crude overall 5-year survival of patients with  head and neck mucosal cancer is still around 50%. Modern  treatments have resulted in much better local control and  improvements in quality of life. With the arrival of new  chemotherapy agents and targeted monoclonal antibodies  (such as the epidermal growth factor receptor antagonist,  cetuximab), used in conjunction with standard modalities  of treatment, overall survival will hopefully improve.’  The management of mucosal head and neck cancers is  complicated by the involvement and/or close proximity of  tumours to many anatomical structures, which are vital for  normal function. Speech, swallowing, eating and speak-  ing are all potentially affected by both the disease process  itself and the resulting treatment. It is therefore essential  that these patients are carefully assessed by a multidisci-  plinary team (MDT) before any treatment is advocated.  In addition to surgeons, oncologists, radiologists, nurses,    speech therapists, dieticians and pharmacists, it is often  helpful to have a clinical psychologist and palliative care  consultant available as well. We have found that taping the  consultation is valuable as the patient is then able to listen  with relatives outside of the hospital setting.°    The main routine investigations for a patient with sus-  pected head and neck cancer are summarized in Table 33.1.  Some specific investigations are discussed as follows:    ® General examination. Examination of the patient for  evidence of other disease (which might influence the  choice of treatment) is important. Isolated suspicious  neck lumps (in the absence of an obvious primary  tumour) warrant examination of the other lymph node  sites and abdomen. Suspicious lumps in the supraclavic-  ular fossa should alert the clinician for possible primary  pathology in the lung, gastrointestinal (particularly on  the left side). In women, breast as a primary pathol-  ogy should be considered and appropriate investiga-  tions arranged as necessary. Nutritional status should  be assessed especially if major surgery is planned - the  biochemical changes of the catabolic state following  treatment lower serum albumin and may impair wound  healing and recovery if the patient is already cachetic.   Examination under anaesthetic. Some would consider  that examination under anaesthetic (EUA) should be    322 Assessment and principles of management of head and neck cancer   Examination under anaesthesia (may not be necessary for small and/or anterior tumours)  Biopsy/fine needle aspiration cytology   Doppler studies of radial and ulnar artery Radial forearm free flap   Ultrasound Neck nodes of uncertain character on CT/MRI  PET/CT Unknown primary, chest evaluation    a standard practice. This is in view of the incidence of  synchronous tumours in the upper aero-digestive tract.  With advances in imaging techniques (positron emis-  sion tomography-computed tomography and magnetic  resonance imaging [PET-CT and MRI]) this may not be  necessary. However, the authors recommended that in  patients who require complex reconstruction especially  in tumours involving the posterior structures of the oro-  pharynx, and tongue base a EUA would help in planning  future surgery. EUA would also confirm the resectability  of tumours with a RO margins, especially in those requir-  ing paryngo-laryngectomies. It also enables the special-  ist anaesthetist to assess the patient at an early stage. It  is worthwhile using pre-fabricated drawings of the oral  cavity, oropharynx and laryngeal inlet to record the  dimensions and extension of the tumour. Nasendoscopy  can be used in the outpatient setting to examine inacces-  sible sites both before and after treatment.   © Biopsy. We would like to emphasize that an experienced  senior staff member who is well versed in the identifi-  cation of tumours should carry out a biopsy. This car-  ries greater importance in patients with sub-mucosal  disease and in those who require a bone biopsy. When  performing a biopsy, either under local anaesthesia or  during an EUA, it is important to take a sufficiently  large piece of tumour, and ideally include some normal  looking mucosa. Tumour depth is sometimes difficult to  assess on a small incisional biopsy, but a generous biopsy  may provide some idea of deep invasion (and therefore  help plan definitive treatment the likelihood of neck  metastasis) as well as providing information about pos-  sible dysplasia at the tumour margins. Tumours greater  than 4 mm thickness have a much higher propensity to  metastasize to the neck.‘ It is often worthwhile taking    separate biopsies of apparently normal looking mucosa  close to the tumour itself, as these may show dysplastic  changes which might influence resection margins.    Blind biopsies are not helpful, especially when done at the  time of EUA. It would be more useful to carry out targeted  biopsies of sites with a potential to harbour tumour focci.  These sites are dictated by findings on clinical examination  and imaging. The authors prefer to call this as imaging dic-  tated/clinically dictated targeted biopsy. This is a useful con-  cept to bear in mind when dealing with occult primaries.    © Fine needle aspiration cytology (FNAC). Useful adjunct  in the assessment of enlarged neck nodes. Even small  suspicious nodes of 5-6 mm can be biopsied using  ultrasound-guided FNAC. Bear in mind that FNAC can  lead to false-negative results (when tumour cells are not  included in the aspirate), and therefore it is only one of  the methods for assessing nodal status. A recent study  found that a 23G (blue in the UK) needle is as diagnosti-  cally accurate and results in less patient discomfort than  a 21G (green) needle and the authors recommends this  smaller needle for head and neck FNAC.°   © Orthopantomogram (OPG) and chest x-ray. An OPG  provides information about the state of the teeth as  well as gross bone destruction (Figure 33.1). For onco-  logic purposes, it can be considered to be a screening  investigation. It is helpful in osteotomy planning when  an access procedure is required. It is always sensible to  obtain a dental opinion before any treatment is com-  menced, and especially prior to radiotherapy, as early  extraction of teeth with poor prognosis minimizes the  later risk of osteoradionecrosis. Extractions can usually  be performed at the time of EUA. A routine chest x-ray  adds very little value.    Figure 33.1 Orthopantomogram showing bone destruc-  tion in the lower left quadrant.    © Routine blood investigations. Full blood count, urea  and electrolytes and liver function tests are routine  baseline tests that should be performed in any newly  diagnosed head and neck patient. With the increased  use of chemotherapy, renal function needs to be known  before adjuvant treatment. Head and neck patients  may have liver disease as a result of chronic alcohol  ingestion. If major surgery is planned, chronic alco-  holic patients should ideally be detoxified for a week  or so prior to their operation to minimize the com-  plications of acute alcohol withdrawal. One should  remember that liver disease may result in changed  clotting factors, and indeed an INR is one of the most  sensitive tests of liver function. It is also useful to  know the pre-operative albumin levels. Where there  might be a wait for a surgical date, it may be useful  to consider feeding patients with high-protein diet via  a nasogastric or gastrostomy tube. There is evidence  to suggest that feeding patients a high-carbohydrate  diet 24 hours prior to surgery improves post-operative  healing and recovery.   Cross-sectional imaging. Both CT and MRI have advan-  tages and disadvantages. Both can be used to image the  neck for possible lymph node metastasis, but neither  is sufficiently sensitive to detect micro-metastases.  However, both CT and MRI will show necrosis within  lymph nodes,° a finding which is usually indicative  of squamous cell carcinoma, rather than lymphoma  (Figure 33.2). MRI cannot be used to assess the lungs  and some claustrophobic patients find the examina-  tion intolerable. In future, open magnet machines may  make the examination easier for these patients. Whilst  cortical bone is poorly imaged on MRI (due to the lack  of water molecules), bone marrow provides high signal,  and loss of this signal can be a sign of bone invasion  (Figure 33.3). MRI is also useful in complex anatomical  areas such as the infra-temporal fossa and tongue base.  MRI may overestimate the size of tumours due to asso-  ciated inflammation, but with all imaging, tumour size  can be underestimated. An example is the superficially  invasive tongue cancer which might not even be evident  on a cross-sectional scan.    Figure 33.2 Computed tomography scan showing necro-  sis within lymph nodes indicative of squamous cell carcinoma.    Figure 33.3 T1-weighted MRI from the same patient as  Figure 33.1 showing extensive loss of bone marrow signal indi-  cating tumour spread.    @ CT is a much quicker procedure, but a considerable  amount of ionizing radiation is used (8 mSV - equiva-  lent to 400 chest x-rays) and there is a greater risk of  an adverse reaction to the intravenous contrast. There  is still controversy about whether to CT the chest in  patients with head and neck cancer. The incidence of  lung metastasis in patients with small T-stage tumours  is low and higher in patients with multiple or large neck  metastasis, particularly if in the low neck levels (III-V).  The authors recommend staging of chest in all patients  at stage II and above. CT chest for stage I disease will  depend on the local MDT protocols.    324 Assessment and principles of management of head and neck cancer    © Ultrasound (US). Ideal for assessing lymph nodes both  prior to, and following treatment. Its ability to assess the  size, shape, consistency (presence or absence of normal  node hilum) and vascularity (with colour flow Doppler)  of a node is invaluable. US is more sensitive than CT  in assessing small metastatic nodes (less than 6 mm),  particularly when used with FNAC.’ It is also helpful  in guiding fine needle biopsies in deep or impalpable  nodes. The use of US in following up patients after treat-  ment is to be encouraged. With appropriate training,  surgeons can perform US in the clinic, and they have  the advantage of knowing the underlying anatomy in  great detail. Liver US may be indicated with deranged  liver function tests, or when a liver is palpated during  routine examination. Some advocate the use of intraop-  erative US with small, high-resolution probes to guide  primary tumour resection although this technique is  not in widespread use. The use of US and guided FNAC  has led to the development of one stop clinics. This has  reduced the patient's journey, resulted in early diagnosis  and proved to be cost effective.   © PET-CT. The localization of the positron-emitting agent  18 fluoro-deoxyglucose (FDG) with CT has enabled even  small tumours to be localized. PET-CT may have a role to  play in the assessment of the unknown primary tumour  and to evaluate suspicious chest nodules.’ However, FDG  is also taken up following biopsy (even several weeks  later) and therefore may give rise to false-positive results.  In patients with a high index of suspicion of an unknown  primary/occult disease it is paramount that a PET-CT is  done before EUA and targeted biopsy. In time, there may  be specific monoclonal antibodies developed that will  bind to cancer cells enabling their detection (for example  to specific cellular adhesion proteins). Studies are looking  to see if the quantitative uptake of 18 FDG will improve  the predictive value of PET- CT.    As mentioned previously, all patients need to be seen in  a multidisciplinary combined head and neck clinic so as  to ensure that an optimum treatment recommendation  is made. Historically, patients would have been treated  initially either by surgery or radiotherapy, or with a com-  bination of both. More recently, the use of neoadjuvant  chemotherapy prior to definitive treatment is gaining  popularity, particularly with large volume disease, and  tumours involving structures such as the soft palate. The  concept of ‘organ-preserving treatment’ should be consid-  ered. Although resection and reconstruction of, for exam-  ple, the soft palate may produce a good surgical result, it  will never function in the same way as before treatment.  Neoadjuvant chemotherapy often shrinks the primary  tumour considerably but whether resection of the primary  tumour should be to the same margins as before chemo-  therapy is controversial, since there is no randomized clin-  ical trial comparing this in head and neck cancer.    Treatment will either have curative or palliative intent  and it is important to establish this at an early stage  whether there is a realistic chance of cure.   Factors influencing the choice of treatment—All of the  following factors need to be considered when planning  treatment:    © General parameters such as age, medical co-morbidity  (such as ischaemic heart disease, peripheral vascular  disease, obstructive airway disease, nutritional status,  liver and renal compromise), as well as social implica-  tions, including smoking and alcohol consumption all  need to be considered. For example, an elderly patient  with a life-long smoking history who drinks 70 units  of alcohol per week may require ‘medical optimization’  and a high calorie and protein diet (possibly by naso-  gastic or gastrostomy feeding) to reduce the likelihood  of significant post-operative complications if major sur-  gery is planned. For posterior oropharyngeal tumours,  it is sensible to place a percutaneous endoscopic gas-  trotomy (PEG) at an early stage to enable feeding post-  operatively. This is also important when radiotherapy  fields may result in a severe pharyngitis, and dysphagia  making eating difficult or impossible.   © Tumour site. Both surgery and radiotherapy can be used  for treatment of lip cancers, although radiotherapy is  arguably better in advanced disease. Primary surgery  or radiotherapy can be used for definitive curative treat-  ment of intraoral tumours, but only surgery is likely to be  curative when bone is involved. Small tumours respond  equally well to radiotherapy at all sites. The results are  comparable to surgery. However, for advanced tumours  at all sites in the oral cavity, primary surgery followed by  adjuvant chemoradiotherapy is recommended for better  disease control and survival. Oropharyngeal tumours,  especially HPV + tumours respond better to chemo-  radiotherapy with better quality of life for patients.  Surgery at these sites is often for recurrent disease or  for a new primary where radiotherapy as an option has  been exhausted by previous treatment. Neoadjuvant che-  motherapy (given before surgery or radiotherapy) may  also be indicated, particularly with large tumours and/or  those involving such sites as the tongue base or soft pal-  ate). Concurrent chemotherapy (given at the same time as  radiotherapy) is also used in some centres. Radiotherapy  can be used for palliation, but may result in osteoradione-  crosis and its associated complications.   ® Tumour size. Surgery is ideal for small Tl and early T2  tumours as long as function is not severely compro-  mised. With larger tumours, each case will be discussed  at an MDT and an appropriate treatment decision  will be made. In many cases, ablative surgery with  microvascular reconstruction is followed by radiother-  apy if this is indicated following pathological analysis  of the resection specimen. Neoadjuvant chemotherapy  (using a combination of drugs such as 5-fluorouracil,  cisplatin and docetaxel) is particularly useful in large  tongue base and soft palate/pharyngeal wall tumours    prior to surgery or radiotherapy. To date, there has been  no clinical trial comparing neoadjuvant chemotherapy  versus surgery or radiotherapy alone on patient survival.  Histology. The likelihood for neck metastasis is increased  with poorly differentiated primary tumours. However,  many surgeons would consider a tumour depth of 4  mm or more to be a greater predictor of neck metas-  tasis. Perineural and vascular invasion are also bad  prognostic indicators, as is an infiltrating tumour front  (as compared to a cohesive pattern). Field change at the  tumour margin — which may be present clinically, or be  apparent from dysplastic changes in biopsies — is a wor-  rying feature. Radiotherapy can change these dysplastic  areas into invasive carcinoma, so it is not surprising that  surgery is usually used in these cases.   Neck status. Should be considered with the primary  tumour when deciding treatment. Even with small T1  tongue cancers, with a depth greater than 4 mm, the  risk of nodal micro-metastasis can be above 20%. In this  situation, most clinicians would advocate an ipsilateral  selective I-IV neck dissection both to stage the disease  pathologically and to remove possible micro-metastatic  disease that may not be evident on the pre-operative  imaging. The management of the node positive neck is  less controversial and may be treated either by surgery  or chemoradiotherapy, depending on the MDT deci-  sion. A modified radical neck dissection (ideally with  preservation of the accessory nerve) is the usual surgi-  cal treatment, but recently the value of dissecting level  V has been questioned in certain circumstances, and  some would advocate a more limited procedure. The  reader is referred to an excellent recent review on selec-  tive neck dissections.’    The overall survival and disease-specific survival is  reduced by 50% in patients with N + neck for all T stages.    © Previous radiotherapy. It is not usually possible to reir-  radiate the same target volume twice, and recurrent  disease in these situations is best treated surgically.  For recurrent neck disease, it is sometimes useful to  bring new vascularized tissue (including skin) into  the area which will enable further radiotherapy to be  given if needed. The use of intensity-modulated radio-  therapy (IMRT) enables radiotherapy to be delivered to  a tumour volume with greater precision than conven-  tional techniques, thereby reducing its side effects (for  example parotid gland sparing).!°    © Primary tumour. The surgeon should have a three  dimensional impression of the tumour in their mind.  The resection should be marked to include a clinical  margin of at least 10 mm. The author routinely uses a  Colorado mono-polar diathermy needle both to mark  the resection. The resection per se can be performed with  either a Colorado needle (using coagulation setting) or a    harmonic scalpel. In the recent past, the use of Lugol's  Iodine as an adjunct has helped to better delineate resec-  tion margins. This technique helps in controlled excision  of dysplastic areas surrounding the invasive component.  This has the drawback of increasing the total volume of  resection. Meticulous haemostasis is paramount - for  example, the lingual artery can be tied off posteriorly  early on during a lateral tongue resection or the maxil-  lary artery tied off prior to the completion of cuts for a  maxillectomy via a anterolateral corridor access. Access  osteotomies are useful for posterior tongue, some soft  palate and pharyngeal/parapharyngeal tumours as well  as for those in the infra-temporal fossa.    There is controversy about the use of frozen sections at the  time of resection. The authors do not use routinely fro-  zen section for margin control. A more appropriate tech-  nique is to pre-operatively carry out volume rendering on  the scans and determine the resection margins based on  sound anatomy. Inevitably, there will be some shrinkage  both after resection and placing the specimen in formalin  and the definitive pathological margin may be less than  that obtained clinically. Close and involved margins are  associated with poor prognosis."    © Neck dissection. Once again, meticulous technique is  essential. Depending on the disease process. Vital ana-  tomical structures should be preserved (particularly the  accessory and marginal mandibular nerves). It is debate-  able whether the primary resection needs to be included  en bloc with the neck dissection for floor of mouth and  tongue tumours. We prefer to carry out an incontinuity  resection of the primary with the neck in cases where  a false-positive margins (deep) may be reported on  final histology ( floor of mouth tumours invading the  mylohyoid, retromolar trigone tumours involving the  palatoglossal attachment). In tumours close to the mid-  line, a bilateral neck dissection should be considered.   © Reconstruction. The details of the different reconstruc-  tive techniques are provided elsewhere in this book.  The reconstructive options depend on size of the defect,  patient co-morbidity and operator preference. Small  defects can be closed primarily or by using a small  local flap such as the buccal fat pad. Alternatively, they  can sometimes be left to granulate. For larger defects,  microvascular free tissue transfer has revolutionized  reconstructive options. It is always sensible to have a  ‘plan B’ so that in the event of problems with the first  choice of reconstruction another option is available  (whether that is a different microvascular flap or ped-  icled flap). In these long cases, it is important to ensure  that the surgeon protects his own health - take regular  breaks, and consider using an operating chair or risk  back problems in later life! The use of more than one  free flap for reconstruction is not that uncommon. One  size does not fit all. It is important that the reconstruc-  tive surgeon should be well versed with the various  armamentariums of flaps available. The authors work in  a team to achieve this end.    326 Assessment and principles of management of head and neck cancer    © Temporary tracheostomy. This should be discussed at  the MDT, and is dependent on tumour size, site and  co-morbidity. Patients can often be de-cannulated at an  early stage.    Surgery has a role in the palliative patient. Debulking  of tumours including fungating neck metastases often  improves quality of life even if only briefly. It is wise to  consult the palliative care team at an early stage for their  input. Potentially mutilating surgery when there is no  chance of cure is to be deprecated, especially if this leaves  the patient in a worse state. In this respect, functional out-  come needs to be considered before embarking on major  palliative surgery. Palliative neck surgery is sometimes  useful (Figures 33.4 and 33.5), but skin incisions need to    Figure 33.4 Modified radical neck dissection type |  (with preservation of the accessory nerve) - same patient as  Figure 33.2.    be planned carefully to minimize great vessel compromise  and possible blow out at a later stage. Occasionally, ‘pal-  liative surgery’ gives unexpectedly good long-term results  (Figure 33.6).    e Think of the whole patient - consider medical history  and co-morbidity when making treatment decisions.   e For large and/or posterior tumours, consider placing a  PEG at an early stage.   e Open treatment discussions taking into account the  views of the patient and all members of the MDT team.    1. D'souza G, Kreimer AR, Viscidi R, Pawlita M,  Fakhry C, Koch WM et al. Case-control study of  human papillomavirus and oropharyngeal cancer. N  Engl J Med. 2007; 356: 1944-1956.   2. Bonner JA, Harari PM, Giralt J, Azarnia N, Shin  DM, Cohen RB et al. Radiotherapy plus cetuximab  for squamous-cell carcinoma of the head and neck.  N Engl J Med. 2006; 354: 567-578.   3. Bowden JR, Brennan PA, Butler-Keating R and Zaki  GA. Use of audiotaped patient consultations in a head  and neck oncology clinic and survey of patient attitudes  to this facility. J Laryngol Otol. 2003; 117: 879-882.    . Pentenero M, Gandolfo S and Carrozzo M.  Importance of tumor thickness and depth of inva-  sion in nodal involvement and prognosis of oral  squamous cell carcinoma: a review of the literature.  Head Neck. 2005; 27: 1080-1091.   . Brennan PA, Mackenzie N, Oeppen RS, Kulamarva  G, Thomas GJ and Spedding AV. Prospective ran-  domized clinical trial of the effect of needle size on  pain, sample adequacy and accuracy in head and  neck fine-needle aspiration cytology. Head Neck.  2007; 29(10): 919-922.   . King AD, Tse GM, Ahuja AT, Yuen EH, Vlantis  AC, To EW et al. Necrosis in metastatic neck nodes:  Diagnostic accuracy of CT, MR imaging, and US.  Radiology. 2004; 230: 720-726.   . van den Brekel MW, Castelijns JA, Stel HV, Golding  RP, Meyer CJ a’ts with head and neck cancer: Is  there a role for (18)FDG-PET? Oral Oncol. 2006; 42:  275-280.    . Brouwer J, Senft A, de Bree R, Comans EF, Golding    RP, Castelijns JA, Hoekstra OS and Leemans CR.  Screening for distant metastases in patients with  head and neck cancer: Is there a role for (18)FDG-  PET? Oral Oncol. 2006; 42: 275-80.    . Ferlito A, Rinaldo A, Silver CE, Gourin CG, Shah JP,    Clayman GL et al. Elective and therapeutic selective  neck dissection. Oral Oncol. 2006; 42: 14-25.  Guerrero Urbano MT and Nutting CM. Clinical  use of intensity-modulated radiotherapy: Part I. Br J  Radiol. 2004; 77: 88-96.   McMahon J, O’Brien CJ, Pathak I, Hamill R, McNeil  E, Hammersley N et al. Influence of condition of  surgical margins on local recurrence and disease-  specific survival in oral and oropharyngeal cancer.  Br J Oral Maxillofac Surg. 2003; 41: 224-231.    Percutaneous endoscopic gastrostomy (PEG) is an endo-  scopically assisted procedure, where a tube passed through  stomach to the abdominal wall (Figure 34.1) to facilitate  patient's enteral feeding.   The procedure was first performed in 1979 and in 1980,  the technique was published by Gauderer et al.! In 2001,  Gauderer published the details of the development of the  procedure.’    The two main indications for placement of percutane-  ous gastrostomy tube are access for enteral feeding and  decompression of the gut.   Gastrostomy may be indicated in situations where nor-  mal or other forms of enteral feeding (e.g. nasogastric) is  not possible. Some of these situations may have anatomi-  cal causes (during the process of cleft lip and palate cor-  rection), neurological causes (stroke, cerebral palsy, brain  injury and impaired swallowing) or other causes such  as recent surgery of the upper gastrointestinal (GI) or  the respiratory tract, head and neck tumours, surgery or  radiotherapy.   A gastrostomy can also be used to decompress the stom-  ach contents in a patient with a malignant bowel obstruc-  tion. This is referred to as a ‘venting PEG’ and is placed to  prevent and manage nausea and vomiting.    Inability to pass the endoscope through the oesophagus,  limited life expectancy, uncontrolled coagulopathy and   However, there are relative contraindications which  include portal hypertension, prior subtotal gastrectomy,  peritoneal dialysis, hepatomegaly, large hiatal hernia,  infiltrative or malignant disorders of the stomach, mor-  bid obesity and anorexia nervosa.*° A critical literature  review by Goldberg and Altman evaluated role of gastros-  tomy tube placement in advanced dementia with dyspha-  gia. They found no evidence to suggest long-term survival  rates improvement.”    Since development of the procedure, various guidance  methods such as endoscopic, fluoroscopic and ultrasound  techniques have been described; however, the main distinc-  tion between different techniques is based on the way the  tube enters the stomach, namely, transoral (Ponsky tech-  nique)* or transabdominal (Russell technique).? There are  different tube designs and as a result associated advantages/  disadvantages with each technique. For example, reports  suggest higher peritubal infection rate and gastrostomy  tract seeding with tumour in patients with upper GI tract or  ear/nose/throat cancers in transoral approach."   On the other hand, transabdominal tubes are smaller in  diameter and less secure resulting in more frequent occlu-  sion and dislodgment."!   A meta-analysis by Wollman et al. found a higher suc-  cess rate (99.2% vs. 95.7%) and lower complication rate  (13.3% vs. 29%) for transabdominal versus transoral gas-  trostomy’? but more recent studies have reported similar  outcomes for both techniques.!*-!5    Figure 34.1 Schematic diagram of bumper type percutaneous endoscopic gastrostomy (PEG) tube.    Table 34.1 Absolute and relative contraindications of percutaneous endoscopic gastrostomy (PEG).   Abdominal wall infection at the selected site of placement  Gastric outlet obstruction and severe gastroparesis (unless PEG is used for decompression)  History of total gastrectomy   Presence of oropharyngeal or oesophageal malignancy (potential risk of seeding of the PEG tract)   History of prior abdominal surgeries (possible presence of adhesions and bowel interposition)   Previous abdominal surgery including previous partial gasterectomy: increased risk of organs interposed between gastric wall and  abdominal wall   Morbid obesity: difficulties in locating stomach position by digital indentation of stomach and transillumination   Intra-abdominal malignancy with peritoneal involvement (tumour seeding into formed channel with subsequent failure)    Obtain appropriate consent. Sacks-Vine technique (push method) is similar to the  Preparation of the abdomen, intravenous antibiotic pull method described earlier except that the PEG tube is  administration and adequate sedation and analgesia. pushed over the single guidewire.!°   An oesophagogastroduodenoscopy (OGD) is performed Russell introducer technique, describes gastrostomy by  in order to evaluate the anatomy of the stomach. passing wire directly into the stomach under endoscopic  Stomach insufflated. visualization.   Using the endoscope light, the abdominal wall is trans- Series of dilators are passed over the wire by using  illuminated (Figure 34.2). Seldinger technique to increase the size of the gastrostomy  Finger pressure is applied at the point of maximal thus allowing final tube to be pushed over the wire into  transillumination with resultant indentation of gas- the stomach.”    tric lumen wall which can be observed endoscopically.  Transillumination and finger pressure manoeuvres help  to ensure that there is no organ between the anterior  stomach wall and the skin.   This area which should be at least 1 in. below the costal  margin and away from the xiphoid process is marked  on the skin.   After adequate local anaesthetic infiltration of the  marked area, 1 cm horizontal skin incision is made and  the needle catheter passed from the abdominal wall into  the stomach which should be visible endoscopically.  Snare is passed through the endoscope into the stomach.  Needle is removed and the guidewire is passed through  the catheter into the stomach (Figure 34.3) and  grasped with snare and pulled out of the mouth along  with the endoscope.   The catheter is then removed back over the guidewire.  The pointed end of the PEG tube is then secured to the  looped end of the guidewire, lubricated and the skin end of  guidewire is pulled allowing the PEG tube to pass through  the mouth, oesophagus and stomach out through the skin.  Avoiding excessive tension, pull the PEG tube till inter-  nal bumper lies against the gastric lumen wall.   To secure the PEG tube, use the external bumper Showing the guidewire is passing through  (Figure 34.4). the catheter into the stomach.    This technique is less likely to cause oropharyngeal  mechanical damage resulted from passage of feeding  tube and can potentially reduce the risk of oropharyn-  geal bacterial contamination and metastatic seeding  from tumours.    Older literature suggested initiation of feeding between 12  and 24 hours after placement of transoral tubes; however,  more recent prospective randomized studies demonstrated  initiation of feeding as early as 3 hours post placement.!*-”°   And even, Stain et al. in their randomized control trial  concluded that in acutely ill intensive and intermediate  care patients, immediate enteral feeding via a PEG tube is  as safe as next-day feeding.”!   These data were further analysed and confirmed by  Bechtold et al.”    Eventually all tubes will require replacement due to occlu-  sion, breakage or dislodgement; however, with good  care, most transoral bumper-type gastrostomy tubes can  remain in place for 1-2 years’ compared with transab-  dominal gastrostomy tubes which require replacement in  1-3 months.    The most common acute complications of endoscopy  include aspiration, haemorrhage and perforation;™ risks  associated with sedation/general anaesthesia such as  hypoxia, hypotension and aspiration.    Complications of PEG can be major or minor and  the overall rate (major and minor) ranges from 0.4%  to 22.5%.*°° Peritonitis, haemorrhage, aspiration and  death are examples of major complications and peristo-  mal wound infection, buried bumper syndrome where  gastric part of the tube migrates into the gastric wall,  and gastrocolic fistula are some examples of the minor  complications.   Table 34.2 illustrates PEG associated complications and  Table 34.3 shows tips to avoid or minimize the risk of some  of the common complications.   Aspiration 0.3-1.0  Haemorrhage 0-2.5  Perforation of viscera/Peritonitis 0.5-1.3  Necrotizing fasciitis Rare  Death 0-2.1  Tumour implantation <1  Minor    Buried bumper 0.3-2.4  Gastric ulcer 0.3-1.2  Fistulous tracts 0.3-6.7  Inadvertent removal 1.6-4.4    Table 34.3 Tips to avoid some of the complication associated with PEG insertion.    Procedure to be performed by experienced operator, avoid excessive sedation and air    Identify any anatomical variations that can increase risk of bleeding prior to procedure and    Careful assessment for any anatomical variations prior to procedure and early recognition of    Ileus Observe for few hours prior to start of the feed, use uncapped PEG for decompression if    internal and external bumpers, and postoperative PEG site care (with mild soap and water)    Avoid excessive tension between internal and external bumpers (position the external    bumper in such a way that the tube can be pushed in and out at least 1 cm) and adjust the   Prevent and control infection, adjust the tension between the bumpers and avoid hydrogen  peroxide for PEG site care   Avoid excessive tension and lateral traction on the PEG tube and consider acid suppression   Perform PEG after surgical removal of primary cancer or use an alternative technique such as  Russell technique    PEG is one of the most commonly performed endoscopic  procedures and it is a safe way to provide long-term enteral  feeding in selected patients.   To achieve best outcome, factors such as experienced  team, appropriate case selection, prevention and early  recognition of complications and their management are  paramount.    Gauderer MW, Ponsky JL and Izant RJ. Gastrostomy  without laparotomy: A percutaneous endoscopic  technique. J Pediatr Surg. 1980; 15: 872-875.    tomy-20 years later: A historical perspective. J Pediatr  Surg. 2001; 36: 217-219.    Experiences with percutaneous endoscopic gastros-  tomy. World J Surg. 1996; 20: 1006-1009.    outcome of percutaneous endoscopic gastrostomy in  two patients with cirrhosis and portal hypertension.  Am J Gastroenterol. 1995; 90: 826-828.    tomy tube placement in advanced dementia with  dysphagia: A critical review. Clin Interv Aging. 2014;  14: 1733-1739.    gastrostomy: A non-operative technique for feeding  gastrostomy. Gastrointest Endosc. 1981; 27: 9-11.    gastrostomy. A new simplified and cost-effective  technique. Am J Surg. 1984; 148: 132-137.   Tucker AT, Gourin CG, Ghegan MD, Porubsky ES,  Martindale RG and Terris DJ. ‘Push’ versus ‘pull’  percutaneous endoscopic gastrostomy tube place-  ment in patients with advanced head and neck can-  cer. Laryngoscope. 2003; 113: 1898-1902.   Funaki B, Zaleski GX, Lorenz J, Menocci PB, Funaki  AN, and Rosenblum JD. Radiologic gastrostomy  placement: pigtail- versus mushroom-retained cath-  eters. Am J Roentgenol. 2000; 175: 375-379.  Wollman B, D’Agostino H, Walus-Wigle J, Easter  D and Beale A. Radiologic, endoscopic and surgical  gastrostomy: An institutional evaluation and meta-  analysis of the literature. Radiology. 1995; 197: 699-704.  Bankhead R, Fisher C and Rolandelli R. Gastrostomy  tube placementoutcomes: Comparison of surgical,  endoscopic, and laparoscopic methods. Nutr Clin  Pract. 2005; 20: 607-612.    Rustom I, Jebreel A, Tayyab M, England R and  Stafford N. Percutaneous endoscopic, radiological,  and surgical gastrostomy tubes: A comparison study  in head and neck cancer patients. J Laryngol Otol.  2006; 120: 463-466.   Silas A, Pearce L, Lestina L, Grove MR, Tosteson A,  Manganiello WD, et al. Percutaneous radiologic gas-  trostomy versus percutaneous endoscopic gastros-  tomy: A comparison of indications, complications  and outcomes in 370 patients. Eur J Radiol. 2005; 55:  84-90.   Hogan RB, DeMarco DC, Hamilton JK, Walker CO,  and Polter DE. Percutaneous endoscopic gastros-  tomy - To push or to pull: A prospective, random-  ized trial. Gastrointest Endosc. 1986; 32: 253-258.  Russell TR, Brotman M and Norris F. Percutaneous  gastrostomy. A new simplified and cost-effective  technique. Am J Surg. 1984; 148(1): 132-137.   Brown DN, Miedema BW, King PD and Marshall  JB. Safety of early feeding after percutaneous endo-  scopic gastrostomy. J Clin Gastroenterol. 1995; 21:  330-331.   Choudhry U, Barde C, Markert R and Gopalswamy  N. Percutaneous endoscopic gastrostomy: A random-  ized prospective comparison of early and delayed  feeding. Gastrointest Endosc. 1996; 44: 164-167.  McCarter TL, Condon SC, Aguilar RC, Gibson DJ  and Chen YK. Randomized prospective trial of early  versus delayed feeding after percutaneous endo-  scopic gastrostomy placement. Am J Gastroenterol.  1998; 93: 419-421.   Stein J, Schulte-Bockholt A, Sabin M and Keymling  M. A randomized prospective trial of immediate vs.  next-day feeding after percutaneous endoscopic gas-  trostomy in intensive care patients. Intens Care Med.  2002; 28: 1656-1660.   Bechtold ML, Matteson ML, Choudhary A, Puli SR,  Jiang PP and Roy PK. Early versus delayed feeding  after placement of a percutaneous endoscopic gas-  trostomy: A meta-analysis. Am J Gastroenterol. 2008;  103: 2919-2924.   Mathus-Vliegen LM, Binnekade JM and de Haan RJ.  Bacterial contamination of ready-to-use 1-L feeding  bottles and administration sets in severely compro-  mised intensive care patients. Crit Care Med. 2000;  28: 67-73.   Kavic S and Basson M. Complications of endoscopy.  Am J Surg. 2001; 181: 319-332.   Lynch C and Fang J. Prevention and manage-  ment of complications of percutaneous endo-  scopic gastrostomy tubes. Pract Gasteroenterol.  2004; 28: 66-76.   Lynch CR, Jones RG, Hilden K, Wills JC and Fang  JC. Percutaneous endoscopic cecostomy in adults: A  case series. Gastrointest Endosc. 2006; 64: 279-282.    Oral and oropharyngeal squamous cell carcinoma:  Pathological assessment of resection specimens  and neck dissections    Lay the specimen on a tile or block (heavy card, foam  or polystyrene) in the correct anatomical position  (Figure 35.1).   Secure with pins or sutures. Avoid critical areas of the  surgical margins. Avoid over-tight sutures (risk of poor  fixation and tearing of tissues).   For modified and selective neck dissections, label  the centre of each anatomical nodal level with a tag  or suture (Figure 35.1). Submit any additional nodal  groups (parapharyngeal, facial, etc.) in separate labelled  containers.   Immerse the specimen fully in fixative. ‘Routine’ is a  formaldehyde-based solution. The volume of fixative  should be at least 10 times the volume of tissue.  Alternatively, divide the neck dissection into separate  anatomical levels, mark superior aspect and submit  each level in a separate labelled container. Take care  not to disrupt integrity of primary tumour when divid-  ing level I from primary tumour in en bloc resection  specimens.    Give complete, accurate details of the name; address  (essential for Cancer Registry), gender and date of birth  of the patient.   State the clinical tumour node metastasis (TNM) stage;  details of previous histology including the laboratory  reference number; and details of previous radiotherapy,  chemotherapy or surgery.   State the type of surgery — curative intent/palliative.  Describe the clinical features and extent of the lesion,  and the extent of the resection, ideally supplemented  by annotated photographs or line diagrams (either free  hand or pre-printed).   Give the key to the markers (sutures or tags) used to  indicate critical margins, other features of particular  interest and the anatomical cervical node levels. In  neck dissections, deal with the left and right sides of  the neck separately by reference to the anatomical lev-  els included (I-III, I-IV etc.) plus brief details of other  structures.    Figure 35.1 Specimen is laid out in the correct anatomi-  cal position with tags indicating the centre of each anatomical  nodal level.   ® Give contact details of a designated member of the sur-  gical team if an urgent report is requested or in case of  a query.    ® Macroscopic examination and description of the extent  of the surgical resection/dissection specimen and the  lesion including measurements ideally supplemented by  photography and when appropriate, radiography.   © Surgical margins are painted with Indian ink or a dye  to facilitate histological assessment of the proximity of  carcinoma to the resection margins.    ® Generally, the specimen is cut into 3-5 mm slices using  a coronal plane for specimens from the central and lat-  eral regions of the mouth and a sagittal plane for ante-  rior specimens. If the tumour is close to/involving bone,  preliminary assessment of amenable soft tissue margins    Figure 35.2 Tongue is sliced in a coronal plane. A streak  of tumour well-ahead of the main front has resulted in a close  deep resection margin. Such streaks may only be present in  a single tissue slice and can be missed if the specimen is not  sampled thoroughly.    is often possible prior to decalcification of the bone and  the remaining closely-bound soft tissues.   ® The tissue slices showing the maximum extent of the  tumour (diameter and depth) and the closest resec-  tion margins are selected for processing (Figure 35.2).  Generally, at least one tissue slice/10 mm of tissue is  processed.   ® Routine histological assessment is based on one hema-  toxylin and eosin (HE)-stained section from each tissue  block. Step-serial sectioning and immunohistochemis-  try may be used in difficult cases.   © The maximum dimension (diameter) and depth (recon-  structed tumour thickness) is measured to the nearest  mm using an optical micrometer to supplement the  macroscopic measurements (Figure 35.3). No compen-  sation is made for the tissue shrinkage that occurs dur-  ing fixation and processing.   ® Detailed histological assessment of the body and in par-  ticular, the invasive front of the tumour is made.   © The width of the surgical resection margins (mucosal,  deep and later on demineralized, bone) is measured to  the nearest millimetre using an optical micrometer.    © The adipose tissue of the fixed specimen is searched by  observation and palpation in order to identify all lymph  nodes >3-4 mm in size.   ® Within each anatomical nodal level, each lymph node  is harvested (surrounded by its immediate perinodal  fibroadipose tissue).   © Lymph nodes are placed in labelled cassettes, slicing  larger nodes as shown in Figure 35.4.   ® Ideally, the position of each node is indicated on a line  diagram or photograph.    Figure 35.3 T, - the actual tumour thickness. The more  important measurement is T, — the reconstructed tumour  thickness which compensates for surface ulceration or an exo-  phytic component. D represents tumour diameter. It is impor-  tant to include all satellite tumour islands ahead of the main  invasive front in the T and D measurements.    Figure 35.4 Larger lymph nodes are bisected and then  one-half is sliced in a perpendicular plane to give several addi-  tional nodal profiles which permit a more thorough sampling.   © Histological assessment is based on assessment of a  single HE-stained section from each tissue block. Step-  serial sections are cut in selected cases (such as further  assessment of potential micrometastases or early extra-  capsular spread).    © Sentinel nodes that appear negative macroscopically are  subject to a more meticulous assessment.   @ The node is bisected or sliced into 2.5 mm slices and  each slice is processed.    © Ifnode is negative on initial routine HE-stained section,  then:  e Step-serial sections at 150 um intervals are prepared.  e One HE-stained section from each step-serial level  is assessed.  e If the HE-stained sections are negative, one slide  from each level is stained immunohistochemically  for cytokeratin using an antibody such as AE1/3.    Certain features of mucosal carcinomas have been shown  to be related to clinical outcome in terms of local recur-  rence, regional and distant metastases and survival, and  hence, provide information that can help in management  and prognosis prediction. Core data sets include only  evidence-based features, and to be of value, it is essen-  tial that the pathological assessment is made accord-  ing to standard protocols that include definitions and  guidance on practical aspects. The UK Royal College  of Pathologists introduced a core data set - outlined  in ‘Pathological data’ - in 1998 with an updated third  edition in 2013.   ® Distance of invasive tumour to deep resection margin  (mm) and status    @ In squamous cell carcinoma (SCC) with a multifocal  origin, the maximum diameter is based on the over-  all area of involvement by SCC. Any simultaneous  tumour(s) - separated by non-dysplastic mucosa -  should be described separately after details of index  tumour.   © The histological degree of differentiation (tumour  grade) is based on the degree of keratinization, cellular  and nuclear pleomorphism, mitotic activity.   © Histological sub-types include verrucous carcinoma;  carcinoma cuniculatum; papillary SCC; adenoid (acan-  tholytic) SCC; adenosquamous carcinoma; basaloid  SCC; spindle cell carcinoma; giant cell (pleomorphic  SCC); undifferentiated carcinoma.   ® Prognosis of verrucous carcinoma and carcinoma  cuniculatum is generally good since nodal metastases  rarely occur. Adenosquamous carcinoma and basaloid  SCC of oral cavity, larynx and hypopharynx have a  poor prognosis due to early regional and distant metas-  tases. Basaloid type and poorly differentiated tumours  of oropharynx are, however, often HPV associated,  hence should be assessed at least for p16 positivity (pos-  sibly supplemented with in-situ hybridization) which,  if positive, is associated with a much more favourable  prognosis.   © Lymphovascular invasion is defined as aggregates of  tumour cells within endothelial-lined channels or  invasion of the full-thickness vessel wall with ulcer-  ation of the intima and fibrin deposition/thrombosis.    ® Optional additional features that may be mentioned  include the presence of sialoadenotropism (extension of  dysplasia down orifices of minor salivary glands) and  ductal invasion.  © Status of resection margins  e Clear is>5 mm  e Close is 1-5 mm  e Involved is <1 mm  e Involved with histological cut-through is 0 mm    Further details such as the precise site of involvement;  apparent explanation (single streak, lymphovascular or  neural/perineural invasion ahead of main tumour front,  etc.) are optional.    State which levels submitted from left and/or right neck  Type: Standard radical/modified comprehensive/selective  Information on nodal yield, number and size of metastases,  and extracapsular spread (see Table 35.1 for example).   © Matted nodes are described by an estimate of the num-  ber of nodes involved and the overall maximum size of  largest matted mass.   e@ ITC denotes ‘isolated tumour cells’. These may be  detected by detailed histological examination of  routinely-stained sections or immunohistochemistry or  molecular methods. Assessment for ITC is not routine  but may be used for examination of sentinel nodes.    Number with metastatic  tumour. Specify whether  isolated tumour cells (ITC)  (<0.2 mm) or   Extracapsular spread Not detected/present at level |, Il, Ill, lV, V, VI, Other (delete as    to invasion of perinodal adipose tissue down to peri- Tumour site: (state with ICD reference)  capsular stromal reaction only detectable on histology New primary/recurrence/not known (delete as appropriate)  (Figure 35.5b). Equivocal cases are upstaged. The extent Histological type (SCC or list subtype)  of extracapsular spread (ECS) (either in mm or by refer- Pathological stage:  ence to tissues/structures involved) may be stated as an pr ;pN ;pM ; TNM stage grouping  optional detail. Status of resection margin: clear/close/involved  © Other optional extras include presence of embolization/  : ; : ; Note:  permeation of perinodal lymphatics; presence of evi-  dence of response of tumour to previous therapy (kera- @ The International Union Against Cancer (UICC) TNM  tin debris/granulomas). clinical and pathological stage categorization criteria  e A radical neck dissection yields an average of 20-30 are similar.    nodes (and occasionally up to 100) in the absence of pre-  vious chemo- or radiotherapy. Salvage neck dissections  may yield <10 nodes.    @ Labelling errors and specimen mix up. Special care is  needed when specimen pots have been labelled during  preparation of the clinic - any unused pots must be dis-  posed of to ensure specimens are not placed in incor-  rectly identified pots.   ® Surgical (failure to clear all nodes within the drainage  area).   @ Laboratory (incomplete harvesting of nodes from fixed  specimen; inadequate sectioning of individual nodes).  ® Inaccuracies in histological detection (failure to notice).   ® Laboratory technical errors and machine malfunction  resulting in specimen mix-up or poor quality slides.   © Shortcomings in the UICC TNM staging system such  as the use of tumour diameter not thickness, omission  of ECS.    Accurate pathological assessment of surgical resection  specimens requires strict adherence to agreed protocols at  each stage:    Figure 35.5 Extracapsular spread varies widely in extent. ¢ Presentation of histological findings (core data set,  (a) Involvement of the sternocleidomastoid muscle. (b) Focal UICC pathological TNM stage)    Woolgar JA. Histopathological prognosticators in oral and  oropharyngeal squamous cell carcinoma. Oral Oncol.  2006; 42(3): 229-239.   Woolgar J and Triantafyllou A. Neck dissections: A prac-  tical guide for the reporting pathologist. Curr Diagn  Pathol. 2007; 13(6): 499-511.    Woolgar JA and Triantafyllou A. A histopathological  appraisal of surgical margins in oral and oropharyn-  geal cancer resection specimens. Oral Oncol. 2005;  41(10): 1034-1043.   Access surgery 341  Coronal scalp flap 341  Maxillary swing: Pedicled osteotomy of the maxilla/hard palate 3.45  Nasal swing: Pedicled osteotomy of the nasal bones and frontal process of the maxilla 348  Transmandibular approaches 351  Transzygomatic approaches 355  Summary 359  References 359  Suggested readings 359  ACCESS SURGERY Over the temporalis muscle the galea is termed as tempo-    The excellent blood supply of the craniofacial skeleton  allows pedicled or free bone fragments to be moved so  gaining access to the skull base and adjacent areas. Tooth  bearing maxillary or mandibular bone segments must  retain their blood supply and if post-operative radiother-  apy is planned pedicled osteotomies are preferable.    The coronal flap provides access to the frontal bone,  upper midface, anterior and middle cranial fossa, orbit,  temporal and infratemporal fossae in a range of clinical  situations.   © Aponeurosis (galea) connecting the paired frontalis  muscle anteriorly and occipitalis muscle posteriorly    roparietal fascia. The subgaleal plane continues laterally  over the temporalis fascia.   The temporal branch(es) of the facial nerve supplying  frontalis are at risk as they run on or within the deep sur-  face of the temporoparietal fascia (Figure 36.1c).    e Atleast 8 mm in front of the cartilaginous meatus at the  zygomatic arch   @ At least 1 cm anterior to the upper anterior attachment  of the helix   ® No higher than 2 cm above the fronto-zygomatic suture  (lateral edge of the eyebrow)    Nerve damage is prevented with dissection deep to the  temporal fascia beyond these limits (Figure 36.2a and b).    Along the line of the incision, the hair is either strip shaved  or parted. The scalp above the galea is infiltrated with lig-  nocaine and 1:200,000 adrenaline.   Ifa parting is used, the angle of the incision is parallel to  the hair follicles to avoid later scar alopecia (Figure 36.3).  Alternatively, zig-zag incision is used to prevent parting of  the hair along the incision line.   The incision is marked from the anterior attachment of  the helix and is carried over the vault of the skull to the  opposite side behind the hairline. The incision commences    Figure 36.1 Layers of scalp in (a) parietal region and (b) temporal region. Temporal/temporoparietal fascia and the periosteum    at the vertex and is made through the galea, to the loose  areolar tissue (avascular plane of Merkel) - lifting the first  three layers as a ‘unit’ and extended laterally to the supe-  rior temporal line (Figure 36.4).   Blunt scissors or a brain retractor can be used to under-  mine the incision line along this plane, down to the root of  the helix and with the brain retractor in situ, the incision  is made down to it. This allows rapid elevation of the flap,  without inadvertent damage to the underling temporal  fascia/temporalis muscle.   The incision is made with a scalpel or Colorado nee-  dle and haemostasis achieved with bipolar diathermy.  Dissection is carried forward in the subgaleal plane.  Approximately 3 cm above the superior orbital rim the  pericranium is incised and the dissection continued sub-  periosteally. Resistance is then met at three points:   © The supra orbital neurovascular bundle is freed from its  bony canal with an osteotome (Figures 36.5 and 36.6).    A midline vertical incision in the periosteum aids expo-  sure of the nasal bones and frontal process of the maxilla.   Detachment of the medial canthal tendon from the ante-  rior lacrimal crest gives unrestricted exposure of the medial  orbit to the optic canal, and the orbital floor to the infraor-  bital nerve.   The medial canthal tendon may be ‘tagged’ through  the periosteum with a suture for later reattachment to a  microplate (Figure 36.7). Subperiosteal dissection medi-  ally is now possible as far the floor of the nose.   To expose the temporomandibular (TM) joint, zygoma  and lateral orbit, the skin incision is extended inferiorly to  just below the cartilaginous meatus either in a naturally  occurring pre-auricular skin crease or endaurally around  the tragus (Figure 36.8a and b). The dissection is taken  forward and medially following the cartilaginous meatus.  Superiorly the skin flap is elevated off the temporalis fascia  by blunt dissection.   At the upper attachment of the helix, the temporalis  fascia is incised - about 1 cm above the zygomatic arch,    Figure 36.2 (a) The outer limits of the temporal branches) of the facial nerve. (b) The temporal branch of the facial nerve is    Figure 36.3 With the hair parted the incision is parallel to  the hair follicles.    and angled forward to connect with the supraorbital  periosteal incision 3 cm above the superior orbital rim  (Figure 36.9). A pericranial flap could be easily incorpo-  rated, by extending the pericranial incision superiorly  to the required length, between the superior temporal  lines, as an extension of the temporalis fascia incision  (Figure 36.10a and b).   The incision in the temporalis fascia is then taken ver-  tically down to the level of the zygomatic arch - easily  palpated immediately above the cartilaginous meatus  (Figure 36.11).    Figure 36.4 The first three layers of the scalp lift as a single  unit.    Figure 36.6 Average distance supraorbital notch/foramen  from midline 32 mm (range, 15-38 mm).    The periosteum over the zygomatic arch is incised and  turned forward with the temporalis fascia, temporopari-  etal fascia containing the temporal branches) of the facial  nerve, and the skin - as a single flap. Subperiosteal dissec-  tion is continued anteriorly to expose the zygomatic arch,  body of the zygoma and lateral orbital rim (Figure 36.12).  Retraction of the temporalis muscle provides additional  exposure of the temporal fossa and superior limit of the  infratemporal fossa.    The periosteum is freed over the lateral and infe-  rior orbital rim, detaching the lateral canthal ligament.  Deep circumferential subperiosteal orbital is now easily  achieved.   The extent of subperiosteal exposure possible with the  coronal scalp flap is demonstrated in Figure 36.13.   @ Transoral (Le Fort I) approach - this is familiar to all  orthognathic surgeons and the surgical technique will  therefore not be discussed.    These approaches mobilize the midfacial skeleton via a  facial incision - ideally pedicled to the soft tissues. The  maxillary and nasal swing procedures are the ‘stan-  dard’ approaches - they can be combined, modified or  extended.    @ Nasal cavity, maxillary, ethmoid and sphenoid sinuses  © Soft palate and nasopharynx    Figure 36.9 The incision through the temporal fascia is  made along line A-B (see Figure 36.2b) to ensure preservation  of the temporal branch of the facial nerve. Complete exposure  omen of the temporomandibular (TM) joint and the entire zygoma is  possible without damage to the temporal branch of the facial  nerve.    Figure 36.8 (a) Incision in skin crease; (b) following the  tragus.    Exposure of the orbital rim, zygoma, zygo-  matic arch and temporal fossa.    A modified Weber-Fergusson incision is made with a  lateral eyelid extension, respecting the nasal subunits  (Figures 36.14 and 36.15). A ‘V’ shaped notch can be incor-  porated in the mucosal aspect of the upper lip and alar  rim, to help accurate localization of the flap. Subperiosteal  stripping is minimized to retain the maximum blood sup-  ply to the bone segments.   The incision is taken vertically through the alveolar  mucosa and attached gingiva between the upper central  incisors. The palatal incision is in the midline extended  laterally at the junction of the hard and soft palate behind  the maxillary tuberosity (Figure 36.16a and b).    The authors preferred approach is to make the inci-  sion around the gingival margins of the teeth, extending  from the canine tooth on the opposite side to the ptery-  goid hamulus, deliberately sectioning the greater pala-  tine neurovascular bundle on the side of the osteotomy.  The nasopalatine bundle is preserved if the bone cut is  between the central and lateral incisor teeth. The palatal  soft tissues are elevated to the opposite side (Figure 36.17).  This incision avoids the risk of palatal fistulae.    The bone cuts are made with fine saws or a fissure burr and  completed with osteotomes.    Figure 36.15 Modified Weber-Fergusson incision respect-  ing the nasal subunits, with a potential for medial glabella  extension (dotted lines).    The mucoperiosteum of the floor/lateral wall of the nose  is elevated and the bone cuts made are as follows:    © Between the central and lateral incisor teeth, continued  paramedially through the length of hard palate into the  nasal floor.   ® Laterally from the piriform fossa, below the inferior  turbinate (preserving the nasolacrimal duct) through  the anterior maxilla inferior to the infraorbital nerve  through the zygomatic buttress back to the ptery-  goid plates. The infraorbital nerve is sectioned at the  infraorbital foramen as it prevents lateral retraction  of the maxilla. The nerve ends may be tagged for later  anastomosis.   ® The bone cut posterior to the zygomatic buttress is  angled downwards and may be made either with a fine  osteotome or reciprocating saw, to reduce soft tissue    © Above the incisor teeth anteriorly  @ At the frontal process of the maxilla  © On the zygomatic buttress    The maxilla and pterygoid plates are separated with a  curved pterygoid chisel placed through a small vertical  buccal incision (Figure 36.18).    Figure 36.16 (a and b) Stepped soft tissue and bone cuts  avoid later wound dehiscence/fistulae.    The maxilla is then outfractured, pedicled to the soft  tissues of the cheek. The maxilla can be secured to the soft  tissues with 0/silk sutures over a gauze swab (Figure 36.19).   Following nerve division, wide lateral retraction of the  maxilla exposes the soft palate, nasopharynx and infra-  temporal fossa (Figure 36.20).   The buccal pad of fat is within the operative field and  immediately available for reconstruction as a pedicled  flap. The coronoid process and the attached temporalis  tendon may impede access to the infratemporal fossa.  A coronoidectomy will improve access and has the added  benefit of reducing post-operative trismus.   When closing an occlusal splint may be used if the bite  is not ‘positive’. The palatal soft tissues are covered with an  acrylic cover plate wired to the standing teeth. Closure of  the palatal tissues is therefore not needed. The plates and  screws are reapplied.    Figure 36.17 Alternative (favoured) palatal incision, with  the incisive and greater palatine foramina highlighted.    e Both the frontal process of maxilla and nasal bones  moved.   e Extend soft tissue incision slightly laterally on the face  to prevent bone/soft tissue cuts being in line.   e Moist tonsillar swab in opposite nostril when complet-  ing the cut through the cartilaginous nasal septum.    The maxilla is frequently mobile to a degree at the com-  pletion of surgery. The palatal cover plate can be left in situ  for 6-8 weeks or until maxillary stability is achieved.    Incision  NASAL SWING: PEDICLED OSTEOTOMY OF A modified Weber-Fergusson incision is made respecting  THE NASAL BONES AND FRONTAL PROCESS the nasal subunits and allowance is made for a transverse  OF THE MAXILLA medial extension along the glabella skin crease (Figure  ——— 36.15). The soft tissues are retracted laterally and superi-  Access to lesions in the nose, ethmoid and sphenoid orly to expose the nasal bones, frontal process of the max-  sinuses. Unlike the lateral rhinotomy it has the advantage illa and the piriform rims. Exposure of the contralateral    Nasal swing: Pedicled osteotomy of the nasal bones and frontal process of the maxilla 349    made with a saw/fine bur, after placement of localizing  plates. The contralateral nasal osteotomy is carried out  with fine osteotomes, if necessary, through separate stab  incisions. The underlying nasal mucosa and soft tissue  along the piriform rim are released with a diathermy.   The soft tissue incisions and the bone cuts are stepped.  The nasal bones are pre-localized with low-profile bone  plates (Figure 36.21).   The nasal septum restricts complete lateral retraction.  A damp tonsillar swab is placed in the opposite nostril  and the cartilaginous nasal septum divided vertically in  line with the osteotomy bone cuts. The septal cartilage is  divided with a cutting diathermy set on ‘coagulation’ -  the damp swab in the opposite nostril prevents accidental  trauma to the mucosa of the contralateral lateral nasal wall    and the facial skin on the opposite side. The 1-cm strut of    nasal cartilage is preserved along the dorsum and colu-  mella to prevent collapse in the distal nose that prevents  later nasal collapse. The nasal bones and the nasal soft tis-  sues are retracted to the opposite side (Figure 36.22).    A soft tissue nasal swing or soft and hard tissue nasal  swing can be combined with a larger midface/craniofacial  resection for pathologies involving adjacent structures  (Figure 36.23a and b).   The nasal swing links readily with a frontal craniotomy  for resection of pathology that also involves the central  compartment of the anterior cranial fossa.    (a and b) Incorporating soft tissue nasal  swing/nasal osteotomy with a craniofacial resection.    The transfacial approaches may also be combined with  mandibular osteotomies for further access.    A significant proportion of oral lesions can be excised ‘per  orally’. This access is principally dependent on the loca-  tion and size of the lesion and the status of the dentition  and mouth opening. An appropriate-sized mouth prop/  gag along with cheek and tongue retractors are utilized to  provide the necessary access (Figure 36.24a and b).    Soft tissue lip split can provide excellent access to the  posterior buccal mucosa and mandible, for lesions that  cannot be safely excised through a per-oral approach.  The principle disadvantage of the approach is the need  to often sacrifice the mental nerve; this must be weighed    (a and b) Per oral resection with appropriate  retraction and mouth opening.    against improved access. This is not a consideration if  the inferior alveolar nerve is sacrificed in the subsequent  resection.   A full-thickness vertical incision is made through the  midline of the lower lip and extended inferiorly across the  midline of the chin/upper neck, continues with an appro-  priately placed low neck skin crease incision. A ‘V’ can  be incorporated in the mucosal aspect of the lower lip to  facilitate accurate approximation (Figure 36.25a).    (a) Skin markings for soft tissue lip split;  (b) exposure obtained.    of the ipsilateral chin, associated with a curvilinear inci-  sion along the mental fold.   The neck skin flap is raised in the subplatysmal plane up  to the lower border of the mandible, taking care to avoid  damage to the marginal mandibular branch of the facial  nerve. The cheek flap is elevated by detaching the platysma  from the lower border of the mandible in the immediate  supraperiosteal plane. More posteriorly, the dissection can  be extended superficial or deep to the masseter muscle.   Intra-oral soft tissue incisions are principally deter-  mined by the location of the tumour (Figure 36.25b).    A visor flap can be utilized for lesions in the anterior  floor of mouth and mandible and can be combined with  bilateral neck dissections. The incision is marked at an  appropriate low-neck skin crease and extends from one  mastoid tip to the other (Figure 36.26a). The skin flaps  are raised in the subplatysmal plane up to the lower bor-  der of the mandible, taking care to preserve the marginal  mandibular branch of the facial nerve. The periosteum  is incised along the lower border of the mandible and a  mucoperiosteal flap elevated, taking care to identify the  mental nerves (Figure 36.26b). Intra-oral mucosal inci-  sions are determined by the location of the lesion and the  mental nerves are often sacrificed to obtain further access  or adequate margins.   The skin flaps are retracted cephalad with rubber drains  (Figure 36.26c). Resection of the lesions in the anterior  floor of mouth along with the mandible results in loss of  attachment of the tongue to the mandible (Figure 36.264).  It is essential that the genioglossus and geniohyoid muscles  are re-attached to the reconstructed mandible to prevent  the tongue falling back (Figure 36.26e). The advantage of  this incision is the avoidance ofa lip split facial scar, which  needs to be weighed against the risk of damage to the men-  tal and marginal mandibular branch of the facial nerves  bilaterally.    e When accessing the oral cavity the osteotomy bone cut  is in the incisor region.   e No incision is made through the lingual mucoperios-  teum - the soft tissues are simply elevated off the lin-  gual aspect of the mandible adjacent to the osteotomy.   e For combined access to the oral cavity and infratempo-  ral fossa, an extended mandibular swing is appropriate;  alip split is necessary.   e For wide access to the infratemporal fossa/parapharyn-  geal space without the need to involve the mouth, a lip  split is avoided.    The technique provides excellent access to the floor of  the mouth, mid and posterior third of tongue, tonsil-  lar fossa, soft palate, oropharynx including the poste-  rior pharyngeal wall, supraglottic larynx and medial  aspect of the mandibular ramus. Extended posteriorly  it provides equally good access to the infratemporal  fossa, and the parapharyngeal space with vascular  control.  There are three separate elements:   3. Elevation of the soft tissues off the lingual aspect of the  mandible    A full-thickness vertical incision is made through the  midline of the lower lip and extended inferiorly across the  midline of the chin/upper neck, continues with an appro-  priately placed low neck skin crease incision. A ‘V’ can  be incorporated in the mucosal aspect of the lower lip to  facilitate accurate approximation (Figure 36.27a and b).   The cosmetic outcome with a midline chin incision is  excellent and reduces the risk of numbness and ischemia  of the ipsilateral chin, associated with a curvilinear inci-  sion along the mental fold.   The neck skin flap is raised in the subplatysmal plane  up to the lower border of the mandible, taking care to  avoid damage to the marginal mandibular branch of  the facial nerve. Intra-orally, the incision through the  labial mucosa and attached gingiva is stepped, so that  it does not lie directly over the planned osteotomy.  The periosteal elevation and mentalis muscle stripping  should to restricted to allow identification and protec-  tion of the mental nerve and placement of the plates  (Figure 36.28).   No vertical incision is made through the lingual  mucoperiosteum. The soft tissues are simply elevated off  the lingual aspect of the mandible adjacent to the oste-  otomy. A full-thickness lingual mucoperiosteal flap is  subsequently elevated off the lingual aspect of the man-  dible through a crevicular incision, when the mandible is  retracted laterally (Figure 36.29). The incision through the  oral tissues is adjacent to the pathology — allowing for suf-  ficient tumour clearance.   The osteotomy is preferably performed in the incisor  region for tumours involving the oral cavity. Non-union  is rare at this site even with post-operative radiother-  apy (Figure 36.30). Osteotomy in the premolar region  anterior to the mental foramen is only employed by the  authors to access tumours in the infratemporal fossa/  parapharyngeal space when avoiding a lip split incision  (see Figure 36.30).    (a) Skin markings for a visor flap. (b) Skin flaps raised to lower border of mandible. (c) Exposure obtained. (d) Lack  of tongue attachments following resection of anterior mandible. (e) Composite fibula free flap reconstruction with re-attachment  of the tongue.    The mandible is divided with a fine saw blade between  the roots of the incisor teeth. Occasionally, an incisor  tooth is removed if there is insufficient room between  the dental roots for the bone cut. Prior to division the  mandible is pre-localized with bone plates across the  osteotomy bone cut - these are removed and replaced  on closure.   ‘The osteotomy bone cut is a simple straight line in all cases.  A stepped bone cut aids neither fixation nor bone union.   Following division the mandible is gently retracted  laterally — the lingual soft tissues including the mylohyoid  muscle are stripped off the mandible.    By stripping the medial pterygoid and the styloman-  dibular ligament off the medial aspect and angle of the  mandible, respectively; further lateral and superior  mandibular retraction is possible and provides wide  access to the infratemporal fossa and parapharyngeal  space (Figure 36.31).   For lesions in the tongue and floor of the mouth, the  mandibulotomy access is very similar, but the lingual  soft tissue margins are determined by the location of the  tumour (Figure 36.32a and b).    Exposure with extended mandibular swing  following detachment of medial pterygoid and stylomandibu-  lar ligament.    For tumours confined to the infratemporal fossa/parapha-  ryngeal space without the need to involve the oral cavity,  the approach is determined by the following:    For smaller tumours, very limited access is provided by  simply elevating the mandibular angle or by detaching  the stylomandibular ligament at the angle of the mandible  and dislocating the mandibular condyle anteriorly (Figure  36.33a and b).   If greater access is needed then one of the following pro-  cedures is used.    (a and b) Exposure of tongue lesion follow-  ing mandibular swing. (Pre-localized plates left in situ.)    If lower lip sensation is already lost or will be lost  in the resection, a simple angle osteotomy section-  ing the inferior dental (ID) bundle is satisfactory  (Figure 36.34).   If lower lip sensation is to be preserved, a lip split can  be avoided by combining a vertical ramus osteotomy  behind the lingula with an additional osteotomy ante-  rior to the mental foramen - usually between the canine  and the first premolar as described by Smith et al.!  (Figure 36.35a and b).    In each case, the mandible is pre-localized with bone  plates. It is possible to trace the internal carotid artery to  the skull base adequately with both approaches.   A horizontal osteotomy of the mandibular ramus as  suggested by Attia et al.? is avoided as the area of bone  contact is limited with this technique.   If resection of the floor of the middle fossa is required  in skull base procedures, additional superior access is    Figure 36.33 (aandb) Limited access to retromandibular and parapharyngeal space by anterior mandibular dislocation and  division of the stylomandibular ligament.    e The lateral aspect of the inferior orbital fissure both  within the temporal fossa and orbit is the key anatomi-  cal landmark.   e The temporalis muscle is reflected superiorly for sub-  cranial pathology.   e Trismus is expected post-operatively and is prevented  with jaw exercises. (b)    The zygoma links the following regions: :  Figure 36.35 (a) Double mandibular osteotomy. (b) Superior    retraction of ramus and body of mandible. (Case courtesy of  Professor V. llankovan and Professor P. Brennan.)    Its disarticulation inferiorly pedicled to the masseter  provides simultaneous exposure of the orbit, temporal fossa  and superior aspect of the infratemporal fossa. A fronto-  temporal craniotomy links the middle and anterior cranial  fossae.   The site of the pathology determines the extent of the  zygoma mobilized and whether the temporalis muscle is  reflected inferiorly or superiorly.    ® For subcranial lesions (orbit/temporal and infratem-  poral fossae) the temporalis is reflected superiorly after  dividing the coronoid process.   © For combined exposure of the middle/anterior fossae,  the orbit and/or the temporal and infratemporal fossa,  the temporalis is reflected inferiorly.    The blood supply of the temporalis is potentially compro-  mised with both superior and inferior reflection.    The zygomatic arch and body are exposed with a coronal  flap.   When exposing the orbit as well as the temporal and  infratemporal fossae, limited subperiosteal dissection is  carried out in the lateral orbit to protect the orbital con-  tents. The temporalis is reflected off the lateral orbit. The  lateral limit of the inferior orbital fissure is identified with  a blunt hook in the temporal fossa.   e Through the body of the zygoma extending laterally  from the inferior orbital fissure. The anterior limit of the  inferior orbital fissure is first identified in the orbit with  a blunt hook. The cut is in an inferolateral direction.   © The posterior bone cut is just anterior to the articular  eminence of the TM joint.   © The bone cut in the lateral orbit extends from the supe-  rior bone cut to the lateral aspect of the inferior orbital  fissure — identified earlier in the temporal fossa (Figure  36.36a and b).    If orbital exposure is unnecessary, the lateral orbital rim  is left intact. A vertical bone cut through the body of the  zygoma lateral to the orbital rim is made. The posterior  bone cut is the same.   The zygoma is pre-localized with bone plates and  screws — 1.7 mm plates are satisfactory.   With gentle taps, the osteotomy is completed with an  osteotome and the zygoma displaced inferiorly. The tem-  poralis is reflected superiorly after a coronoidectomy. The  mandible is opened widely with a mouth prop increas-  ing vertical exposure. The lingual and inferior alveolar  nerves can be identified in the lateral infratemporal fossa  (Figure 36.37).   For correction of a malunion of the zygoma the coro-  noidectomy and superior reflection of the temporalis are  unnecessary.   ® Medially to the lateral wall of the nasopharynx fol-  lowing resection of the lateral and medial pterygoid  muscles    Medial exposure is restricted which limits the approach to  treatment of benign pathology in the infratemporal fossa  if used as the sole means of access. Malignant disease in  the infratemporal fossa is better accessed with a trans-  mandibular and/or transfacial approach.   For exposure of the lateral orbit to the apex, a fronto-  temporal craniotomy is necessary. This allows the safe  removal of the greater wing of the sphenoid under direct    Zygoma displaced inferiorly, temporalis  superiorly and the mouth opened widely. Lingual (anterior)  and ID (posterior) nerves identified after resection of the  coronoid.    vision and the exposure of the contents of the superior  orbital fissure and the optic nerve.    This approach is useful for lacrimal and lateral/supe-  rior/inferior extra- and intra-conal orbital lesions and  for reconstruction following orbital exenteration with a  temporalis flap. It can be combined with craniotomies for  additional access to the orbital apex.    A coronal flap is raised and the zygomatic complex  exposed as described in section “Standard” zygomatic  osteotomy’ for the zygomatic osteotomy. For isolated  lesions, a Stallard—Wright ‘S’ shaped incision extending  from the upper lid skin crease/eyebrow inferolaterally  over the lateral orbital rim to the crow’s feet skin crease  can be utilized. The temporalis muscle is retracted pos-  teriorly to expose the temporal aspect of the lateral orbit  and the orbital periosteum is elevated from lateral orbital  wall (Figure 36.38). The inferior orbital fissure is identi-  fied both within the orbit and temporal fossa with a blunt  hook. Perforating blood vessels are identified and coagu-  lated prior to division.   The orbital contents are protected with a malleable  retractor and the bone cuts are made with a thin saw.   Inferior: Inferior lateral orbital rim along the superior  border of the zygomatic arch (the superior border of  the zygomatic arch is at the same level as the orbital  floor) up to the anterior limit of inferior orbital fissure  (Figure 36.39).    Posterior bone cut in the lateral orbital wall  from the temporal aspect.    Posterior: Cut in the lateral orbital wall with a fine bur  joining the superior bone cut to the anterior limit of the  inferior orbital fissure (Figure 36.40). This is more easily  made from the temporal aspect.    The superior and inferior bone cuts are pre-plated prior  to removal of the osteotomized segment and fixed plates  following completion of the procedure.   The lateral orbitotomy can be combined with a supe-  rior orbitotomy for wide exposure of the superior orbital  fissure and optic nerve/canal. This is usually performed  in conjunction with a fronto-temporal craniotomy. The  craniotomy is best performed initially and the supe-  rior orbital wall delineated from the cranial aspect.  With malleable retractors in situ, the superior and lat-  eral orbitotomy can be carried out under direct vision  (Figure 36.41a through c).    (a) Marking for superior/lateral orbitotomy and fronto-temporal craniotomy; (b) exposure of the orbital roof  following craniotomy and (c) exposure following orbitotomy and craniotomy.    Note: Excludes endoscopic approaches which can be utilized alone or  in combinations with the open approaches.    e The first three layers of the scalp lift as one unit in an  avascular plane.   e Knowledge of surgical landmarks prevents damage to  temporal branches of facial nerve.   e Closure of the galea is the most important element in  wound closure.    1. Smith GI, Brennan PA, Webb AA and Ilankovan V.  Vertical ramus osteotomy combined with a para-  symphyseal mandibulotomy for improved access  to the parapharyngeal space. Head Neck. 2003; 25:  1000-1003.   2. Attia EL, Bentley KC, Head T and Mulder D. A new  external approach to the pterygomaxillary fossa and  the parapharyngeal space. Head Neck Surg. 1984; 6:  884-889.    Feynas DW. Landmarks for the trunk and temporofa-  cial division of the facial nerve. Br J Surg. 1965; 52:  694-696.   Shepherd DE, Ward-Booth RP and Moos KF. The morbity  of bi-coronal flaps in maxillo-facial surgery. Br J Oral  Maxillofac Surg, 1985; 23: 1-8.    Altemir FH. Transfacial access to the retromaxillary area.  J Maxillofac Surg. 1986; 14: 165-170.   Brown AMS, Lavery K and Miller BG. The transfacial  approach to the postnasal space and the retromaxil-  lary structures. Br J Oral Maxillofac Surg. 1991; 29:  230-236.   Curioni C, Padula E, Toscano P and Maraggia A. Gli  angiofibrorni del rinofaringe. Chirugia della testa e  del colla. 1984; 1: 47-56.   Wei WL, Lam KH and Sham JST. New approach to the  nasopharynx: The maxillary swing approach. Head  Neck Surg. 1991; 13: 200-207.    Biedlingnaier JF and Ord R. Modified double mandibular  osteotomy for tumours of the para pharyngeal space.  J Oral Maxillofac Surg. 1994; 52: 348-352.   Chatni SC, Sharan R, Patel D, Iyer S, Tiwari RM and  Kuriakose MA. Transmandibular approach for exci-  sion of maxillary sinus tumors extending to the pter-  ygopalatine and infratemporal foaas. Oral Oncol.  2009; 45: 720-726.    Evans BT, Wiesenfeld D, Clauser L and Curioni C. Surgical  approaches to the infratemporal fossa. In Langdon J,  Berkovitz BKB, Moxham BJ (eds.), Surgical Anatomy  of the Infratemporal Fossa. Valley Stream, NY: Martin  Dunitz Publishers. pp. 141-180.   Obwegesser HL. Temporal approach to the TMJ, the orbit,  and the retromaxillary-infracranial region. J Head  Neck Surg. 1985; 7: 185-199.   Shahinian H, Dornier, MD and Fisch U. Parapharyngeal  space tumours: The infratemporal fossa approach.  Skull Base Surg. 1995; 5: 73-81.   Temple and cheek defect operations  Orbital defects and reconstruction  Eyelid resection and reconstruction  Nasal defects    Most facial skin cancers are basal cell carcinomas (BCCs)  which are well demarcated and do not extend below the  deep dermis. These lesions can be excised with a margin  of 5 mm and the depth of incision is located at the level of  the muscle fascia. The lesion is excised as an ellipse placed  parallel to the natural expression lines (Figure 37.1), and  closed without tension or distorting structures such as  the eyebrow. The skin incision is made perpendicular to  the surface and the wound is closed in layers. The wound  edges are undermined as necessary.   Recurrent lesions, post-radiation tumours, morphoeic  (sclerosing) BCC and tumours in lines of embryonic  fusion require special consideration. These tumours are  poorly demarcated; therefore, microscopic controlled sur-  gery (Mohs’ technique) may be required to ensure tumour  extirpation. Mohs’ technique is also indicated where mini-  mal removal of normal tissue is indicated, e.g. the eyelids.  The technique relies on accurate mapping of the excised  specimen with microscopic examination of the deep sur-  face to ensure complete removal of the tumour.   Figure 37.2 shows a basal carcinoma at the medial can-  thus (an embryonic fusion line). The excision margin is  marked out as shown in Figure 37.2a (dotted line).    Figure 37.1 Various elliptical excisions of lesions are dem-  onstrated. Generally, these should be placed parallel to the  relaxed skin tension lines (RSTLs) to avoid tension.    The tumour is excised with the knife blade held at 45°  to the surface (incision A-A' in Figure 37.2b), and a sec-  ond clearance slice of tissue 1-2 mm thick is excised from  the tumour bed (incision B-B'). This thin slice of tissue  is turned over onto a slide with the deep surface upper-  most and is divided into sections (usually four) like slices  of pizza. At least one edge is stained with Indian ink or  another dye to accurately orient (‘map’) the position of  residual tumour. In Figure 37.2c, slices 1 and 4 which cor-  respond to the nasal portion of the tumour are seen to  contain residual tumour.   Further slices of tissue (5 and 6 in Figure 37.2d) will be  removed in the area corresponding to specimens 1 and 4  and the process is continued until all slices are tumour  free. Many Mohs’ surgeons prepare frozen sections from  the deep surface, and after reviewing the slides them-  selves continue the serial excision on the same day. An  alternative method is to fix the slices of tissue for per-  manent section. Slides will be ready in 24-48 hours. The  wound is left open and dressed with mupirocin (bactro-  ban) cream. Further, excision is carried out in the areas  indicated. An important component of this technique is  review of the sections by the surgeon to ensure accurate  mapping.   When the defect is tumour free, it may be closed with  flaps or in some sites allowed to granulate.    Figure 37.2 (a) Medial canthal lesion, ideal for Mohs’  technique in order to preserve tissue and prevent distortion  of adjacent structure after definitive repair; (b) tumour exci-  sion with blade at 45° (A-A’); (c) deep disc partitioned into four  slices to be stained, analyzed and mapped to correspond to  the tumour bed; residual tumour is observed in slices 1-4 and  (d) residual tumour slices 1 and 4 correspond to tumour bed  slices 5 and 6; in turn, these will be stained and mapped until  margins are clear of tumour.    Primary closure is the procedure of choice for small (<1  cm) defects where tissue laxity allows it. In the brow and  temple regions, care should be exercised not to displace  the hair-bearing margins. The first step in the ‘reconstruc-  tion ladder’ is split- or full-thickness skin graft.   For larger defects (>1 cm) or where scar contracture has  altered tissue character, local flaps may be used. Local tis-  sue flaps can be designed as V-Y advancement, rotational  or transposition flaps which will be applicable at different  facial sites. Where there has been loss of hair in the scalp  region, a combination of staged tissue expansion with  local scalp flaps can be undertaken. Temporary resurfac-  ing of avulsion scalp wounds may be performed with free  skin grafts (allografts or autografts). At a later date, tissue  expansion with eventual scalp flap advancement or rota-  tion to restore scalp integrity is performed. Total or near-  total brow loss is generally reconstructed with a free tissue  graft from the scalp. For smaller brow defects, punch  grafts can be placed.    The V-Y advancement flap is used for small and moderately  sized midline defects, the limiting factor being the area of  tissue laxity. These flaps are particularly useful in resurfac-  ing glabellar, nasal and medial canthal regions. The colour  and texture match is excellent. The V-Y midline or glabel-  lar flap is nourished by supratrochlear and canthal arteries  and random-pattern facial artery distribution. Care must  be taken to preserve the arteries, if possible, when the flap  is elevated. Design of the flap (Figure 37.3) must take into  consideration the pivotal point of the flap, located at the  flap base opposite the defect. The inferior incision on the  pivotal side should not extend below the medial canthal  level in order to maintain vascularity.   The length of the vertical limbs of the flap will be dic-  tated by the defect length and laxity of glabellar tissue.    Figure 37.3 Glabellar V-Y advancement flap. Distance A-B  should be no more than half of the distance A-C in order to  ensure vascular integrity through the area of pivotal point C.    The base of the flap (B-C) should be half to two-thirds of  the entire base (A-C) which also includes the defect (A-B).  Dissection of the flap is carried out in the areolar plane to  preserve subdermal plexus.   Once the flap has been elevated and turned into the  defect, the flap’s leading edge should be sutured to the  defect margin with polydioxanone suture in a buried  fashion. Closure of the V-Y segment (Figure 37.4) begins  superiorly and continues inferiorly, the last sutures being  placed at the pivotal area of the flap base. A standing cone  (dog ear) usually occurs at the pivotal area, which may  resolve over time, or require secondary z-plasties and/or  dermabrasion.    With lateral forehead defects, a transposed median fore-  head flap (Figure 37.5) may be used; however, animation  of the frontalis is adversely affected. For small forehead    Figure 37.4 Transposition and closure of glabellar V-Y flap.  The leading edge should be sutured first. The standing cone  (dog ear) at the pivotal point will settle with time.    Figure 37.5 Diagram of median forehead flap to resur-  face a right forehead defect. Same principles apply as in a  turned down forehead flap to the nasal region as described in  Figure 37.3. A smaller left forehead defect is shown repaired  with a sliding ‘H’ flap. Burow’s triangles correct the standing  cones at the corners.    defects, sliding horizontal advancement flaps with inci-  sions hidden nicely in existing frontalis relaxation lines  and small Burow’s triangles to facilitate closure work well.  If tissue loss or resection encompasses the supraorbital  nerve in its first 3-4 cm, then microneural repair should  be undertaken with a cable graft using the greater auricu-  lar nerve. A vein graft or a commercially derived nerve  sheath graft may also be micro-anastomosed to serve as a  conduit for the regenerating nerve.    Rotational forehead flaps are primarily utilized for clo-  sure of large midline defects. They have a semi-circular  design with an arc of rotation near the middle of the flap.  At times bilateral rotation flaps may be necessary. The  midline defect is triangulated with the base at the hair-  line, and the apex angle may approach 50°. When the flap  is designed, the leading edge should be made long enough  to allow adequate rotation of the flap and coverage of the  defect.   First, mark out the proposed excision and then, a tri-  angulated defect may be constructed (Figure 37.6). If a  defect is located cephalad (near the hairline), the lead-  ing edge (A-C, B-C) should be longer than the defect  margin to ensure adequate rotation of the tip (A or B). In  order to achieve rotation, a back-cut can be performed  at the flap pedicle (D or E). Also, wide undermining of  the pedicle and surrounding tissue may be undertaken;  however, extensive undermining may disrupt vascular  perforators.   Rotation of the flap into the defect typically leaves a  secondary defect at the flap margin (BB', DD’, or AA’, EE}).    Figure 37.6 Midline defect repaired with a rotational fore-  head flap. The leading edges (A-C, B-C) should be longer than  the defect in order to gain enough tip (points A and B) rota-  tion. Back-cuts at the flap base (DD', EE’) are necessary to gain  adequate rotation. Areas of incomplete closure (AA’, BB', DD',  EE') will usually close with advancement of the cephalad and  caudal margins.    If the defect is a narrow gap at the hairline, this can be  closed by simple vertical advancement of both margins  (B-B’, etc.). The hairline may be temporarily displaced  inferiorly in such cases. Other gaps may be closed by  extending incisions to allow more rotation and dis-  tributing tension during closure along the whole of the  wound margin. Rarely, free full-thickness skin grafts  may need to be placed in a secondary defect caused by  flap rotation.    Temple and cheek area defects are closed with local tissue  flaps, which offer laxity, good texture and colour matches.  Transposition flaps (rhombic, Dufourmental, bilobed  flaps, etc.) offer excellent repairs for small and moderately  sized defects, designed and sited such that the incisions  fall into relaxed skin tension lines (RSTLs) and the trans-  posed tissue does not distort adjacent structures. There  are four possible rhombic flaps for each defect; however,  usually two are more favourable owing to RSTL topogra-  phy. The correct donor flap extends from lax tissue and the  sides of the flap, particularly the leading edge, should be  slightly longer than the defect side to compensate for piv-  otal restraint. If the recipient skin tissue is lax, then sur-  rounding structures, such as eyelids or eyebrow, will move  towards the flap.   A rhombus is drawn around the proposed area of exci-  sion (see Figure 37.7): Two defect sides (A-B and C-D)    Figure 37.7 Rhombic flaps incorporate 60° and 120° angles  in the design. For flap BDFG, incision F-B is equal to B-C, and  F-G is parallel to B—D. The leading edge (A-C for flap ACEH,  or B-D for flap BDFG) lies perpendicular to RSTLs. The more  favourable rhombic flap is that which distorts surrounding tis-  sue the least. In the temple region, this is usually the caudally  based flap as shown.    are drawn perpendicular to the RSTLs and extended to  encompass the defect. These are then connected with par-  allel lines and the short link diagonal (B-C) is extended  to create one edge of the donor flap. As noted above, the  transposed edge (B-F or C-E) and back-cuts may need to  be slightly oversized to accommodate the necessary rota-  tion and closure.   Adequate recipient site and pivotal area (flap) undermin-  ing are critical for ease of transposition and minimizing  tension (with consequent ischemia). Closure (Figure 37.8)  begins first at the leading edge corner (1C) followed by a  suture at the near corner (BG).   Several buried sutures in the deep dermis plus ‘cor-  ner sutures’ and mattress sutures will assist in distribut-  ing tension. The transposed flap tip (2A) should require  minimal suturing, thereby reducing tissue ischemia and  necrosis.    The Dufourmental flap (Figure 37.9) is a variation of the  rhombic design. Its application is in areas of limited tis-  sue reservoir necessary for advancement or transposition  of the flap. With the construction of a bisector (B-G) of  the angle (EBF) created by extension of the short diago-  nal (A-B) and defect margin (B-C), a more obtuse leading  edge margin is created. The back-cut is generally parallel  to the long diagonal (C-D) of the rhomboid defect. This  design diminishes the degree of vertical tension on the  transposed flap.   A wider base is created in the Dufourmental design,  and this may contribute to difficulty in flap transposition.  However, tension at the tip is placed more lateral (not as  vertical as in the rhombic design), thereby creating a more  stable flap.    Figure 37.8 Closure of the rhombic flap begins first at 1C  then corner stitches placed at the areas BG and 2A. If flap tip  ischemia is evident after suturing, either too much tension  exists or improper suture placement is to blame.    The bilobed flaps are a combination of transpositional  and rotational flap manoeuvres. The key design involves  construction of long enough limbs to accommodate the  restraint at the flap base, which inevitably results from the  distance necessary for transposition. A pivotal angle of  >30° will usually result in “standing cones’ at the flap base.  If cones persist, they may be excised secondarily.   Orientation of the bilobed flap is determined by the res-  ervoir of tissue in the area of the defect - from the cheek  area for transposition superiorly into the temple region - if  the defect is high, and inferiorly as shown in Figure 37.10  if the defect is low. The incision lines should lie in relaxed  skin lines.    Figure 37.10 Bilobed flaps should have bases in fairly lax  tissue and the incisions made parallel to RSTLs, if possible, for  cosmesis and stability. Pivotal angles should be 30° or less to  avoid standing cones.    Access to the medial orbit and ethmoid sinuses for resec-  tion of extensive tumours usually involves a combined  craniofacial approach from above and access through the  naso- orbital region. Craniofacial approaches are discussed  elsewhere. For smaller tumours confined to the ethmoid  air cells, the lateral rhinotomy approach may be used.  Typically, the orbit is not entered and the eye is preserved.   The incision is carried superiorly from the alar (as in a  Weber-Fergusson approach) midway between the medial  canthus and mid-nasal point. Greater postero-superior  access can be gained through extension of the incision  into the supraorbital recess. If a margin can be safely  obtained without involvement of the lacrimal crests, then  the medial canthus may remain attached. Wider exposure  may be obtained with canthal detachment. Osteotomizing  a portion of the crestal insertion facilitates canthal  re-attachment with microplate fixation. Exposure of the  entire medial orbital wall is permitted. After delineation of  tumour extent, a 1-cm bony margin is planned. Removal  of the lamina papyracea may assist in determining tumour  extent and bony margins.   To facilitate tumour exposure, the nasal bones may be  osteotomized (Figure 37.11). Microplates are placed first.  If encroachment on the lacrimal canaliculi or sac is antici-  pated, cannulation is undertaken for identification pur-  poses and repair.   After resection, the cavity is lightly packed with gauze  strips impregnated with antibiotic ointment. If resection  has involved the superomedial orbital wall or cribriform  plate, the defect should be lined with transposed peri-  cranial flaps or split calvarial grafts. Such a defect may  also communicate with the frontal sinus in which case  a pericranial flap will serve as a barrier. Fibrin sealant is  applied to secure a water-tight seal (Figure 37.12). If the    Figure 37.11 Diagram illustrates nasal osteotomy for  access to the superior nasal and ethmoid regions. Fixation  plates should be placed initially in situ which facilitates replace-  ment after resection.    Figure 37.12 A pericranial or galeal flap may be made  to cover a resection defect and provide vascularity for bone  grafts. Retention of the flap to the recipient bed is facilitated  by placing holes in the bony margins, suturing the flap in place,  and sealing with fibrin glue. A portion of the outer calvarium  may be osteotomized as a pedicled myo-osseous flap for  reconstruction of the bony orbit.    frontonasal duct is implicated or frontal sinus disease is  present, sinus obliteration is performed via mucosal strip-  ping and autogenous (calvarial cortical chips and dust)  bone graft placement. (Dual access for extended resection  into the superior orbit or frontal sinus region is necessary  via coronal and rhinotomy approaches.)    Lateral orbital masses, usually epidermoid or dermoid  cysts or tumours arising from the lacrimal gland, are  approached through brow, eyelid (with or without lat-  eral canthotomy) or coronal access incisions. Computed  tomography (CT) and magnetic resonance imaging  (MRI) delineate the mass size, location and vascularity.  A coronal approach will allow better access for malig-  nant lesions, particularly with skull base involvement.  Transconjunctival incisions with lateral canthotomy give  sufficient access for biopsy of large masses or removal of  small lateral orbital tumours (Figure 37.13).   A coronal approach is performed, exposing the supra-  orbital and lateral orbital rims. If CT or MRI has indicated  the posterior extent of the mass to be more than one-  half of the orbit, fronto-orbital craniotomy is indicated.  Anterior masses can be approached via an orbital rim  osteotomy which is planned to allow sufficient margins of  bony and peri-orbital tissue for malignant tumours of the  lacrimal gland. The inferior limb of the osteotomy can be  taken to the orbital floor and posterior to the sphenozy-  gomatic suture. Before the lateral canthus is detached, it    Figure 37.13 Lateral orbital osteotomies for lateral, supe-  rior or deep orbital lesions. The lateral orbital bone can be  removed with rongeurs to facilitate access to the retro-orbital  region.    is identified with a suture or it can be osteotomized with  a small (6-8 mm) portion of lateral rim bone to allow  precise reattachment with wire or micro-screw fixation.  The orbital rim and wall are put aside (with miniplates  attached) for later placement.   Rongeur nibbling (Figure 37.13) of the orbital wall  will also create more postero-inferior access to the retro-  orbital region. Superior access is best gained through a  fronto-orbital craniotomy.    Some posterior masses may require combined approaches  to the orbit. A lateral orbitotomy (Figure 37.14a) with  outward displacement of the globe combined with a  medial approach will provide improved access to medial-  posterior masses. An extended lateral canthotomy inci-  sion gives good exposure of the lateral rim. The anterior  third of the lateral orbital wall is osteotomized and the rim  is cut above and well below the frontozygomatic suture.  Out-fracture (Figure 37.14b) of the lateral wall preserves  the attached periosteum as a vascular pedicle.   A Lynch incision to the medial wall or lateral rhinotomy  is performed. The medial canthus is identified and either  tagged or osteotomized with attached bone. The medial  orbital wall is removed and an ethmoidectomy performed.  After detachment of the medial rectus muscle, the globe  can be gently retracted laterally, thus exposing the pos-  terior intraconal region. If access is still limited, a supe-  rior approach through the orbital roof is necessary. After  tumour resection, the medial canthus is reattached with  light polydiaxanone sutures or 28G wire. A gauze pack  with antibiotic ointment is placed in the ethmoid resec-  tion and a small Penrose drain placed. The lateral wall and  rim are affixed with miniplates.    Figure 37.14 (a) Lateral orbitotomy may be performed to out-fracture the lateral orbit pedicled upon its musculoperiosteal  attachment. The globe can then be mobilized laterally to provide access for medial and paranasal lesions. (b) Axial view demonstrat-  ing out-fracture of the lateral orbital wall which then provides improved medial access. (c) Enlargement demonstrating incision lat-  eral to the limbus (1) and dissection of Tenon’s capsule over the globe (2). The rectal muscle insertion (3) is incised to gain intraconal    For intraconal lesions, Tenon’s capsule (bulbar fascia)  may need to be incised (Figure 37.14c) lateral to the limbus  with dissection over the globe to the muscle insertions.  Dissection here is a little more difficult and tedious; there-  fore, the muscle insertion is identified, incised and tagged  for later reinsertion. After reflection of the muscle, dissec-  tion to the posterior intraconal region is possible.   To reconstruct lateral or inferior wall defects after orbi-  totomy and resection, a temporal pericranial flap may be  mobilized and turned into the defect (Figure 37.12). To  provide bony support for a resected orbital site, the outer  table of calvarium can be harvested (‘guitar pick’ size),  with its pericranial pedicle and tunnelled into the orbit.  The subcutaneous tunnel needs to be sufficiently under-  mined to accommodate the flap and prevent constriction  of the pericranial vessels.   Orbital floor or inferior rim reconstruction can also  be accomplished by an intra-oral coronoidectomy with  temporalis insertion preserved and then tunnelling  the coronoid to the orbit (Figure 37.15) where it is fixed    Figure 37.15 This demonstrates reconstruction of an  orbital rim/floor defect with the coronoid process hinged on  the temporalis muscle.    to surrounding bone with titanium miniplates. This  manoeuvre will provide support to the peri-orbital tissues  as well as a buttress for the lower eyelid retractors and sup-  portive tarsal structures.    A variety of benign and malignant lesions are found on the  eyelids. Benign lesions include nevi, keratoses, cysts (seba-  ceous, meibomian), papillomas, etc. Benign lesions are  excised with immediate reconstruction. The commonest  malignancy is BCC followed by squamous cell carcinoma,  sebaceous gland carcinoma and melanoma. These lesions  should be biopsied for diagnosis, then resection performed  with Mohs’ technique or frozen section guidance.   BCCs require a 3-4 mm margin while squamous car-  cinomas and melanomas should have at least 1 cm of  lid margin. Deeply invading tumours affixed to bone or  involving the scleral conjunctiva may necessitate exentera-  tion. Reconstruction of the lid may involve lid remnants,  local peri-orbital or opposite lid tissue, full-thickness skin  grafts, local flaps, distant flaps and cartilaginous or banked  tissue grafts (allografts). Eyelid reconstruction involves  three types of defects: skin only, skin and orbicularis and  full thickness with the tarsoconjunctival layer. Repair may  also require reestablishment of the canalicular and naso-  lacrimal ducts. Large defects need some structural support  for the reconstructed lid.    Partial-thickness defects are repaired by advancing local  skin and muscle, or with a full-thickness skin graft. Skin  grafts are harvested from the opposite lid, post-auricular  region or supraclavicular area. These areas provide excel-  lent tissue match for thickness, colour and texture. Small  lid defects (<2 cm) are easily repaired with opposite lid  skin, while larger areas require post-auricular or supracla-  vicular grafts.   The defect is measured. The donor area is ‘ballooned’  with local anaesthetic and a vasoconstrictor. The graft is  obtained, the donor area closed primarily, and the donor  skin is thinned by trimming subcutaneous tissue. The  graft is fashioned to the defect, taking care to allow sufh-  cient, loose coverage of the defect. The lid should be under  full stretch to allow correct fit of the graft to the defect.   The graft is sutured in place with 6-0 black silk inter-  rupted sutures with long tails fora tie-over bolster. For larger  grafts, 6-0 chromic gut suture is placed in the mid portion  to assist in graft adaptation to the recipient area. Good hae-  mostasis of the recipient bed is critical to the success of the  graft. A non-stick dressing with cotton-wool is used as a  bolster. The bolster sutures are removed 7 days later.    opposite lid (usually upper to lower lid) may be performed  (Figure 37.16). The donor can be transferred as a “bucket  handle’ or one end pedicled which allows more flap mobil-  ity. Pinching’ the upper lid skin with a forceps, similar  to a blepharoplasty, will assist in determining the amount  of tissue available for transfer. These flaps are normally  indicated for smaller, narrower defects. Both peripheral  and central sutures using light chromic suture should  be placed to affix the flap to the defect bed. Frost sutures  should be placed for several days to reduce tension on the  flap. The flap is divided 7-10 days after surgery.   Full-thickness defects <1 cm can usually be closed primar-  ily by performing a wedge excision (Figure 37.17). The tar-  sal margins are coapted with 5-0 chromic or polyglactin  suture under loop magnification in order to avoid suture  placement through the conjunctiva and subsequent irrita-  tion. The lid margin is approximated by placement of a 6-0  or 7-0 silk or polypropylene suture in the lash grey-line.  This suture can be left long to incorporate into the dressing  at the end. Skin closure is performed with 6-0 or 7-0 inter-  rupted nylon or polypropylene sutures. A tape dressing  (Steri-Strip) is placed to support the wound. Ophthalmic    Figure 37.16 (a) Restoration of a lower lid defect may be  performed with redundant upper eyelid. A ‘finger flap’ is cre-  ated leaving one end pedicled, and then transposing to the  lower defect. (b) Transposed ‘lid-switch’ flap is secured with  interrupted suture. Frost sutures should be placed to immobi-  lize the lid for several days. The flap is divided at 7-10 days.    Figure 37.17 (a) Full-thickness lower lid defects <1 cm can  be primarily closed with sutures placed in the tarsal plate (6-0  resorbable suture) with 6-0 or 7-0 nylon or silk at the grey line  and skin. (b) The lid margin suture is left long in order to tape  the tails inferiorly and avoid irritation of the eye.    antibiotic ointment is applied to the wound twice daily  for 2-3 days. The lid margin stitch and tape dressing are  removed at 3-4 days and the nylon sutures at 7 days.   Larger full-thickness defects (>2 cm) require a lateral  advancement flap which is a lateral canthotomy incision  which is carried laterally to the hairline, if necessary. The  key to flap success is for the lateral incision to be gently  curved in an upward arc for lower lid flaps, and down-  wards for upper lid flaps. This provides adequate vertical  length to the flap as well as resistance to lagophthalmos of  the reconstructed lid. Flap mobilization is carried above  the musculoaponeurosis but includes the orbicularis mus-  cle in the advanced lid to lend some support.   As the flap is mobilized and advanced medially, the  conjunctiva will freely follow. A Burow’s triangle is placed  at the lateral-most extent of the incision to ease tension;  McGregor incorporated a Z-plasty at the lateral mar-  gin. The lower limb of the ‘Z’ roughly parallels the defect  margin. Closure begins with placement of a 4-0 or 5-0  polydioxanone suture at the canthal region to tack the lid  subcutaneous tissue to the rim periosteum. The transposed  Z-plasty triangles may require further mobilization and  trimming to fit properly. The wound is taped for 1 week to  provide flap support.   For defects too large to provide tarsus in the advanced  lid, a septal or conchal cartilage support may be required.  The best cartilage is harvested from the scaphoid cartilage  of the ear as it usually is thin and pliable enough to prevent  lid distortion.   Conjunctival coverage is provided by a turn-down flap  (Figure 37.18) from the opposite lid or a free palatal or    Figure 37.18 Conjunctival flap from upper eyelid to reconstruct the lower lid defect. (1) The conjunctival flap is seen lying over  the cornea. (2) The extent of dissection is high into the fornix. (3) The flap is sutured into the recipient bed of the reconstructed lower  lid which, in this case, is on the advanced cheek flap and secured with mattress sutures.    buccal mucosal graft. Both tissues must be secured with  direct and tie-over bolsters to immobilize the flap or graft  until healing has occurred. This is accomplished with fast-  absorbing direct sutures as shown in the figure, making  sure the knots are buried, or with full-thickness horizontal  mattress sutures with or without bolsters. Frost sutures are  placed to facilitate lid immobilization. The flap is divided  2-3 weeks later.   Lid defects, particularly with an element of sym-  blepharon, may also be reconstructed with a strip of  temporalis muscle and fascia with its attendant vascular  supply. Figure 37.19 demonstrates clinical application of  this flap. The flap is dissected on its anterior superficial  temporal vessels and then tunnelled over the zygomatic  arch to the orbital rim. The distal margin of temporalis  is introduced via a pull-out suture into a subcutaneous  pocket. The flap traverses the whole of the eyelid to its  medial extent. It is secured with multiple small bolsters.  Deep to the flap and superficial to the eyelid conjunctiva,  a free cartilage graft should be placed to restore lid sup-  port and competency. A temporary bulge of temporalis  muscle over the zygomatic arch will atrophy and flatten  with time. The superoposterior ‘pull’ of the temporalis  will naturally assist in tightening and lifting the newly  reconstructed eyelid.   Total lid defects are reconstructed with cheek rotational  flaps (Figure 37.20). A lateral canthotomy approach is  performed with extension to the hairline laterally and  then inferiorly in the pre-auricular region. The flap is  elevated above the musculoaponeurosis and carried as  far medial as necessary. A small back-cut at the infe-  rior limb will allow more superior rotation of the flap. A  chondral-perichondral graft is placed and sutured into  the defect with buried 5-0 chromic gut suture. A pull-out  light nylon suture may also be placed to assist in stabi-  lizing the cartilage graft. These flaps have a tendency to  migrate inferiorly after healing, resulting in some element  of cicatricial ectropion and dystopia. If the malar fat pad  is present, then superior ‘lifting’ of the pad with 2-0 clear  nylon or polydioxanone sutures pexed to the lateral rim  periosteum will help to resist inferior gravitational pull of  the cheek flap. Conjunctival reconstruction is undertaken  as previously described. Care must be exercised to avoid  sutures piercing the remnant of conjunctiva which will  result in abrasion and irritation. Tape dressing is placed  for 1 week and ophthalmic antibiotic ointment applied for  3 days.    Nasal skin is thick, sebaceous and relatively inelastic  which makes reconstruction with nasal tissue challeng-  ing. In nasal reconstruction, the surgeon should approach  the nasal subunits separately - the dorsum, tip and alar    Figure 37.19 (a) Clinical photo of a temporalis myofascial  sleeve for lower eyelid reconstruction. (b) Photo of temporalis  sleeve introduced laterally through an extended canthotomy  incision and placed in a subcutaneous pocket. Note the distal  pull-out sutures which assist in flap placement. (c) Photo of  reconstructed lower eyelid and post-operative Frost sutures to  immobilize and support the lower lid.    regions. Each has its own characteristics which define  repair. The nasal area has a blood supply from two sources;  a rich terminal network of the facial artery which spreads  onto the nose as angular and alar branches. These anasto-  mose superiorly on the dorsum with terminals of the oph-  thalmic artery - the medial palpebral and dorsal nasal.    Figure 37.20 (a) Large lid defect is reconstructed with  a cheek advancement flap as outlined. A free chondral-  perichondral graft harvested from the ear is placed and  secured to the conjunctival margins with buried 5-0 or 6-0  chromic suture. (b) Closure of cheek advancement flap. Eyelid  margins are closed with a running or subcutaneous 6-0 nylon  suture.    Usually flaps from the glabella and radix can be planned  based upon these latter two vessels.    Defects of the dorsum may be resurfaced with either a gla-  bellar flap (superior defects) or dorsal nasal flap (inferior  defects). The glabella flap (Figure 37.21) may be modified  to cover defects up to half of the upper dorsum of the nose.  The limiting factor in flap transposition is the pivotal area  where the nutrient supratrochlear vessel enters the flap.  Suturing is in two layers with buried 4-0 polyglactin suture  subcutaneously and 5-0 or 6-0 nylon for skin. The leading  edge of the flap is under the most tension; therefore, ver-  tical mattress sutures may be helpful in maintaining flap  position and viability.   The dorsal nasal flap is pedicled on the medial palpebral  vessel. As long as this artery is preserved, a large flap can  be raised off the upper dorsal surface and extended into    Figure 37.21 (aand b) Diagram of glabellar flap to cover a  small nasal dorsal defect. The pivotal area includes the nutrient  vessel (supratrochlear).    the glabellar region. The flap rotates around the pedicle  and so kinking of the vessel must be prevented. Also, a  dog ear remains at this pivotal region but should be cor-  rected secondarily.    The paramedian or midline forehead flap is used for resur-  facing large nasal dorsal and tip defects. This is a staged  procedure, the first stage for placing the flap and a second  stage 2-3 weeks later to divide the pedicle. The flap offers  a fair tissue match for the nose, particularly in thicker  skinned individuals.   Vascularity to the flap is via the supratrochlear vessels  (Figure 37.22), which allows the total vertical dimension of  the forehead to be incorporated in the flap. The contralateral  vessel is selected as the pivot point for the flap base to prevent  kinking of the vessels with subsequent failure and necrosis.   Two vertical limbs extending from the nasal root area  are inscribed, and these may taper to the hairline or run  parallel to be joined by a horizontal limb at the hairline.  Doppler flow can be used to confirm supratrochlear artery  location. Prior to the incision, the precise defect size and  shape should be traced as a template and transferred to the  donor site. Verification of flap length is confirmed with a  gauze strip extending from the pivotal base to the donor  site plus about 10% extra to allow for adequate tissue when    turning the flap inferiorly. The incision is carried down to  periosteum and a subgaleal dissection performed. Periodic  Doppler assessment will confirm vessel viability. If tissue  blanching disappears, this is usually due to vasospasm  which will resolve after several minutes.   The flap is trimmed to fit the recipient site and sutured  in place with polyglactin suture in the deep dermis and  fine suture for the skin. A drain or gauze wick may be  placed under the tissue bridge.   The donor site is closed (Figure 37.23) by first widely  undermining the forehead tissue with fine, vertical galeal  incisions to gain laxity. Next, heavy (2-0 or 3-0) sutures  are placed in the galea to gain tissue approximation.  Periodic vertical mattress sutures can be placed for skin  approximation in conjunction with a running suture.   The flap is divided 2-3 weeks later. Usually the flap  base can be discarded; however, if the brows have been  displaced too far medially, then return of the flap base in  the glabella region will correct it. Persistent lymphedema    Figure 37.22 Diagram illustrating pattern of vascular sup-  ply to the forehead region. The contralateral vessel is selected  as the nutrient pedicle to the flap.    Figure 37.23 Closure of defect and donor site. A gauze  wick should be placed under the bridge of tissue to maintain  hygiene until the undersurface sufficiently heals.    often accompanies these flaps for several months and  manual massage may be helpful in resolving edema of the  reconstructed nasal tip.    Nasal tip lesions usually require full-thickness skin  excision and if there is tumour extension to the deep  dermis, cartilage should also be included in the resec-  tion. Full-thickness skin defects of the nasal tip can  be resurfaced with local nasal flaps or nasolabial flaps.  Local flaps are optimal for tissue colour, texture and  thickness match.   Lobed flaps are popular for small nasal tip defects off the  midline. After excision, a decision must be made whether  a one- or two-lobed flap is required. Generally, the larger  the defect and the closer to the midline, the more lobes are  required (Figure 37.24). Lobes derived from the nasal side  wall do not transpose easily but those from the nasolabial  area are more mobile and therefore they can be narrower  as the donor sites are easily closed.   Tip defects just off the midline may result in some dis-  tortion when resurfaced from lobes nearby. The alar rim  is particularly affected; however, this usually settles with  time. The leading edge is under the most tension so a two-  layered closure with an occasional vertical mattress suture  is done.   Larger central tip defects are best restored with tissue  transposed from a more distant flap, such as the dorsal  nasal flap or forehead finger flap as previously discussed  (Figure 37.25). The nasolabial flap can also be used if thick-  ness and colour are similar. Persistent tip lymphedema  will be most pronounced and enduring, and ultimate  nasal tip form will not be attained until at least 1-year  post- operatively.    Figure 37.24 (aandb) Nasal alar or domal defects may be  restored with a transposed bilobed flap. These local flaps offer  good texture and colour matches. More lobes are created for  larger defects closer to the nasal midline.    Figure 37.25 Clinical photos demonstrating application of the forehead flap for reconstruction of a nasal tip defect. (a) The  flap is marked after confirmation of the supratrochlear vessel and the defect size and length of flap is verified. (b) The flap is sutured  into place with buried 4-0 or 5-0 resorbable sutures and 5-0 nylon sutures. A gauze wick dressing is placed under the tissue bridge.    Lesions of the nasal ala usually require excision that  includes cartilage or results in total rim resection.  Restoration of the alar contour requires enough tissue to  fold over, e.g. a nasolabial flap, or a free composite graft  from the ear.   Nasolabial flaps can be pedicled superiorly, rotated  medially and turned in on itself to restore rim contour  and bulk (Figure 37.26). The distal portion of the flap is at  risk for ischemia because kinking of the small vessels typi-  cally occurs at the fold area. Suturing should be enough to  hold the flap in place as there is little tension on the flap.  Division of the pedicle is then carried out in 2-3 weeks.   Alar rim defects up to 1.5 cm can be repaired with  auricular free grafts of cartilage or composite grafts of  skin and cartilage (Figure 37.27a). The outer helix pro-  vides an acceptable contour and bulk for restoration of the  rim. Since these are free grafts, it is important to stabilize  the graft in order to allow capillary ingrowth and tissue  survival. The size and depth of the defect dictates what  portion of the helix provides an appropriate match. The  outer helix is good for long but shallow defects where a  rigid span is required, however, the fleshier lower helix or  that portion next to the superior crus provides more bulk  and depth when required. The longer the graft the greater  the risk of necrosis.    Figure 37.26 (a and b) Alar rim defect is restored with a  local nasolabial flap. The flap may be turned over onto itself  to restore the rim margin with lined tissue. A through and  through tie-over bolster is then applied to provide form and  stability of the flap.    incorporated in the graft. These will insert into medial  and lateral pockets in the defect. Prior to graft placement,  soft tissue pockets are created in each defect margin where  the cartilage feet will be inserted and sutured to remnant  rim cartilage and tissue. One 3-0 nylon suture is placed  through each defect from out to in, piercing each ‘foot’  (Figure 37.27b). This is then brought back up through  the graft and nasal skin from the inside. Antibiotic gauze    Figure 37.27 (a) Composite skin-cartilage free graft from  the outer helix is demonstrated. Extended cartilaginous ‘feet’  are harvested to insert on either side of the defect and pro-  vide additional support and form to the rim. The donor site is  closed primarily. (b) Retention of the free graft is obtained with  through and through sutures to secure the graft. (c) Intra- and  extra-nasal bolsters are placed through the sutures to assist in  flap stabilization.    pledgets 3-4 mm in diameter are placed intra- and extra-  nasally through each nylon suture loop to serve as a bolster  for the graft (Figure 37.27c); 4-0 and 5-0 nylon is placed to  secure the remainder of the graft to its recipient site. The  graft typically appears dusky for the first 48 hours after  which vascular ingrowth will be evident. If hyperbaric  oxygen is available, this has served well in ‘resurrecting’  or enhancing the ‘take’ of large free composite grafts. The  bolster and sutures are removed after a week and the graft  stabilized with tape dressings for another week. Some  free grafts lose their pigmentation or do not have as much  vascularity as surrounding tissue so that they are readily  noticeable. Cosmetic tattooing can be done if the colour  match is not acceptable. Figure 37.28 demonstrates a com-  posite auricular graft to a post-ablative defect of the alar  rim and complete nasal stenosis.    Total nasal reconstructions are performed in several  stages. The first stage is providing adequate soft tissue cov-  erage, both extra-nasally through the forehead flap and  intra-nasally with local mucosal flaps. Free mucosal flaps  harvested from the buccal mucosa may be necessary to  provide a physiologic intra-nasal covering and prevent cic-  atrization of the raw flap undersurface. Intra-nasal stents  and bolsters are necessary to maintain nasal patency and  function.   Once adequate soft tissue is in place, cartilaginous  struts and framework harvested from the nasal septum,  conchal bowl, and crestal regions can be undertaken.  Overgrafting is usually necessary as cicatrization and  retraction generally ensue over the next several months  after graft placement.    Figure 37.28 (a) Clinical photos of a post-ablative defect of  the right ala with complete nasal stenosis. (b) Two-week post-  op after composite auricular graft placed. Note the regrowth of  skin and nasal aperture restoration.    Final stage reconstruction involves soft tissue adjust-  ments to the nasal base (dermabrasion or excision of scar),  tip (thinning thickened transplanted forehead skin) and  alar rim areas (selective thinning of cartilage or skin).  Great care should be exercised to avoid compromise of the  lining mucosa and nasal vestibular area.    Planning for scalp reconstruction must consider the size  and location of the defect, tissue reservoir, health of the  recipient defect and contiguous tissue and systemic or psy-  chological issues which may impact upon the proposed  treatment. The underlying connective tissue of the scalp  does not allow sufficient laxity for simple direct wound clo-  sure. Small defects (<2-3 cm?) can usually be closed with  local rotational or advancement flaps. Generally, the length  of a scalp flap should be four to six times the diameter of  the defect site if primary closure is planned. This amount of  scalp mobilization often mitigates against its use for large  defects. Defects that are greater than 3 cm? will require large  field rotational flaps or tissue expansion in order to mobilize  and move enough desirable tissue into the recipient site.    A variety of rotational flaps incorporating crescent-shaped  or ‘pinwheel’ designs can be utilized for small avulsion  defects. The temporal myofascial flap is a smaller but reli-  able flap for small- or medium-sized defects where calvarial  coverage is desirable prior to a free skin graft. These flaps are  based on the superficial temporal vessels which will allow  rotation forward to the orbit or posterior to the post-auricu-  lar region (Figure 37.29). The vessels should be mapped out  with a Doppler to confirm location and integrity.   Larger defects of the hair-bearing scalp are best covered  with similar tissue of texture and composition, therefore  tissue expansion is preferred. True scalp expansion can be  achieved through mechanical creep (skin expansion beyond  its natural laxity) and biologic creep (cellular response to  tension). Site preparation may involve serial wound debride-  ment, pressure-vacuum devices to encourage neovascular-  ization and granulation, and maturation of the recipient site  prior to reconstruction or tissue expansion (Figure 37.30).   Expander selection is based on the size and location of  the defect. Oval and rectangular expanders work well on  the frontal and forehead regions, whereas crescent-shaped  expanders work well on the parieto-temporal and occipital  regions. The size (volume) should be approximately 2-2.5    (a) Doppler confirmation of the superficial  temporal artery. (b) Temporalis myofascial flap for peri-orbital  reconstruction.    times the volume (surface area) of the defect. Typically,  200-250-mL crescent-shaped reservoirs (Figure 37.31) have  been the workhorse expanders in the author's practice.  The depot site is placed within the defect region of scalp  for similar texture and composition but not contiguous in  order to avoid defect expansion, dehiscence and exposure  of the reservoir. The incision for placement can be located    Serial photos of scalp defect preparation  after traumatic avulsion. (a) Avulsive injury with necrotic tis-  sue and exposed calvarium. (b) Pressure-vacuum device after  initial debridement. (c) Defect bed preparation with early cal-  varial granulation.    Tissue expansion. (a) Forehead-vertex recon-  struction with crescent-shaped expanders. (b) Mid-expansion  of scalp reservoir tissue.    at the margin of planned excision or in the advanced mar-  gin of scar where future excision and closure will take  place (Figure 37.32). However, care needs to be exercised in  order to avoid dehiscence of the incision once expansion  is underway; therefore allowing the tissue to settle (about  2 weeks) and permanent suture closure of the access site  are recommended before expansion is commenced.   Port placement can be either buried (acceptable for  adults) or externalized through a small stab incision for easy  and painless access to the diaphragm of the port (good for  children). Expansion is performed on the table to confirm  proper placement and orientation, removal of dead space,  and to begin initial expansion. Blanching of the overlying  tense skin should be observed, then resolve in a few minutes  after initial vasoconstriction. If not, then removal of some  saline is in order. Expansion then takes place about every  2 weeks with instillation of 20-30 mL of saline or until the  skin blanches. Confirmation of return of skin vascularity is  paramount after each expansion session and documented.    Photo demonstrating planned expander  placement for a central scalp defect and access incisions. (1)  Incisions at the defect margin where lateral tunnelling can be  made to each site. (2) Mid-site incision distant from the defect  for access to both sites.    Tissue expansion for temporal alopecia in  a 5-year old. (a) Pre-expansion. (b) Six-month post-expansion  with good temporal coverage of hair-bearing scalp.    Figure 37.34 Extrusion of the expander through compro-  mised skin and the access incision site which was placed too  close to the reservoir.    illustrates reconstruction of temporal alopecia in a 5-year  old who successfully underwent tissue expansion.   Complications include expander dehiscence either into  the access site or depot site (Figure 37.34) and infection,  which is uncommon. Dehiscence and exposure of the  reservoir will delay treatment unless expansion is near  the end at which time the expander can be removed and  reconstruction may proceed. Usually dehiscence of over-  lying skin suggests either overinflation, insufficient time  between expansion periods, poor overlying tissue and/or  patient systemic factors, e.g. smoking or diabetes.    Flap design in the facial region should consider the follow-  ing essentials:   e Minimal distortion of donor or recipient site landmarks  (e.g. brow, lid, lips, nasal ala) after reconstruction.   e Dissection of Tenon’s capsule and disinsertion of the  rectus muscle for intraconal lesions.   e Adequate length, laxity and support of flaps to avoid  post-operative cicatrization and lid incompetency in  conjunction with judicial use of cartilaginous grafts and    e Sufficient inner (conjunctival) lining to provide a physi-  ologic covering for the globe.    Nasal reconstruction of the dorsum and tip is optimally  accomplished through the following:    e Proper wound bed preparation to receive local flaps or  expanded tissue.   e Patient selection and preparation for tissue expansion  for compliance, emotional and psychological suitabil-  ity, and timing issues.    All properly selected and placed flaps will improve in  appearance with simple massage, skin support dressings  (silastic), and time - the patient must be informed of this  beforehand.    Baker, SR. Local Flaps in Facial Reconstruction, Third  Edition. Philadelphia, PA: Elsevier; 2013.   Hoffmann JF. Tissue expansion in the head and neck. Facial  Plast Surg Clin North Am. 2005; 13(2): 315-324.  Jackson IT. Local Flaps in Head and Neck Reconstruction,  Second Edition. St. Louis, MO: Quality Medical Pub.;   Jackson IT. Craniofacial tumors. In Georgiade N, Georgiade  G, Riefkohl R and Barwich W (eds.), Essentials in  Plastic, Maxillofacial and Reconstructive Surgery, Vol.  1. Baltimore, MD: Willams and Wilkins; 1992.   Pepper JP and Baker SR. Local Flaps: Cheek and lip recon-  struction. JAMA Facial Plast Surg. 2013; 15(5):  374-82.    The standard of care for most lip and oral cavity cancers  still remains today as primarily surgery. Although radia-  tion therapy may be equally effective in Tl and T2 can-  cers, it is reserved for the patients who are medically  unfit, refuse surgery or have unresectable disease. The  major guiding principle of surgery is excision of the entire  cancer with negative margins. Negative margins are usu-  ally regarded as 5 mm or more histologically normal tis-  sue around the squamous cell carcinoma. To achieve this,  surgeons usually makes their incision >1 cm around the  palpable defined margins of the cancer.    Any surgically resectable tumour of the lip or oral cavity  is an indication for a wide-local resection. The resection of  the lip and oral cavity may be combined with a neck dis-  section depending on the depth of invasion and the TNM  stage of the cancer. The need for adjuvant radiotherapy  and chemotherapy depends on specific criteria outlined  by the relevant national guidelines.    These operations are generally undertaken in the operat-  ing room under general anaesthesia administered through    a nasal endotracheal tube. The need for a tracheostomy is  dependent on the size and location of the cancer and the  planned method of reconstruction. Some surgeons per-  form a pan-endoscopy in patients who are smokers and  drinkers prior to commencement of the ablation of the  tumour.    Resection of the lip and repair can be divided into lesions  requiring one-third of the lip or less to be resected,  one-third to two-third of the lip to be resected and  those tumours needing more than two-thirds of the lip  resected.    In lesions involving less than one-third of the lip the nat-  ural elasticity of the lip will allow primary closure. For  small lesions, a shield-shaped incision gives the greatest  diameter at the vermilion border and avoids the flattening  of the lip often seen with simple ‘V’ excision (Figure 38.1).  Some surgeons prefer to use methylene blue as a tempo-  rary tattoo to assist with accurately repositioning the skin  vermilion interface during closure.    The lip is held tightly compressed between finger and  thumb by the assistant who also assists with everting the  lip. The initial incision through skin is made with a no. 15  scalpel blade; the excision is continued with either a scalpel  or a needle-tip electrocautery through the orbicularis oris.  The labial artery is encountered superiorly under the muco-  sal surface. The artery can be clipped, ligated or cauterized  and excision can be completed. Once the tumour is excised,  frozen sections can be taken at the vermilion margins.   The lip can then be closed using a combination of  chromic gut, vicryl and sutures. The skin vermilion  border is sutured first. The orbicularis oris muscle is  re-approximated with vicryl and then the mucosa and  skin is closed.   For a slightly larger lesion, a ‘W’ incision is planned  (Figure 38.2). Here a 3-5-mm margin is outlined with a  marking pen to provide an oncologically sound resection.  The resection is similar as outlined above and the “W’ inci-  sion is closed as a “Y’.    Actinic damage may affect the entire lip. For those patients  with actinic keratosis or multifocal dysplasia and superfi-  cially invasive carcinoma vermilionectomy is warranted.    Figure 38.1 Tumour is marked with a 5-mm margin and  the vermilion skin junction on each side temporarily tattooed  with two dots using methylene blue. This allows accurate  suture and alignment post-resection.    This procedure can be undertaken by two methods: CO,  laser or scalpel. The entire vermilion from the wet line to  the skin is marked out with a marking pen. If the surgeon  prefers to use the laser, it is calibrated and the mucosa is  ablated with two to three passes. Each pass is completed  in a different direction. If the preferred method is surgical,  once the site has been marked, the lower lip is stretched by  using skin hooks placed in the commissure. A no. 11 blade  is then used to transfix the width of the vermilion starting at  one corner. With a sawing motion, the blade is advanced to  the opposite commissure. This technique can be combined  with any of the lip resection outlined in Figure 38.3a and b.  The depth of tissue removed will depend on the depth of  the lesion and can reach up to 3 mm. The closure of the  vermilion when using the scalpel is by local advancement  of the mucosa. However, this causes thinning of the lip and  eversion of any beard bristles. In the case of the laser, the  area can be left to granulate. If more substance is needed  for the lip, a tongue flap can be used to add bulk. A bucket  handle, which is 5 mm thick, is created on the dorsum  of the tongue and advanced to the lip (Figure 38.4). The  dorsum of the tongue is closed primarily and the bucket  handle is sutured to the lip. This remains attached until it is    Figure 38.3 (a) The vermilion is excised in toto from wet  line to vermilion-skin margin using a blade (a needle-tipped  cautery may also be used). (b) Undermining the oral mucosa  with scissors to the depth of the sulcus to allow tension free  advancement to reconstruct the vermillion.    Figure 38.4 (a) Raising the bipediclled flap from the dor-  sal tongue. (b) The bipediclled flap is passed anteriorly like  a ‘bucket handle’ to be sutured to the vermillion defect. The  tongue is primarily closed.    surgically separated 2-3 weeks later. Facial artery musculo-  mucosal (FAMM) flap is also a good choice to reconstruct  the skin-vermillion area.    For these lesions, a ‘stepladder’ reconstruction gives the  best results (Figure 38.5). This method is well suited for  lesions in the lateral portion of the lip not involving the  commissure. In this flap design, each line of the incision  is of equal length. This line follows the submental crease.  This incision is carried out once the tumour has been  resected. It is carried through skin but leaving the mucosa  intact. The flap is then advanced to close the defect. Since  this incision is placed in the submental crease, the inci-  sions are well hidden once healed.   For those lesions involving the commissure of the lip,  McGregor variation of the fan flap is preferred (Figure 38.6).  The tumour is excised as a square as depicted in the image.  Two squares are designed as described in Figure 38.6, these  are full thickness flaps. This is then rotated into the defect  with the pivot point being the commissure. The remain-  ing defect is closed primarily. The vermilion is recreated  by local mucosa advancement.    For this type of defect, the best option is the Fries modi-  fication of the Barnard flap (Figure 38.7). The tumour is  removed as a rectangle. Local flaps, which are full thick-  ness, are advanced by incisions in the submental crease.    Figure 38.5 (a) Markings for flap, see text for explanation.  (b) The tumour has been excised and the flap raised full thick-  ness through skin and muscle. The mucosa can be left intact.  Excess skin is removed in shaded areas to prevent ‘dog ears’.  (c) Closure. (d) Unilateral flap for lateral lesion.    A Burrow’s triangle in the nasolabial crease can be excised  to prevent bunching of the tissue. The amount of the tissue  removed is determined by the bunching created when the  orbicularis oris is re-approximated. When creating these  incisions on the cheek, the mucosa remains intact and the    Figure 38.6 (a) Flaps drawn out, blood supply enters at  point X. (b) ia tumour excision, square B is rotated to  the defect and replaced in position by square C. (c) The loose  cheek tissue superior to square C closes the defect in the naso-  labial area.    tissue is undermined to allow for movement. The commis-  sural sphincter must be recreated to prevent drooling. This  flap works well in older patients with laxity of the skin.  However, if the skin is too tight not allowing for much  advancement, a free flap must be considered.    When planning the resection margins for floor of mouth  tumours, the elasticity of the tissue can be misleading. It  is best to mark out the margins when the area is relaxed    Figure 38.7 (a) Planned rectangular excision, with shaded  areas representing Burow’s triangles where skin will be excised  in the nasolabial and submental regions to allow flaps X  and Y to advance without ‘bunching and dog ears’. (b) Flaps  X and Y advanced to reconstruct the lip. Large ‘0’ prolene  non-resorbable suture is placed to suture upper lip and lower  lip orbicularis muscles together to reconstruct commissure  and prevent drooling. (c) Flaps sutured in layers.    Figure 38.8 Lingual incision of mucosa (point X) and then  of periosteum at site of arrow to allow mobilization of the floor  of mouth and visualization of a floor of mouth cancer close to  the lingual mandible.    to ensure adequate margins. Tumours encroaching on the  lingual aspect of the mandible can make resection difficult  as well as reconstruction. This is even more pronounced  in the dentate patient. In such cases, it is best to start at  the mandible, by incising the mucosa and stripping off  the periosteum from the mandible. This is a good way to  evaluate the mandible for erosion by the tumour abutting  the mandible. For these cases, the periosteum is a good  surgical margin (Figure 38.8).   Ifa neck dissection is not planned at the same time and  the tumour margins will involve the submandibular duct,  then sialodochoplasty of Wharton’s duct is necessary. The  duct is medial to the sublingual gland. The proximal end  of the duct is tagged with a 6-0 nylon suture so that it will  not retract into the soft tissue. The tumour is then resected  and oriented for the pathologist.   At this point, the duct needs to be re-positioned poste-  riorly. An opening into the mucosa of the floor of mouth  about 1 cm behind the resection margin is made. The  tagged duct is then passed through the opening. The orifice  of the duct is ‘fishtailed’. This is then sutured to the mucosa  with 6-0 nylon sutures (Figure 38.9). The patency of the  duct is tested. This is important so that an obstruction is  not missed. In a context of a malignancy, an obstructive  sialadenitis can be confusing and mistaken for a malig-  nant node.    Most tumours of the palate are salivary gland in origin and  most of the time they are low grade. They usually do not  involve the palatal bone. They occur mostly at the junction of  the hard and soft palate. The resection margins usually involve    the greater palatine foramen and the greater palatine artery.  In these cases, resection of the periosteum and visual inspec-  tion of the bone for erosion is appropriate (Figure 38.10).  Similar to the other resections described in this chapter,  a l-cm margin is outline. Typically, this will involve the  greater palatine foramen. This area is then outlined with  the needle-point diathermy. First, the medial aspect is  incised to bone. This is followed by the next incision which  is adjacent to the alveolus. The anterior margin is then  incised to bone. At this time, a periosteal elevator can be  used to elevate the tumour off the palatal bone. Hopefully  the greater palatine vessels are still intact and then can be  clipped with hemo-liga clips or ligated. If this is not the    case, then the foramen can be cauterized to control for  bleeding. The specimen is then dissected posteriorly to the  soft palate. Here is it elevated off the palatal muscles. The  specimen is oriented before being sent to the pathologist.  The defect can be closed with a buccal fat pad, a healing  stent is also a good option, and local flaps may also be used.    Tongue cancer is the most common oral cancer and tends  to behave aggressively. Deep muscle invasion is seen early.  Here wide resection margins of 1.0-1.5 cm are accept-  able as well as adequate depth of resection. Tumours of  the anterior two-thirds of the tongue are respectable via  an intra-oral approach. More posteriorly located tumours  may require a lip split mandibulotomy, pull-through or  transoral robotic surgery (TORS). The surgical resection  margins are outlined with a marking pen followed by  needle-point electrocautery. The excision of the tumour is  then carried out using a combination of blunt and sharp  dissection. It is important to always point the needle tip  or scalpel blade away from the tumour while excising the  tumour. By angling the needle tip away from the tumour,  it allows for safe and deep resection margins by account-  ing for tendency for the muscle to stretch during retrac-  tion and spreading (Figure 38.11).   Most small tongue cancers can be closed primarily. The  key point to closure of the tongue is to maintain adequate  length for speech. The deep muscles are closed in layers  with everting mattress sutures on the mucosa. Wound  dehiscence is common with glossectomy due to muscle  pull. There are other options for closure of tongues. These  will take into consideration the size of the defect and the  ability of the tongue to have adequate mobility to allow    Figure 38.11 (a) Correct and (b) incorrect angulation for  tumour excision.    for speech and swallow. Skin grafts, radial/ulnar forearms  flaps, submental island flaps, supra-clavicular flaps are all  viable options for tongue reconstruction.    In considering the reconstructive options for small oral  defects, most sites are satisfactorily dealt with by pri-  mary closure, skin grafting or local flaps. In larger cases  where microvascular free flaps are not being utilized but  imported tissue is required, there are a number of use-  ful local pedicle flaps available to the surgeon e.g. buccal  fat pad (Figure 38.12). This section reviews of submental  island and FAMM flaps.    The submental island flap is based on the submental  branches of the facial artery and the anterior facial vein. It  is an excellent donor site with low morbidity and provides  thin pliable skin for reconstruction the lower two-thirds of  the face. Caution is advised when using this flap for recon-  struction of defects acquired after resection of malignant  tumours. For tumours which drain into the submental tri-  angle, a neck dissection is warranted.   Inan elderly patient, with laxity of the skin, a sizeable skin  paddle can be harvested. A skin paddle as large as 15 cm X  7 cm is available. The pinch test is to determine the ease of  closure. The skin paddle is outlined starting with the supe-  rior incision ‘a which is made approximately 1-1.5 cm below  the chin (Figure 38.13a and b). This incision is carried to  the angle of the mandible approximately two-finger widths  from the inferior border. This incision can be incorporated  into a neck dissection. The incision is carried down to the  sub-platysmal plane and care taken to preserve the marginal  mandibular nerve. The inferior incision ‘b’ is determined by  the pinch test and the amount of tissue need to be harvested.    Figure 38.12 (a) Mucoperiosteal flap reflected and hori-  zontal incision opposite the maxillary second molar allows  access to the buccal fat pad. (b) Using a clamp or scissors to  spread the tissues around the fascia of the buccal fat pad flap  allows the pad to be mobilized or prolapsed into the mouth  to reconstruct palatal/maxillary defects.    The flap is harvested by identifying the facial artery  and vein, as they are posterior and medial to the sub-  mandibular gland. The submental vessels are identified  running horizontally and superficial to the mylohyoid  muscle and close to the inferior border of the mandible.  Perforators to the skin can sometime pass through the  anterior belly of the digastric muscle. Since 70% of the  time, this occurs the anterior belly of the digastric mus-  cle is harvested with the flap. The flap can be rotated into  the oral cavity. The arc of rotation can be improved by    Figure 38.13 (a) Skin flap marked in submental region (see  text for details). (b) Usual anatomical distribution of submental  vessels.    dissecting the proximal portion of the facial artery and  vein (Figure 38.14a through c).    This flap is based on the facial artery which crosses the  cheek from the gonial notch of the mandible anterior  to the masseter muscle to the alar nasi. It is lateral to  the buccinator muscle. Although mostly the vein runs    Figure 38.14 (a) Patient with desmoplastic melanoma of  the parotid for sentinel node biopsy + selective neck, paroti-  dectomy with skin resection and submental flap marked out.  (b) Island flap based on submental vessels. (c) Flap inset to  show good arc of rotation for lower face.    with the artery, this is not always the case. Above the  inferior border of the mandible, the vein diverges from  the artery and lies up to 15 mm posterior to the artery.  The drainage of the flap is not dependent of the vein  since it is not always incorporated into the flap. This is  accomplished by the buccal plexus of veins. The flap can  be superiorly based or inferiorly based depending on  the site to be reconstructed. This musculomucosal flap  can be used to reconstruct the palate, retro molar fossa,  alveolus and lip.   The Doppler is used to outline the course of the facial  artery. The flap is elevated by carrying the incision to the  buccinator muscle at the level of the artery where the  facial artery is ligated. This 1-2 cm wide tissue can be  raised making sure that the facial artery is included with  the flap. It can then be rotated to close the required defect  (Figure 38.15).    Figure 38.15 Section through cheek in premolar region  to illustrate anatomy of facial artery musculomucosal (FAMM)  flap. Dotted line is deep margin lateral to buccinator and facial  artery. The two small arrows show full thickness incision supe-  riorly with ligation of the facial artery. The inferior incision is  through mucosa and muscle only preserving the vessels and  developing a mucosal island flap. The flap is mobilized into the  neck and transposed to the floor of mouth/tongue via a tunnel  created by sectioning the mylohyoid muscle from the lingual  mandible.    In the immediate post-operative care, the airway needs  to be assessed. If considerable swelling is anticipated, the  endotracheal tube can remain in place or a tracheostomy  should be considered. All flaps, pedicled or free should be  monitored for congestion or ischemia. If the airway is not  compromised, depending on the reconstruction, feeding  option needs to be considered. Sometimes the authors  prefer to place nasogastric feeding tubes. There are no  occlusive dressings placed on the neck, the authors pre-  fer neomycin ointment at the suture lines. The patient is  encouraged to rinse their mouth with chlorhexidine oral  rinses after meals.    The most common complication is bleeding. This can be  avoided by adequately drying the field prior to inset of  the flap. Also, blood pressure control is necessary in the  immediate post-operative phase. In the cases of glossec-  tomy, wound dehiscence is common. When this occurs,  it is best to keep the wound clean and allow the area to  granulate. If the patient encounters scarring and tethering  of the tongue, this can be addressed after several months  of healing.    e Take time to approximate the skin vermilion border.  A small malalignment is very noticeable.   e Useanon-resorbable suture or vicryl to re-approximate  the orbicularis oris in lip reconstruction.   e If bleeding is persistent through the greater palatine  foramen and electro cautery does not work, consider  bone wax.    e When closing tongue defects, take into consideration  the distance from the floor of mouth and the amount  of tethering anticipated. In some cases, a flap will give   The deep margin is the most worrisome in tongue  cancers. A recurrence there is difficult to identify and  has poor outcomes.    Dupoirieux L. Anatomical basis and results of the facial  artery musculomucosal flap for intra oral reconstruc-  tion. British J Oral Maxillofac Surg. 1999; 37: 25-28.   Faltous AA and Yetman RJ. The submental artery flap: An  anatomic study. Plastic Reconstruc Surg. 1996; 97: 56-62.   Johanson B, Aspelund E, Breine U and Holmsrom H.  Surgical treatment of non-traumatic lower lip  lesions with special reference to the step technique.  Scandanavian J Plast Reconstruc Surg. 1974; 8:  232-240.   Langdon JD and Ord RA. The surgical management of lip  cancer. J Cranio-maxillofac Surg. 1987; 15: 281-287.   Martin AD, Pascal JE, Baudet J, Mondie JM, Farhat JB, Athoum  A et al. The submental island flap: A new donor site.  Anatomy and clinical applications as a free or pedicled  flap. Plastic Reconstruc Surg. 1993; 92: 867-873.   Pribaz J. A new intra-oral flap: FAMM facial artery mus-  culomucosal fla. Plastic Reconstruc Surg. 1992; 90;  421-429.   Pribaz JJ. Lip and vermilion reconstruction with the facial  artery musculomucosal flap. Plastic Reconstru Surg.  2000; 105: 864-872.   Van der Wal JE, de Visscher JG, Baart JA and Van der Wal  I. Oncologic aspects of the vermilionectomy in the  microinvasion squamous cell carcinoma of the lower  lip. Int J Oral Maxillofac Surg. 1996; 25: 446-448.    This chapter concentrates on the resection of squamous  cell carcinoma arising in the oral cavity or the midface.  A similar approach is required for the resection of bone  invaded by malignant salivary tumours but the points on  the patterns of tumour invasion and entry may be dif-  ferent. The principles of the resection techniques may be  appropriate to the management of odontogenic tumours  especially if these are recurrent. Resection of the jaws for  osteoradionecrosis or osteonecrosis is more of a debride-  ment requiring the resection of bone back to a bleeding  base prior to reconstruction. Bone resection for osteosar-  coma or primary intraosseous carcinoma requires a more  radical removal of bone as the tumour will invade the  bone preferentially.    The mandible provides a bony framework to hold the teeth  and sensation to the lip and chin is provided by the inferior  alveolar nerve which enters at the mandibular foramen  and exits at the mental foramen. Although there are often  attempts to preserve this nerve in the treatment of benign  disease, the loss of sensation to the lip and chin is an  acceptable morbidity for most patients. The relationship of    the teeth to the bone varies with patients and the molars  run from a buccal position to a more lingual position pos-  teriorly. The temporomandibular joint articulates with  the skull base and in some cases the condylar head may  require resection. The loss of teeth results in the loss of  the supporting alveolar bone. The inferior alveolar nerve  will come to lie on the alveolar ridge and the relationship  of the floor of mouth muscle insertions will alter with the  loss of bone (Figure 39.1 and 39.2).    The maxilla is a complex structure which provides bone  for the upper dental arch supports the alar base and facial  curtain as well as providing the orbital floor, malar but-  tress and lateral nasal wall. The articulation with the rest  of the skeleton is important to understand in tumour  resection.   Medially, the lateral nasal wall is the least important  structure, but care is required in maintaining the lacrimal  system. The frontal process of the maxilla and the nasal  bones articulate with the frontal bone and immediately  behind these structures is the ethmoid sinus and then  the sphenoid sinus. The cranium lies directly above these  bones and experience in skull base resections is required  to safely resect these structures. The lamina papyracea of  the medial wall often requires resection and care must be  taken to identify the anterior ethmoidal artery in particu-  lar. The maxilla provides much of the orbital floor as far as  the inferior orbital fissure, and more laterally the lateral  wall is made up of the greater wing of the sphenoid and  the malar.    Figure 39.1 A rim or marginal resection maintains the  lower border and a segmental resection requires the full thick-  ness of the mandible to be resected.    Figure 39.2 The commonest form of rim resection is coro-  nal. This figure illustrates the method used to enter the floor of  the mouth deep to the tumour to obtain a clear margin even  though the bone is not invaded.    Early or shallow invasion of the mandible from the oral  cavity will often show an erosive pattern with a pushing  front and a connective tissue layer separating the bone  from the tumour. The more infiltrative pattern is related to  deeper invasion in which the connective tissue layer is lost  and separate islands of tumour infiltrate in a less favour-  able manner.’ It is not possible to predict the pattern of  invasion so the judgment on how much bone to resect  remains clinical and based on imaging. Various theories  of the route of tumour entry to the mandible have been  suggested but it seems most likely that the tumour enters    Table 39.1 Summary and comparison of the imaging  techniques and clinical examination.    the mandible at the point of contact. In the dentate man-  dible, this tends to be at the junction of the attached and  reflected mucosa and in the edentulous mandible, this is  more likely at the crest of the ridge due to the lowering of  the floor of the mouth due to the loss of teeth.** These are  important issues if a marginal or more conservative resec-  tion of the mandible is being considered.    There are multiple papers looking at the accuracy of pre-  operative imaging techniques and their accuracy in pre-  dicting the presence of tumour invasion of the mandible.  A recent review article has summarized the findings which  are included in Table 39.1.°   A widely accepted standard is to use a magnetic reso-  nance imaging scan (MRI) as a standard image of the  primary tumour and the neck nodes. This will usually pro-  vide 5-mm slices and will include T1, T2 and fat suppres-  sion sequences as well as gadolinium enhancement. The  fat suppression sequence is the most sensitive in indicat-  ing tumour invasion of the mandible. The only additional  image would be an orthopantomogram (OPG) if there is  clear invasion of the mandible or in which the mandible is  unlikely to be invaded. For tumours in which it is unclear  if the mandible is invaded a single photon emission com-  puterized tomography (SPECT) scan is included to get a  further sensitive imaging of the mandible. The combina-  tion of an image with a high specificity with one with a  high sensitivity can provide a reasonably accurate predic-  tion of the extent of mandibular invasion and therefore  the most appropriate method of resection. Cawood and  Howell published a widely accepted classification of the  mandible following the loss of teeth and it is clear that in  Class V and VI mandibles (Figure 39.2) there is insufhi-  cient height of bone to safely perform a marginal resection  for malignant disease. As a result, a guide to mandibular  resection has been published which relates to the size of  the mandible and the results of the investigations predict-  ing bone invasion (Table 39.2).    OPG-, MRI-, BS-  No invasion/periosteal OPG- MRI or BS+ OPG+, MRI+, BS+   Mandible classification invasion early invasion (<5 mm) late invasion (>5 mm)  1-2 (dentate) Rim Rim Rim/segment  3-4 (>20 mm mandibular Rim Rim/segment Segment    In the past, the ‘commando’ operation in which the  body of the mandible was sacrificed to remove potential  lymphatics containing tumour and to facilitate the soft  tissue reconstruction has now been discontinued and  yet there are series published in which only 29% of the  resected mandibles were invaded by tumour.® As in all  oncological surgery, the aim is to cure the patient of dis-  ease through adequate resection. At the same time, the  skilled surgeon should be trying to reduce the morbidity  of the operation to a minimum and maintain the best  possible function. Good functional results for patients  depend more on the tissue left behind than the method  of reconstruction.   There are two basic methods of mandibular resec-  tion. In the marginal or rim resection, the integrity of  the lower or upper border of the mandible is kept intact  (Figures 39.1 and 39.2). In the full or segmental resec-  tion of the mandible, both the upper and lower border  are included in the resection so that there is a loss of  continuity of the mandible. There is clear evidence to  show that functional and aesthetic results are poor if the  continuity of the mandible is not restored.’ The need to  reconstruct the mandible to achieve the best functional  and aesthetic result will often involve composite-free  tissue transfers for malignant disease which will add  to the donor site morbidity and increase the risk of flap  failure.®?    A marginal resection of the mandible can be performed in  the coronal or the sagittal plane. In the majority of cases,  a coronal marginal resection is used (Figure 39.2). This is  the standard method for tumours in which a margin of  normal bone is required. It can be used for smaller odon-  togenic tumours in which there is sufficient residual bone  to maintain the lower border. A sagittal marginal resec-  tion cannot be used for bone pathology as preserving any  kind of margin is not possible. It has been used for floor of  mouth squamous cell carcinomas to obtain a clear mar-  gin when tumour is abutting the mandible but not obvi-  ously invading. This is a high-risk strategy as any invasion    Figure 39.3 This is a partial sagittal rim resection but this  diagram illustrates the angle of the body of the mandible from  medial to lateral if the full sagittal rim is required.    through the cortex will be reported as an involved margin.  In addition, the angle of the mandible in the body region is  difficult to judge (Figure 39.3). In this situation, it is a safer  oncological approach to perform a segmental resection of  the mandible. Rim resections that involve the ramus of  the mandible can only be done in the coronal plane as the  ramus is too thin to split for oncological reasons, and it  is best to include the coronoid process as this may reduce  trismus post-operatively.   If the lower border of the mandible is to be preserved  then 10 mm of the depth of bone will be necessary for jaw  continuity to be reliably maintained.   For marginal resections involving malignant disease  (all osteosarcomas and primary intraosseous carcinomas  require segments), it is possible to assess the extent of  tumour invasion into the mandible from the surround-  ing soft tissues and estimate the extent of the resection  required. This technique is illustrated through Figure  39.4. Note that periosteal stripping to assess the pres-  ence of mandibular invasion and its extent has been  used. The use of periosteal striping is an essential part of  the technique in the decision-making process for man-  dibular resection. It has been shown to be a reliable tech-  nique? and in a large series from the unit in Liverpool our  involved bone margin rate is very low compared to the  soft tissue margin rate."    (a)-(d) Pre-operative clinical photograph, OPG, SPECT scan and MRI scan showing early tumour invasion of the  mandible. (e) The resection of the buccal side of the mandible. (f) Completion of the planned coronal rim resection. (g) Turning the  bone over to inspect the lingual side of the rim resection and ensure clearance of invaded mandible. (h) The resulting defect post  resection. (Continued)    Figure 39.4 (Continued) (i) The specimen with lingual  periosteal stripping to confirm clearance of resection. (j) and  (k) Post-operative OPG and clinical photograph of anterolat-  eral thigh flap reconstruction.    This is a basic procedure in the management of malignant  disease once the decision has been made not to preserve  any part of the involved mandible. The decision as to  where the bone cuts are made will depend on the assess-  ment of mandibular invasion and the entry and exit points  of the inferior alveolar nerve. In benign disease, it is often  possible to keep the nerve intact and allow it to lie in the  soft tissues overlying the reconstructed bone.   Periosteal stripping is also an important factor in  the segmental resection of the mandible in malignant    Figure 39.5 (aand b) Periosteal stripping postresection to  ensure that the buccal and lingual surfaces are clear of tumour  in the distal part of the resection in the region of the lower  right canine.    disease. Periosteum can be striped back from the undam-  aged bone until it becomes adherent, or the tumour is  seen entering the bone. Once this is established, the mar-  gin can be decided and the bone cuts planned. It is also  important to examine the specimen to ensure that the  bone margins are clear of disease by direct inspection  (Figure 39.5). This is much less reliable in a malignant  tumour arising in bone such as a primary intraosseous  carcinoma or an osteosarcoma. In these cases, the peri-  osteum and the cortex of the bone may look clear of inva-  sion as the tumour spreads along the marrow space. As  a result, it is necessary to be much more aggressive in  mandibular resection and frozen sections should be per-  formed if possible.   It may be necessary to excise the overlying skin in  mandibular resection. In most cases, it is possible to  preserve the skin cover but care must be taken in the  buccal aspect of the resection to take sufficient tissue.  It is seldom necessary to use an access procedure with  segmental mandibular resection. The overlying skin is  raised or excised depending on the needs of the onco-  logical ablation and once the bone cuts have been made  the mandible can be delivered into the neck and any  further resection lingual to the jaw can be undertaken  as the last part of the resection prior to the delivery of  the specimen (Figure 39.6).    Figure 39.6 (a-b) There is no need for access surgery such  as a lip split in segmental surgery as the tumour can be deliv-  ered into the neck to complete the resection.    There are various methods used to maintain the occlu-  sion prior to mandibular reconstruction. Some surgeons  will use a form of external fixation of the nonresected  part of the mandible but this is very cumbersome and  the device impedes accurate oncological resection.  Templates have been devised using stereolithographic  models but again these are often impractical in surgery  for malignant disease. The simplest technique is to pre-  bend a plate if the tumour does not involve the buccal  aspect of the mandible. In this way, the harvested bone  can be grafted into position with the plate already in  place. I usually move the plate back by a screw-hole in  the edentulous situation to take the pressure off the soft  tissues and reduce the risk of dehiscence. If the use of a  pre-bent plate is not possible then the condylar position  can be fixed with a miniplate from the part of the ramus  that does not require resection to the maxilla prior to  the resection with the mandible in occlusion. Once the  mandible has been resected, the position of the ipsilat-  eral condyle remains fixed and the collateral mandible  can be located with the residual occlusion. A plate can  then be bent into position prior to the placement of the  graft. This can be carried out bilaterally for extensive    mandibular resections. The length of the plate may need  to be estimated but at least the condyles will be in the  correct position relative to each other.    In most cases of squamous cell carcinoma, it is possible  to maintain the condyle and the condylar neck sufh-  ciently to maintain a plate so that this important part of  the joint is left in function. The need to resect the con-  dyle makes the subsequent reconstruction more difficult  as the condyle cannot be fixed and it is not possible to  prebend a plate. The resection of the condyle with the  ramus and body of the mandible is relatively straight  forward but care must be taken to protect or tie-off the  maxillary artery and avoid damage to the facial nerve.  The facial nerve can be damaged by inappropriate retrac-  tion in this region. It is often necessary to use some form  of intermaxillary fixation if the patient is dentate to help  the patient maintain a functioning occlusion in the post-  operative period.    There is much less controversy over the more conserva-  tive approach to maxillary resection than the mandible.  It is possible to preserve the bone of the maxilla with a  limited resection of the palatal or alveolar mucosa and  place a dressing plate and await the pathology report.  If there is an involved or close margin then bone can  be resected at a second procedure. This process is also  possible in more extensive resections of the maxilla in  which an obturator can be placed and again the margins  checked and more tissue taken at the time of the obtura-  tor change.   There is little discussion on the role of pathology  either in terms of the pattern of spread in the bone or  the pathway of entry. Most accept that the route of entry  in the maxilla is at the point of contact and thus the  maxillary resection is guided by the extent of the soft  tissue mass.   For the assessment of bone invasion in the maxilla,  most prefer a computed tomography (CT) scan. In our  practice, both MRI and CT scans are used to fully assess  the tumour when there is concern over the involvement  of the orbit, skull base or the infratemporal or ptery-  goid fossa. The CT scan is probably best for the skull  base, and the MRI to assess the infratemporal fossa and  both contribute equally to the invasion of the orbital  contents.   The methods of resection are based on the classification  illustrated in Figure 39.7.7    Figure 39.7 Classification of the maxillectomy defect." The need for reconstructive options increases from Class 1 to 4.    For Class I defects (Figure 39.1), there is no need to  use an access procedure, as the tumour can usually  be visualized with ease. This classification includes a  medial maxillectomy often used for inverted papillomas  but resection for this pathology is not included in this  chapter (Figure 39.8).   In this situation, the orbital floor is not involved with  the resection and if the lesion is below the level of the  infraorbital nerve then no access procedure may be  required. Either a lip-split combined with a lateral rhi-  notomy or a midfacial degloving procedure may be used  for access with equal effect.!*4 There are four osteoto-  mies required to deliver the low-level maxilla in ablative  surgery:    1. Vertical alveolar (Figure 39.9a): In the dentate maxilla,  it is best to remove a tooth in the line of the osteotomy  which is continued to the floor of the nose. Maintaining  bone adjacent to the remaining tooth helps the stability  of the adjacent tooth to the bone cut for obturated cases.  Ensure there is sufficient soft tissue to cover the exposed  bone.   2. Le Fort 1 level: A further osteotomy is required at the  required height which may include the infraorbital  nerve if required. This is carried through to the ptery-  goid plates.   3. Pterygoid plates: If the tumour is contained in the  antrum, the pterygoid plates can be split from the max-  illa with a chisel. If the tumour is through the antrum  posteriorly it is essential to make a bone cut through the  pterygoid plates superior to the position of the tumour  and then resect the through the pterygoid muscles to  obtain a margin of resection.   4. Palatal: The alveolar osteotomy is continued into the  palate. If possible, the soft tissue incision should allow  some of the redundant mucoperiosteum to cover  the bone cut especially if obturation is the method of  rehabilitation.    Figure 39.8 An example of a Class 1 type of resection  without causing an oroantral fistula. Healing by secondary  intention with the use of a dressing plate may be all that is  required.    Once these osteotomies have been carried out the hemi-  maxilla can be mobilized and any soft tissue attachments  released.    Class III (high-level maxillectomy maintaining the orbit)  The midfacial degloving technique reaches its limit if the  orbital floor requires resection or there is extension into  the medial orbital region of the ethmoids. In this situa-  tion, the lip split and lateral rhinotomy may be sufficient  or it may be necessary to extend the incision as a blepharo-  plasty incision or sub-ciliary incision (Weber-Fergusson).  In most situations, it is possible to reach the lateral orbital  wall and malar without this extension reducing the risk of  ectropion.   This is the most complex resection because of the need  to preserve the orbit and the lacrimal apparatus. A guide  to the osteotomies is as follows (Figure 39.10):    Figure 39.9 (a) The vertical, Le fort 1 level and pterygoid  plate resection is shown. (b) This shows the palatal bone cut. It  is usually best to remain on one side or other of the nasal sep-  tum depending on the extent of resection required. It is also  important to ensure there is sufficient redundant mucoperios-  teum to cover the bone cuts for obturated cases.    Figure 39.10 Class Ill. This shows the higher bone cuts  required if the orbital floor and/or medial orbital wall require  resection.    1. Vertical alveolar and nasal: The previously described ver-  tical alveolar bone cut is extended to include the nasal piri-  form fossa and extended to the level of the lacrimal crest.    Care must be taken to expose the lacrimal sac and to pre-  serve this structure.   2. Orbital: In this situation, the orbital floor is included as  far as the inferior orbital fissure. This horizontal bone  cut can be extended to the lateral orbital wall or the  frontal process of the malar bone as required.   3. Malar: The orbital bone cut is linked to the malar but-  tress cut which is made lateral to the position of the  tumour.   4. Pterygoid plates: This often requires the plates to be  sectioned higher than in the low maxillectomy close  to the skull base. A chisel can be used to fracture off  the pterygoid plates with a tumour contained within  the antrum.    In these more extensive tumours, this part of the max-  illectomy can be delivered intact. In most situations,  there will be extension into the ethmoid sinuses or supe-  rior to the lacrimal sac which will make delivery of the en  bloc specimen more difficult. It is still essential to attempt  to deliver the main part of the maxillectomy intact and  carry out further resection of the medial orbital wall and  ethmoid and sphenoid sinuses as required. If it has not  been possible to maintain the lacrimal system, the punc-  tum is stented with a silastic tube and delivered into the  nose and tied off. The silastic tube can be cut between  the upper and lower punctum at about 3 weeks. It may  be possible to repair parts of the lacrimal sac and duct  at the time of the resection but the placement of silastic  tubes is still important to guide the tear flow as healing  takes place.    If the orbit requires resection with the maxilla then the  approach includes the upper and lower lids if there is no  attempt to reconstruct the defect with a prosthetic eye.  This operation is much easier to perform as no orbital  structures need to be preserved.   In this operation, it is better to release the optic nerve  after exenterating the superior part of the orbit after the  access procedure.   The same vertical bone cuts are made in the alveolus and  nasal bones but no special attention is required regarding  the medial canthal ligament and the lacrimal apparatus.  The lateral bone cut is made from the inferior oblique fis-  sure to the malar buttress prior to the release of the pter-  ygoid plates. The palatal bone cuts link with the vertical  alveolar and nasal cuts and at this stage the specimen can  be mobilized. The soft tissue resection at the base of the  orbit is completed and now it should be possible to deliver  the specimen. Tumour extending into the skull base, the  ethmoids and sphenoid sinuses require removal after the  delivery of the main specimen.   Tumours involving the skull base require a multidis-  ciplinary team approach. In this situation, a coronal flap,  craniotomy and frontal bar osteotomy may be required to  obtain adequate access to the anterior skull base.   e Pre-operative imaging should include a sensitive (bone  scan, MRI) and specific (OPG) technique.   e Pre-operative imaging, clinical examination and the  use of perioperative periosteal stripping all help to  decide the type and extent of resection.   e Remember that the tumour will invade the mandible  at the point of contact which may be below the dental  line or the crest of the ridge.   e Early invasion is more likely to be the erosive pattern  and late invasion infiltrative, requiring a wider margin.   e The option of a rim resection decreases with the extent  of mandibular resorption following the loss of teeth  (Class V and VI).   e Pre-operative imaging will include an OPG and a CT  scan and often an additional MRI will be useful to assess  the skull base.   e The main issues in maxillary resection involve the  removal of the orbit and the extent of the disease into  the infratemporal fossa.   e Using a saw to resect the pterygoid plates above the  tumour will ensure a safer resection at the posterior  maxilla.   e Close cooperation with the restorative dentist is essen-  tial in the planning of maxillary resection.    1. Slootweg PJ and Muller H. Mandibular invasion by  oral squamous cell carcinoma. J Cranio-Maxillo-  Facial Surg. 1989; 17(2): 69-74.   2. Brown JS, Lowe D, Kalavrezos N, D’souza J, Magennis  P and Woolgar J. Patterns of invasion and routes of  tumor entry into the mandible by oral squamous cell  carcinoma. Head Neck. 2002; 24(4): 370-383.   3. Brown JS, Griffith JF, Phelps PD and Browne RM. A  comparison of different imaging modalities and direct  inspection after periosteal stripping in predicting the  invasion of the mandible by oral squamous cell carci-  noma. Br J Oral Maxillofac Surg. 1994; 32(6): 347-359.   4. McGregor AD and MacDonald DG. Routes of entry  of squamous cell carcinoma to the mandible. Head  Neck Surg. 1988; 10(5): 294-301.    the mandible in the management of oral squamous  cell carcinoma: A review. Br J Oral Maxillofac Surg.  2001; 39(6): 411-418.    P and Woolgar JA. Factors that influence the method  of mandibular resection in the management of oral  squamous cell carcinoma. Br J Oral Maxillofac Surg.  2002; 40(4): 275-284.    Sheiner A, Parker R et al. Functional evaluation fol-  lowing microvascular oromandibular reconstruc-  tion of the oral cancer patient: A comparative study  of reconstructed and nonreconstructed patients.  Laryngoscope. 1991; 101(9): 935-950.    Evans GR, Robb GL et al. Choice of flap and inci-  dence of free flap success. Plast Reconstr Surg. 1996;  98(3): 459-463.    R, Vaughan ED et al. Trends in head and neck micro-  vascular reconstructive surgery in Liverpool (1992-  2001). Br J Oral Maxillofac Surg. 2006; 44(5): 364-370.  Shaw RJ, Brown JS, Woolgar JA, Lowe D, Rogers SN,  Vaughan ED et al. The influence of the pattern of man-  dibular invasion on recurrence and survival in oral squa-  mous cell carcinoma. Head Neck. 2004; 26(10): 861-869.  Marchetti C, Bianchi A, Mazzoni S, Cipriani R and  Campobassi A. Oromandibular recosntruction  using a fibula osteocutaneous free flap: Four differ-  ent preplating methods. Plast Recosntr Surg. 2006;  118(3): 643-651.   Brown JS, Rogers SN, McNally DN and Boyle M. A  modified classification for the maxillectomy defect.  Head Neck. 2000; 22(1): 17-26.   Casson PR, Bonanno PC, Converse JM, Casson PR and  Bonanno PC, Converse JM. The midface degloving  procedure. Plastic Reconstr Surg. 1974; 53(1): 102-103.  Price JC, Holliday MJ, Johns ME, Kennedy DW,  Richtsmeier WJ, Mattox DE et al. The versatile midface  degloving approach. Laryngoscope. 1988; 98(3): 291-295.    Orbital tumours pose numerous challenges in terms  of diagnosis, imaging and management. They can be  classified into three main groups according to their  origin: (1) primary lesions, which originate from the  orbit itself; (2) secondary lesions, which extend into  the orbit from neighbouring structures (intra-cranial  tumours and tumours of the paranasal sinuses) and (3)  metastatic tumours. Orbital tumours are also divided  according to their anatomical site into intra-conal and  extra-conal.    The orbit is a pear-shaped bony chamber with an ante-  rior opening measuring approximately 40 and 35 mm  in horizontal and vertical diameters, respectively. Its  volume expands approximately 1 cm posterior to the  bony orbital rim and then gradually decreases towards  the apex, which consists of the optic canal at its nar-  rowest diameter. In the axial plane, the medial wall  measures approximately 45-50 nm from the anterior    lacrimal crest to the optic canal. Posteriorly, the lateral  wall is bordered with the superior orbital fissure, situ-  ated between the greater and lesser wings of the sphe-  noid bone. This foramen transmits the third, fourth and  sixth cranial nerves and the ophthalmic branch of the  fifth cranial nerve, the superior orbital vein and sympa-  thetic nerves.   The peri-orbita is important because it acts as a barrier  to the extension of neoplastic growth.    Orbital tumours can derive from tumours of epithelial,  mesenchymal, haematologic and nervous origin: vascu-  lar tumours, fibrohystiotic tumours, fibro-osseous and  cartilaginous tumours, peripheral nerve tumours, hae-  matologic tumours, lacrimal gland tumours, tumours of  the lacrimal drainage system, eyelid and peri-ocular skin  tumours, conjunctival tumours, ocular tumours, tumours  of the cranial and nasal cavities, brain tumours and meta-  static tumours.   Orbital lymphoma is the most common malignant  tumour of the eyes. It can occur either as the primary    site of disease or rarely as a secondary site of systemic  non-Hodgkin lymphoma (NHL). Orbital lymphoma typi-  cally is a disease of the elderly as the majority are non-  Hodgkin’s type and are seen primarily in adults in the  50-70-year age group.   Malignancies of the ocular adnexa are the most com-  mon reason for orbital exenteration and include squa-  mous cell carcinoma (SCC), sebaceous cell carcinoma and  basal cell carcinoma (BCC). Other less common tumours  include conjunctival malignant melanoma, adenoid cystic  carcinoma of the lacrimal gland and uveal melanoma with  extra-scleral extension.   Lacrimal gland lesions can be classified as epithelial and  non-epithelial lesions. Epithelial tumours can be benign  (e.g. pleomorphic adenoma) or malignant (e.g. adenoid  cystic carcinoma). Conjunctival melanoma is a rare but  aggressive ocular tumour. The most common primary  malignant intra-ocular tumour in adults is uveal mela-  noma, whereas in children it is retinoblastoma. Rarely,  intra-ocular tumours extend transclerally and invade the  peri-ocular tissues and the orbit. The uveal melanoma  originates from the monocytes of the uvea and has the  capacity to invade the adjacent tissue structures aggres-  sively and metastasize systemically.   A variety of pathologies can involve the preseptal space.  Frequently these tumours are benign, for example, xanthe-  lasmas and tumours of limited malignancy. Rare tumours  include capillary haemangiomas, lymphomas and orbital  metastases from distant sites.    The most important feature is proptosis. Slowly growing  masses of the orbit usually do not alter the anatomic rela-  tionship of the eyelids to the globe and extra-ocular motil-  ity is affected only at extreme gazes (Figure 40.1).   Lacrimal gland tumours typically present with upper  eyelid fullness, alteration of eyelid contour, and down-  wards and nasal displacement of the globe.   There are two mechanisms by which a tumour can  cause diplopia: first, by infiltrating the nerves supplying  the extra-ocular muscles, as seen with malignant tumours,  and second, by restricting the normal extra-ocular motil-  ity function and/or deviating the axis of the eye.   Infiltrating tumours have a tendency ‘freeze’ the eye in  the primary position of gaze because of their indiscrimi-  nate infiltration into the muscles and the soft tissues of the  orbit (Figure 40.2).   Uveal melanomas have an early sign impairment of  visual acuity (Figure 40.3).   Primary lacrimal sac lesions, or those affecting the lacri-  mal sac as part of a systemic process, present with epiphora,  dacryocystitis or a hard, fixed mass arising above the medial  canthal tendon, sometimes with serosanguinous tears.   Intra-cranial tumours may rarely extend into the orbit.  Orbital extension may produce ophthalmoplegia, optic  neuropathy and proptosis.    Figure 40.1 (a) Clinical photograph of a patient with orbital  lymphoma. There is marked proptosis with chemosis of the  conjunctiva. (b) Magnetic resonance imaging (MRI) (T2 weight-  ing) showing diffuse infiltration of the occulomotor muscles  from the lymphoid tissue. (c) MRI (T1 weighting) depicting the  same radiological findings. There is marked enlargement of  the rectus muscles.    Orbital imaging serves three distinct purposes: (1) to  confirm that the signs and symptoms are due to an  orbital tumour; (2) to identify the nature of the tumour,  its malignant potential, tissue type and extension into    (a) Clinical photograph of a patient with squamous cell carcinoma (SCC) of the ethmoids with extension into the  left orbital cavity. The tumour produces marked proptosis to the left eye with outer displacement and ‘freezing’ of the eye due  to extensive infiltration of the occulomotor muscles. (b) The MRI (T2 weighting) shows the extension of the tumour of the ante-  rior ethmoids and the nasal cavity into the orbit. There is direct invasion of the globe by the tumour which is confined into the  anteriolateral compartment of the orbit. (c) Coronal plane of the MRI (T1 weighting). The tumour mass is depicted invading the orbit  having destroyed the inner lateral thin bony wall. (d) Coronal plane of the MRI (T2 weighting). The tumour is confined in the naso-  ethmoidal area with extension into the orbit without invading the base of the skull and the anterior cranial fossa.    (a) Clinical photograph of a patient with orbital extension of a uveal melanoma. The intra-ocular extension  of the tumour produces proptosis and conjunctival ecchemosis. (b) MRI (T2 weighting) showing the distraction of intra-ocular  architecture of the globe by an ill-defined mass with irregular periphery and a mixed consistency. The lesion does not invade the  peri-orbita.    other neighbouring tissues and (3) to monitor treatment  effectiveness and the early identification of recurrence.   The main radiographic modalities used in orbital  imaging are computed tomography (CT), magnetic reso-  nance imaging (MRI), ultrasonography, positron emis-  sion tomography, digital angiography and radio nuclear  scintigraphy.   Digital angiography should be considered for any  patient with pulsatile exophthalmos.    Orbital biopsy techniques include excisional, incisional,  core and aspiration biopsies and intra-operative biopsy  with frozen section and Moh’s methods. Sentinel node  biopsy is also utilized occasionally for staging purposes of  certain tumours.    Enucleation is removal of the globe alone, whereas orbital  exenteration refers to enucleation combined with removal  of the entire orbital contents, including the globe, optic  nerve, extra-ocular muscles, lacrimal gland and lacrimal  drainage system, as well as the orbital fibroconnective and  adipose tissues.   Individualization of exenteration cases should take into  account the location, size and aggressiveness of the pathol-  ogy, as well as the reconstruction plan. If the bones of the  orbit are involved with malignancy, bone resection should  be performed at the time of initial orbitotomy, even if that  procedure is not an exenteration. Orbital exenteration may  be subtotal, total and extended.    In eyelid-sparing exenteration, one may need to spare either  the entire eyelid structure or just the eyelid skin. If the eyelid  skin is to be spared, the skin incision is placed approximately  2-3 mm above and beyond the lash lines. The skin is dis-  sected until the orbital rim is reached, then the periosteum is  cut 360° 2 mm beyond the orbital rim, to continue the exen-  teration. If the entire eyelid anatomy is to be preserved, the  operation is similar to an extended enucleation in which the  eye with the bulbar conjunctival lining and the other orbital  tissues are removed en bloc (Figure 40.4).    In total orbital exenteration, the eyelids are closed with silk  sutures. The bony landmarks are palpated and the line of the  desired incision marked out. A circumferential skin incision  is made overlying the orbital rim (Figure 40.5a). Unless the    Figure 40.4 Schematic representation of the eyelid-spar-  ing incision for subtotal orbital exenteration. (a) Lateral view.  (b) Front view.    extent of the disease makes it necessary to do, otherwise the  line of the incision lies just inside the orbital rim. Medially,  it lies on the anterior lacrimal crest and laterally, it passes  close to the outer canthus. On the nasal wall of the orbit, the  periosteum must be raised gently, because the orbital plate  of the ethmoid is very fragile and a sinus may result if the  ethmoid air cells are opened. When the underlying soft tis-  sues have been reached the incision is continued, usually  with the use of unipolar cautery with a fine needle tip (a  Colorado tip). To minimize bleeding, an incision is made in  the upper quadrant, at the 12 o'clock position, which then  proceeds clockwise, leaving dissection of the vascular nasal  quadrant to the end. The peri-orbita is best incised a few mil-  limetres outside the orbit, rather than on the orbital margin,  as the blade of the knife can then be used perpendicularly  to the bone (Figure 40.5b). Although the peri-orbita here  is firmly adherent to the bone, it is thick and does not tear  when raised. It is elevated with a sharp periosteal elevator  (Figure 40.5c). When the periosteum of the orbital rim is  reached, it is elevated and the dissection is swiftly contin-  ued beyond the rim into the orbit, to complete the procedure  as quickly as possible (Figure 40.5d). In the region of the  anterior lacrimal crest, the lacrimal sac is reflected laterally  with the orbital contents when the periosteum is separated  from the nasal wall. The nasolacrymal duct is identified  as the dissection proceeds from the nasal wall to the floor    Figure 40.5 Schematic representation of total orbital exenteration in stages (see text for explanation of panels [a through g]).    of the orbit. Ligation of the duct prevents ascending infec-  tion from the nose and prevents blood running down into  the nasopharynx. During dissection, bleeding is ignored  unless haemorrhage is so profuse that it interferes with the  view of the surgical field. Laterally, the temporal and malar  branches of the lacrimal artery enter the malar bone and    medially, the anterior ethmoidal artery passes from the  orbit into the anterior ethmoidal foramen. These vessels are  exposed and are clamped and coagulated with diathermy to  avoid bleeding in the depths of the wound. When the soft-  tissue dissection is complete, haemostasis with cautery is  achieved (Figure 40.5e). When the dissection towards the    apex is completed, the apical bundle of soft tissues, including  extra-ocular muscles, blood vessels and nerves, is reached.  These tissues cannot be clamped or cut with one move. The  bundle is approached from its nasal aspect, a strong curved  haemostat is placed and the pedicle is cut with unipolar  cautery or a curved pair of scissors above the haemostat.  The same manoeuvre is repeated laterally and inferiorly to  free the apex from orbital soft tissues. The bleeding sources  of the apex (ophthalmic artery and vein) should be identi-  fied, clamped and tied after the removal of the bulk of the  soft tissues (Figure 40.5f). Excessive application of elec-  trocautery at the apex may create damage in the proximal  portion of the optic nerve, which may extend into the optic  chiasma. During orbital exenteration, most of the bleeding  originates from the supraorbital and infraorbital vessels, the  anterior and posterior ethmoidal arteries and the ophthal-  mic artery when the dissection reaches the apex. Although  the posterior bleeding is the most significant, it is easier to  control, since by the time the apex of the orbit is reached,  all soft tissues have been freed and there is better visibility  (Figure 40.5g). After removal of the orbital contents, it may  be possible to apply clamps behind those previously used to  reduce the size of the stump by the removal of more tissue.  The pedicle is transfixed and ligated.    After total orbital exenteration, the orbital walls are exam-  ined for any evidence of neoplastic involvement. If there  is any diseased bone it is then chiselled away, cutting  through healthy bone. There are no standard techniques  for bone resection. In most cases, removal depends on the  extent and location of the bony invasion. In most areas of  the orbit, it is preferable to score the bone with an oscillat-  ing saw along the predetermined limits of resection and  then fracture the bone en bloc with a strong rongeur. In  some sites, a sharp osteotome and a mallet may be needed  to remove pathologic bone (Figure 40.6).    Extensive primary paranasal and skull base malignancies  can infiltrate the orbital content. There are four grades  of orbital involvement through the paranasal sinuses:  (1) tumour adjacent to the orbit, without infiltration of the  orbital wall; (2) tumour eroding the orbital wall without  ocular bulb displacement; (3) tumour eroding and infil-  trating the orbital wall, displacing the orbital content,  without peri-orbital involvement; (4) tumour invading the  orbit with peri-orbital invasion. In cases of obvious bony  orbital tumour involvement, the orbit with the adjacent  bone and sinuses should be removed. The conventional  treatment of the sinonasal malignancies with orbital  extension is maxillectomy with orbital exenteration. This    Figure 40.6 Extended orbital exenteration with resection  of the osseous orbit. (a) Incision lines resemble those of the  total orbital exenteration. If needed a lateral rhinotomy exten-  sion is performed to facilitate resection of the orbital floor.  (b) An osteotomy is performed to include parts of the lateral  orbital wall and the bony floor of the orbit. (c) The surgical bed  after the extended orbital exenteration.    extended hemi-maxillectomy is approached through a  Weber-Fergusson-Dieffenbach skin incision (Figures  40.7 and 40.8). Ethmoidal malignancies invade the orbit  in over 80% of cases. The anatomy of the area and the    Figure 40.7 Schematic representation of extended orbital exenteration with resection of the paranasal sinuses. (a and b) The  incision line when a lid-sparing procedure is favoured. (c and d) The cheek flap is reflected and the anterior and lateral walls of  the maxillary sinus and the orbit are visualized. (e) Osteotomies are performed to separate the lateral middle third of the face from  the facial skeleton. Transection of the zygomatic arch and bone are necessary for the mobilization of the osseous part of the skeleton  containing the tumour. (f and g) After the resection of the specimen additional fragments of the facial skeleton may be necessary  to be removed. (h) The skin closure lines.    Figure 40.8 (a) Schematic representation of extended  orbital exenteration with resection of the paranasal sinuses  when the lids must be resected with the tumour. (b) The surgi-  cal defect after tumour resection.    separation of the orbital cavity from the ethmoids by the  lamina papyracea favours the invasion of tumour into the  orbit (see also Chapter 39).    An essential part of the decision-making process is recon-  struction and rehabilitation of the exenterated orbital  socket. A decision should be made pre-operatively whether  the patient will wear a patch or a prosthesis.    Primary surgical closure of the orbital cavity is advanta-  geous with respect to both function and aesthetic outcome,  and makes early post-operative radiotherapy possible.  With CT and MRI, early local recurrence can be identified.   Orbital exenteration results in significant deformity.  The primary goal of reconstruction is the restoration of  boundaries between the orbit and surrounding cavities  and an acceptable aesthetic outcome.   Orbital reconstructive techniques can be divided in  three groups: (1) local reconstructive options (healing by  secondary intention, split skin graft or dermis—fat graft),  (2) regional reconstructive options (temporalis muscle  transfer, frontalis rotational flap or a variant of these pro-  cedures) and (3) distant reconstructive options (pedicle  musculocutaneous flaps or free vascularized flaps).   The simplest approach is to pack the orbit with iodine  impregnated gauze and allow the socket to granulate.  When the eyelids are entirely removed, the free skin mar-  gin is tacked to the orbital rim with interrupted silk sutures  and the socket is lined with antibiotic-soaked Vaseline or  Xeroform gauze.   Healing may take 8-10 weeks. By the time granula-  tion is complete, the orbit is covered with a very thin epi-  thelium, which has the advantage of allowing the visual  detection of recurrent tumour at an early stage. The result-  ing cavity is deep, but can be fitted with a silicone ocu-  lofacial prosthesis. The need for regular dressing changes  must be weighed against the potential benefits of healing  by secondary intention.   Significant numbers of patients develop sino-orbital  fistulas from perforation of the sinuses occurring  pre- operatively (Figure 40.9).   Because the eyelids and conjunctiva are supplied by an  extensive vascular network, these tissues remain viable  after loss of the posterior orbital circulation. Eyelid-  sparing, subtotal exenteration offers significant advan-  tages in terms of reconstruction of the orbit and cosmesis.  When it is consistent with the complete removal of all  malignant disease, the lids are preserved, and either turned  into the cavity as a lining or used to retain a prosthesis  (Figure 40.10).    The socket may be lined on completion of the exentera-  tion with a split-thickness skin graft. There are a number  of advantages for this technique. It is a technically simple  procedure which takes little time and it provides a socket  that is easily accessible for clinical examination. While  split skin grafts provide a reliable lining, they take time to  heal and stabilize.    Figure 40.9 Clinical photograph of a left exenterated orbit  after spontaneous granulation. The stub of the optic nerve  with its adjacent vessels can be seen. A sino-orbital fistula has  been created resulting in an orbito-ethmoidal communication.    Figure 40.10 Clinical photograph of a left exenterated  orbit with lid-sparing technique.    The graft must be free of hair follicles. A graft measur-  ing 8 cm at its widest point is sufficient to line the orbital  cavity and a graft of this size can be obtained from the  anterior thigh. When the skin graft has been inserted into  the orbit, it is important to ensure close approximation of  the graft to the bony wall. It is sutured to the margins of  the skin with interrupted absorbable sutures, and the orbit  is packed with Xeroform gauze as a mould to provide firm  apposition of the graft to the bone. Success depends on the  entire surface being held in contact with the bone by firm  even pressure.   Although orbits lined by skin grafts heal faster than  ungrafted ones, they do not have the advantage of devel-  oping fibrosis (Figure 40.11).    Because forehead flaps are designed with an intact major  blood vessel, they provide healing and do not require    Figure 40.11 Clinical photograph of a right exenterated  orbit lined with split thickness skin graft.    specialized microvascular surgery. Forehead flaps provide  ample tissue for the repair of nasal and maxillary defects  that often accompany the resection of orbital and peri-  orbital tumours.   The forehead flap results in aesthetic morbidity at the  donor site, a common complaint of patients who undergo  such procedures.   The median forehead flap is outlined on the skin (Figure  40.12a). An incision in the natural horizontal furrow of  the forehead or parallel to it is made down to the fron-  tal bone periosteum (Figure 40.12b). The flap is dissected  from its apex towards the base. The subdermal dissection  is performed with care taken to leave subdermal vascular  territory to maintain the blood supply of the remaining  skin, and also with care taken to leave sufficient tissue,  including muscle, at the level of the brow to fit the bulk of  the flap and to protect hair follicles (Figure 40.12c). When  the subperiosteal dissection is made towards the level of  the orbital rim, the supratrochlear and supraorbital vas-  cular pedicles and supraorbital nerve should be identi-  fied. After that, the base of the flap can be undermined  sufficiently to permit its easy adaptation (Figure 40.12d).  Based on its pedicle, the flap is rotated 90°, with a rotation  point at the level of the orbital rim (Figure 40.12e). After  the flap is adapted as a turnover to the defect, it is sutured  to the edges of the skin of the orbital defect with 5/0  Vicryl sutures (Figure 40.12f). The defect in the forehead,  depending on the size of the elevated median forehead  flap, is either primarily sutured or can be covered with a  full-thickness free skin graft (Figure 40.12g). The grafted  full thickness skin can be harvested from the supraclavical  area or when in the form ofa split-thickness skin graft can  be taken from the thigh. A tie-over dressing is applied and  is left in place for 10 days (Figure 40.12h and i). The entire  middle third of the forehead will survive elevation on the    Figure 40.12 Schematic representation of the use of median forehead flap to cover a total exenteration surgical defect [see text    basis of the dominant vascular pedicle and its height can  reach the hairline. The 90° twist needed to reach the exen-  terated orbital cavity does not usually impair the blood  supply. A potential complication is transfer of eyebrow  hair to the socket.    From a functional and an aesthetic standpoint, the  median forehead flap is an excellent choice for small- or  medium-sized orbital defects. The forehead skin more  closely matches the pigmentation and structure of the peri-  ocular tissue. Forehead flaps can be used in conjunction    with other local and regional flaps to repair larger orbi-  tofacial defects. The relative ease of harvesting the flap  minimizes operative time and the robust blood supply  decreases failure rates (Figures 40.13 and 40.14).    Among the advantages of the temporalis muscle flap  (TMF), one can include easy surgical technique, reliabil-  ity of the vascular pedicle, sufficient volume to cover large  surgical defects, versatility in its application, minimal  post-operative complications and freedom from dysfunc-  tion at the donor site.   The TMF is one of the most frequently used flaps to  obliterate the orbital cavity, but only a small portion of the  muscle can be used unless additional procedures, such as  fenestration of the lateral orbital wall or resection of the    Figure 40.13 Clinical photograph of a female patient with  a right total orbital exenteration and a median forehead flap to  reconstruct the orbital defect.    Figure 40.14 Clinical photograph of a male patient with  a right total orbital exenteration reconstructed with a median  forehead flap.    lateral orbital rim, are performed. Even these procedures  do not enable the entire mass of the muscle to be used,  because most of the muscle bulk acts as the pedicle.   The temporoparietal fascial flap (TPFF) is the only fascial  flap that can be harvested as a pedicled flap for peri-orbital  and socket reconstruction. Its thin width (average width  2-3 mm) and need for grafting are the main disadvantages.   Small paranasal sinus or brain fistulas are obliterated  by performing locoregional flaps transposed through the  lateral orbital wall. In more extensive cases, the boundar-  ies between the empty orbit and adjacent cavities must be  re-established with free tissue transfer. A common proce-  dure is to borrow a portion of the temporalis muscle from  its anterior half, pass it through the lateral wall, and fill the  orbital cavity with the bulk of this graft. Skin graft can be  placed over the muscle flap. In most instances, this pro-  cedure effectively makes the exenteration cavity shallow.    Pedicled flaps  Regional flaps are used frequently for reconstruction fol-  lowing exenteration, but these flaps can cover only the  anterior orbit and leave potential dead space posteriorly.  Use of the pectoralis major myocutaneous flap for  orbital reconstruction is limited, due to the distance the  muscle pedicle has to travel from the anterior thoracic wall  to the orbit. There have been attempts to use the sternoclei-  domastoid, trapezius, latissimus dorsi and platysma flap.  Other local flaps like the cheek flap, the submental and  the retroauricular island flap can also be used to recon-  struct peri-orbital defects. They provide superior cosmetic  results through enhanced matching of skin colour, texture  and structural characteristics, have a rich vascular supply  and a low complication rate, and do not require complex  microvascular surgery.    Surgical reconstruction of the orbital cavity after orbital  exenteration with maxillectomy is technically challeng-  ing. The reconstruction of such defects obliterates any  communication between the orbit and the nasopharynx,  reconstructs the palatal surface and the nasal airway,  and provides an acceptable cosmetic result. Ideally, the  selected tissue should facilitate this and provide a well-vas-  cularized bed to withstand post-operative radiotherapy.   Microvascular free flaps have also been used to cover  defects following extended orbital exenteration. Facial or  temporal vessels may be suitable for microvascular anasto-  moses. A wide selection of free flaps can be used in orbital  and orbitomaxillary defects.   Primary reconstruction of orbit and maxillary defects  with free microvascular rectus abdominis flaps has  numerous advantages. In contrast with procedures that  use the temporalis or the pectoralis major as a pedicled  flap, the rectus abdominis free flap permits reconstruction    with larger volumes of well-vascularized tissue and greater  flexibility in placement without associated orientation  problems.   Maintaining the nasal airways is often the most difficult  problem in this particular group of patients, and a second  skin island to address lateral nasal wall reconstruction is  often helpful (Figure 40.15).    Orbital prosthetics are never completely lifelike, because  vital eye movements are absent. Spectacles can camouflage  this aesthetic deficiency and protect the uninvolved eye at  the same time.   The key decision to be made when approaching an  orbital exenteration defect is whether to leave the cav-  ity open or closed. An open cavity requires less sophis-  ticated surgery, may permit better tumour surveillance  and allows the use of a prosthesis. However, an open  cavity can lead to surrounding tissue contracture with  inferior displacement of the brow and distortion of the  cheek.   Despite recent advances in contemporary oculofacial  prosthetics, the aesthetic results after a standard orbital  exenteration remain poor and unacceptable for many  patients. Although traditional exenteration with a spec-  tacle mounted, osseointegrated or adhesive-secured pros-  thesis may achieve acceptable cosmesis, many patients  have difficulty in obtaining good prosthetic support.  Many patients prefer to wear an eye patch to cover the sur-  gical site.   The basic requirements for an exenterated socket that  can maintain an ocular prosthesis are (1) orbital tissue  volume to support the prosthesis, (2) a mucous membrane    surface with fornices to accommodate the prosthesis and  (3) eyelids to hold the prosthesis within the socket. The  limiting factor in most exenteration cases is the pres-  ervation of a mucosal surface, which is essential if the  prosthetic shell is to be comfortable. Unless significant  portions of the conjunctiva can be retained, an ocu-  lar prosthesis is not a rehabilitative option after orbital  exenteration, and the surgical plan should take this into  account.   Osseointegrated implants have helped overcome a  number of the problems associated with facial prosthe-  ses. They provide reliable anchorage for large and heavy  prostheses and facilitate their rapid placement and  removal. Modern magnetic capped implants are very  simple to use.    The most serious post-operative complication in orbital  surgery is haemorrhage, which can happen immediately  post-operatively or weeks later, but generally occurs in the  4-6 days after the operation. Because the orbit is small  and closed, any haematoma may be significant. Wound  infection and dehiscence, as well as orbital cellulitis, are  unusual postoperative complications following tumour  resection.   Orbital exenteration defects left to granulate spon-  taneously can be complicated by a prolonged healing  phase, chronic hygiene problems, orbitosinus or orbi-  tonasal fistula formation, dural exposure and cerebro-  spinal fluid leaks. The high rate of sino-orbital fistulas  following spontaneous granulation of exenterated orbital  cavities can be avoided by formal surgical closure and  reconstruction.    Figure 40.15 (a) Clinical photograph of a patient with extensive basal cell carcinoma (BCC) of the eyelids which extends to the  peri-orbital skin tissues. (b) The extended orbital exenteration defect has been reconstructed with the use of a rectus abdominis   e Use CT for the identification of osseous extensions of  the orbital mass.   e Use periosteal elevator to dissect the peri-orbita from  the orbital walls.   e Use curved scissors to cut the optic nerve, and ophthal-  mic artery and vein.   e Start the reconstruction after the extirpation of the  tumour as you may need to change the reconstructive  plan according to intra-operative findings.    Ben Simon GJ, Schwarcz RM, Douglas R, Fiaschetti D,  McCann JD and Goldberg RA. Orbital exenteration:  One size does not fit all. Am J Ophthalmol. 2005; 139:  11-17.   Callender DL, Frankenthaler RA, Weber RS, Dodd L and  Batsakis JG. Carcinomas of the lacrimal drainage sys-  tem. Head Neck. 1993; 15: 313-319.   Chepeha DB, Wang SJ, Marentette LJ, Bradford CR, Boyd  CM and Prince ME. Restoration of the orbital aesthetic  subunit in complex midface defects. Laryngoscope.  2004; 114: 1706-7013.   Cook BE Jr and Bartley GB. Epidemiologic characteristics  and clinical course of patients with malignant eyelid  tumors in an incidence cohort in Olmsted County,  Minnesota. Ophthalmology. 1999; 106: 746-750.   Cook BE Jr and Bartley GB. Treatment options and future  prospects for the management of eyelid malignancies:  An evidence-based update. Ophthalmology. 2001;  108: 2088-2898.   Esmaeli B, Ahmadi MA, Youssef A, Diba R, Amato M,  Myers JN et al. Outcomes in patients with adenoid  cystic carcinoma of the lacrimal gland. Ophthalmic  Plast Reconstr Surg. 2004; 20: 22-26.   Esmaeli B, Golio D, Kies M and DeMonte F. Surgical man-  agement of locally advanced adenoid cystic carcinoma  of the lacrimal gland. Ophthalmic Plast Reconstr Surg.  2006; 22: 366-670.   Fan J. A new technique of scarless expanded forehead flap  for reconstructive surgery. Plast Reconstr Surg. 2000;  106: 777-785.   Gil Z, Abergel A, Leider-Trejo L, Khafif A, Margalit N,  Amir A et al. A comprehensive algorithm for anterior  skull base reconstruction after oncological resections.  Skull Base. 2007; 17: 25-37.   Goldberg RA, Kim JW and Shorr N. Orbital exenteration:  Results of an individualized approach. Ophthalmic  Plast Reconstr Surg. 2003; 19: 229-236.   Iannetti G, Valentini V, Rinna C, Ventucci E and Marianetti  TM. Ethmoido-orbital tumors: Our experience.  J Craniofac Surg. 2005; 16: 1085-1091.    Imola MJ and Schramm VL Jr. Orbital preservation in  surgical management of sinonasal malignancy.  Laryngoscope. 2002; 112: 1357-3565.   Jackson IT. Midline forehead flaps in nasal reconstruction.  Eur J Plast Surg. 2004; 27: 105-113.   Jung WS, Ahn KJ, Park MR, Kim JY, Choi JJ, Kim BS et  al. The radiological spectrum of orbital pathologies  that involve the lacrimal gland and the lacrimal fossa.  Korean J Radiol. 2007; 8: 336-342.   Karcioglu ZA. Orbital Tumors. Diagnosis and Treatment.  Berlin: Springer Science + Business Media, Inc; 2005.   Leibovitch I, McNab A, Sullivan T, Davis G and Selva D.  Orbital invasion by periocular basal cell carcinoma.  Ophthalmology. 2005; 112: 717-723.   Liarikos S, Rapidis AD, Roumeliotis A and Angelopoulos  AP. Secondary orbital melanomas: Analysis of 15  cases. J Craniomaxillofac Surg. 2000; 28: 148-152.   Menon NG, Girotto JA, Goldberg NH and Silverman RP.  Orbital reconstruction after exenteration: Use of a  transorbital temporal muscle flap. Ann Plast Surg.  2003; 50: 38-42.   Nassab RS, Thomas SS and Murray D. Orbital exentera-  tion for advanced periorbital skin cancers: 20 years  experience. J Plast Reconstrive Aesthetic Surg. 2007;  60: 1103-1109.   Park SS. The single stage forehead flap in nasal reconstruc-  tion. An alternative with advantages. Arc Facial Plast  Surg. 2002; 4: 32-36.   Perez DEC, Pires FR, Almeida OP and Kowalski LP.  Epithelial lacrimal gland tumors: A clinicopatho-  logical study of 18 cases. Otolaryngol Head Neck Surg.  2006; 134: 321-325.   Price DL, Sherris DA, Bartley GB and Garrity JA. Forehead  flap periorbital reconstruction. Arc Facial Plast Surg.  2004; 6: 222-227.   Pryor SG, Moore EJ and Kasperbauer JL. Orbital exentera-  tion reconstruction with rectus abdominis microvas-  cular free flap. Laryngoscope. 2005; 115: 1912-9126.   Rapidis AD and Liarikos S$. Malignant orbital and orbito-  maxillary tumors: Surgical considerations. Orbit.  1998; 17: 77-88.   Santamaria E and Cordeiro PG. Reconstruction of maxil-  lectomy and midfacial defects with free tissue trans-  fer. J Surg Oncol. 2006; 94: 522-531.   Shields JA, Shields CL, Demirci H, Hanovar S and Singh A.  Experience with eyelid sparing orbital exenteration:  The 2000 Tullos O. Coston Lecture. Ophthalmic Plast  Reconstr Surg. 2001; 17: 355-361.   Shields JA, Shields CL, Giithields and Cater J. Clinical fea-  tures predictive of orbital exenteration for conjuncti-  val melanoma. Ophthalmic Plast Reconstr Surg. 2000;  16: 173-178.   Shields JA, Shields CL and Scartozzi R. Survey of 1264  patients with orbital tumors and simulating lesions:  The 2002 Montgomery Lecture, part 1. Ophthalmology.  2004; 111: 997-997.    Sturgis CD, Silverman JF, Kennerdell JS and Raab SS.  Fine-needle aspiration for the diagnosis of primary  epithelial tumors of the lacrimal gland and ocular  adnexa. Diagnostic Cytopathol. 2001; 24: 86-89.   Yeatts RP. The esthetics of orbital exenteration. Am J  Ophthalmol. 2005; 139: 152-153.    Zwahlen RA, Gratz KW and Obwegeser JA. The galea  fascia flap in orbital reconstruction: Innovative  harvest technique. Eur J Surg Oncol. 2006; 32:  804-807.    Many of the surgical principles described in this  chapter have not changed significantly since 1906  when Crile published his classic paper describing  132 neck dissections (36 radical and 96 more selec-  tive procedures). Only 2 years later, Sir Henry Butlin  described a procedure that is essentially the same as  a current supra-omohyoid neck dissection (SOHND).  Despite this publication of a ‘selective’ neck dissection,  most elective treatment of even the clinically negative  (NO) neck during the first half of the 20th century con-  sisted mainly of radical neck dissection (RND). Over  the last 20 years, there has been an increasing trend  towards selective neck dissection (SND) for the initial  management of patients with no clinical evidence of  neck metastasis, and in carefully selected patients with  nodal metastasis (although its use in the latter remains  controversial).   Whilst SND preserves many vital structures (such  as the accessory nerve), the functional results after  these procedures are not as good as expected. Shoulder  function and pain scores are worse in patients who  undergo posterior triangle dissection, which may not  recover despite preservation of the accessory nerve. A  study has found that the variables that contribute most  to quality of life scores relating to the neck were age  and weight, radiotherapy to the neck and type of neck  dissection.    Neck dissection nomenclature can be confusing. It can be  simplified as follows:    ® Radical neck dissection. This refers to removal of  lymph nodes in levels I-V en bloc with the sternomas-  toid muscle, also known as sternocleidomastoid muscle  (SCM), internal jugular vein (IJV) and spinal accessory  nerve. This operation is both cosmetically and function-  ally mutilating and is used in gross metastatic disease,  involving multiple levels of the neck and when preserva-  tion of the above structures would compromise surgical  clearance. Although this operation has been regarded as  the ‘gold standard’ for the surgical treatment of meta-  static neck disease, it has largely been replaced by more  selective surgery.   © Modified radical neck dissection (MRND) refers to  dissection of levels I-V but with the preservation of one  or more of the following structures: IJV, spinal acces-  sory nerve and sternomastoid. The nomenclature refers  to the number of structures preserved (so MRND type I  is preservation of one of these structures, MRND type II  is preservation of two structures and so on). Both RND  and MRND are used when the neck has evidence of  nodal metastasis (N+), although there is growing evi-  dence to suggest that the more SND (see below) has a  role to play not only in staging but in the management  of the N+ neck as well. The reader is referred to an excel-  lent recent review of this subject by Ferlito et al.    ®@ Selective neck dissection. In 1991, the Committee for  Head and Neck Surgery and Oncology of the American  Academy of Otolaryngology and Head and Neck Surgery  indicated that ‘in all SND, the IJV, spinal accessory nerve  and SCM are routinely preserved. If removal of one  or more of these structures is necessary, the structure  should be listed after the appropriate term for the neck  dissection’.' As a result, SND can easily be confused with  MRND and indeed some surgeons use the terms inter-  changeably. However, SND should refer to the dissection  of one or more levels of the neck (with careful preservation  of the anatomical structures listed above, as well as other  nerves such as the marginal mandibular branch of the  facial nerve) rather than all five levels. Examples include  the SOHND, (levels I-III), lateral compartment neck dis-  section (levels II-IV) and levels I-IV neck dissection.    The most significant change to the well-known Robbins  classification was the publication of an updated system in  2002. In addition to the five standard levels, nodal levels  were subdivided into levels IA and B, IIA and B (below  and above the accessory nerve) and VA and B (above  and below the accessory nerve in the posterior triangle)  (Figure 41.1). The concept of sublevels is clinically rele-  vant since metastasis to level IIB from anterior oral cavity  tumours is uncommon and metastases to level VA is rarer    Figure 41.1 Levels of the neck. Level is divided into 1A  (submental) and IB (submandibular triangles).    still, with studies advocating that the dissection of these  levels is not usually necessary.    The rationale for neck dissection is based on predictable  patterns of lymphatic spread from the primary tumour  site, and the relative risk of nodal metastatic disease.  Over 30 years ago, Lindberg’s clinical study found that  the jugulo-digastric and mid-cervical nodes (levels II  and III) were the most frequently involved in metastatic  disease from the oral cavity. Tumours of the lip, ante-  rior two-thirds of the tongue, floor of mouth and buccal  mucosa also metastasize to the level I nodes (submental  and submandibular triangles), often bilaterally. Lindberg  described the possibility of skip metastasis, avoiding the  first echelon nodes and spreading directly to the level III  area. More recent studies have found that when levels I-IV  are negative and level V is never node positive, supporting  the use of the SND for the NO neck. Despite many pub-  lished studies, there is still controversy about neck  dissection surgery and the reader should refer to specialist  textbooks for a full discussion.   When taking trainees through a neck dissection, the  author makes the analogy of walking through a jungle.  Some structures in the neck (suchas the digastric and omo-  hyoid muscles) will help to delineate the path — these are  your trusted guides. However, you will also come across  many dangers, which if not treated with respect could take  you by surprise, sometimes when you least expect it! These  include structures such as the phrenic, hypoglossal and  marginal mandibular nerves.    1. Patient position. For all neck dissections, the fully  anaesthetized (but unparalysed) patient should be  placed supine on the operating table with the head  turned away from the side being operated. A sandbag  can be used if required to elevate the shoulder. It is sen-  sible to expose the neck from the sternum and lateral  clavicle to the ear and lips. Following skin preparation,  the drapes need to be secured in place using adhesive  strips, sutures or skin clips. It is useful to keep the  lower lip exposed (to check for marginal mandibular  nerve function).   2. Choice of incision. This depends on the type of neck  dissection being undertaken. Ideally, skin incisions  should be placed in natural skin creases, following  Langer’s lines. The lower border of the mandible, ster-  nomastoid and clavicle can be marked to assist place-  ment of the incision. For a SND, an incision running  from the mastoid to submental area 3 cm below the  mandible is usually adequate. When levels IV and  V are being dissected, it may be necessary to place a    second incision to gain access to these areas. The author  routinely uses a Schobinger-type incision for MRND  (Figure 41.2), except in the previously irradiated neck,  where a MacFee incision is preferred (to reduce the risk  of wound dehiscence). When a Schobinger incision is  used, it is important not to place the tri-radiate part  of the incision over the great vessels, especially if the  sternomastoid is removed (risk of wound infection and  vascular compromise!). If a MacFee incision is used -  this is the correct spelling of the author who described  it in 1960? - some spell it McFee! - an adequate bridge  of skin between the incisions (of at least 4 cm) is essen-  tial to minimize the risk of skin necrosis (Figure 41.3).  It is important to mark either side of the incisions  (using needle and Bonney’s blue, or superficially scor-  ing the skin with the back of a scalpel blade) to facili-  tate subsequent skin closure.   . Development of skin flaps. It is usual to raise skin flaps  in a subplatysmal plane. Local anaesthetic solution  may be injected to facilitate this process. The flaps  can be raised using monopolar diathermy (Colorado  needle), scalpel or scissor dissection. With all of  these techniques, but particularly when diathermy is  used, care should be taken in the upper skin flap to  minimize damage to the marginal mandibular nerve,    which lies just deep to the platysma muscle in the  deep cervical fascia. It can be readily identified as it  crosses the facial vessels (FVs) and great care should  be taken to preserve this nerve. It is sometimes pos-  sible to preserve the great auricular nerve as it crosses  the SCM although the roots (C2,3) are often trans-  acted later on in the dissection. In both the submen-  tal and posterior triangles, the platysma muscle often  fades away and care should be taken to ensure that the  skin flap does not become too thick or thin in these  areas. It is sometimes surprising just how superficial  the accessory nerve can be! The external jugular vein  is easily damaged when the inferior skin flap is being  raised as it lies immediately deep to the platysma  muscle and may need to be ligated. The flaps should  be developed beyond the boundaries of the neck dis-  section to be performed. For a MRND, the flap should  be extended to the trapezius muscle in the posterior  triangle. The muscle can be brought into view by hav-  ing an assistant pushing it upwards and forwards. In  bulky disease, it may be necessary to leave the pla-  tysma on the metastatic nodes, or even include skin  in the resection if clinically indicated. In these cases,  it is important to plan skin incisions to facilitate sub-  sequent closure.    Figure 41.3 MacFee incision. Distance between incisions  should be at least 4 cm.    4. Start of neck dissection proper: I-IV SND. Where should  I start the neck dissection? This is a question often asked  by newcomers to this procedure. There are many ways  to perform the procedure (inferiorly to superiorly, pos-  terior to anterior and so on) and it is often good to try  different methods and to vary these on separate occa-  sions to find a way that works for each operator. Even  then, one’s routine procedure may need to be modified  when, for example, a large metastasis is present in level  II, in which case it is often wise to start somewhere else.  Also, if one particular area is proving difficult, move on  to another region and come back to it. The procedure  described below is for a level I-IV SND. The RND and  MRND variations are discussed subsequently.   . Mobilization of the SCM. The fascia overlying the  SCM is incised along the whole posterior margin  length of the muscle and lifted anteriorly. The dissec-  tion is continued close to the muscle in a broad front  inferiorly and superiorly around its anterior border.  Superiorly, the tail of the parotid and the posterior  digastric muscle will come into view on its way to  the mastoid process. The SCM is then retracted pos-  teriorly, and the carotid sheath will come into view,  initially with the IJV (Figure 41.4). By maintaining a  broad front, the SCM can be skeletonized away from  the underlying deep structures. It can then be retracted  with vascular slings. The omohyoid muscle will be  seen inferiorly, the tendon of which passes superficial  to the IJV. This muscle arbitrarily divides the ‘surgi-  cal neck’ into levels HI and IV, although the position  of the muscle varies with neck position. For a level IV  dissection, the omohyoid is dissected free from the IJV,  whereas ina SOHND, the dissection commences supe-  riorly to the upper border of this muscle. As one dis-  sects superiorly, the accessory nerve will be found deep  to the posterior digastric passing in a medial to lateral  direction into the anterior border of the upper third    Dissection around sternomastoid muscle  (SCM) to reveal internal jugular vein (IJV). The accessory nerve  is just coming into view (arrowed).    of the SCM. It can often be felt as a cord like struc-  ture. By hugging the anterior border of the SCM ina  broad front, this important nerve is easily identified.  It is worth noting that this nerve has many anatomical  variations (one can be seen in Figure 41.5), and it can  pass superficial, deep or even through the IJV.    sue containing nodes posterior to the IJV is carefully  incised at the inferior extent of the dissection in a  horizontal direction. This is done in stages, so as to not  inadvertently go through the thin pre-vertebral fascia.  The use of scissor dissection combined with the inter-  mittent use of a wet swab to sweep this tissue off the  pre-vertebral fascia enables easy identification of this  fascia. The phrenic nerve will be seen under the pre-  vertebral fascia passing from lateral to medial on the  scalenus anterior muscle (Figure 41.6). More laterally at  the root of the neck, the upper trunks of the brachial  plexus may also be visualized, again under the fascia.    Clearance in level IV. The phrenic nerve under  the pre-vertebral fascia is arrowed.    The author routinely extends this dissection laterally to  the area over which lies the posterior border of the SCM  (effectively including the anterior border of level V in  the dissection). Once the correct depth has been estab-  lished, it is quite easy to carry the postero-lateral part of  this dissection in a superior direction. This can be facil-  itated by appropriate retraction and counter-traction.  As the dissection proceeds in this way, one will come  across cervical nerves that have pierced the pre-verte-  bral fascia. These can be cut as long as they are super-  ficial to it and the phrenic nerve has been identified. In  some cases it is possible to preserve some of these nerves,  thereby maintaining sensation to the skin in the derma-  tomes supplied by them. As one reaches the accessory  nerve superiorly, the sternomastoid is retracted fully,  and the level IIB can be cleared down to the muscular  floor. The anatomical variations of this nerve should be  remembered (it can be anterior [most common] or pos-  terior to the IJV, or even pass through the vein). Level  IIB contains the occipital artery, which runs postero-  inferior to the posterior digastric muscle. Once cleared,  the fatty tissue can be passed under the accessory nerve  in continuity with the neck dissection specimen.   7. Dissection and clearance around the great vessels.  The dissection now proceeds anteriorly onto and  around the IJV. The fascia overlying the posterior  aspect of the IJV is incised in a broad front (superi-  orly and inferiorly), and dissection is carried around  the IJV itself. With a left-sided neck dissection and  when approaching the IJV inferiorly in level IV, an  attempt should be made to identify the thoracic duct  on its posterior surface. It is also vital to identify the  vagus nerve (Figure 41.7), which usually lies between  the IJV and common carotid artery. Superiorly, the  hypoglossal nerve will be seen crossing the internal  and external carotids. It gives a descending branch  (C1) which joins with C2,3 to form the ansa cervi-  calis. This nerve usually lies antero-lateral to the IJV    Figure 41.7 Further dissection reveals the vagus nerve  and ansa cervicalis (arrowed).    and should be preserved if possible (if only to show off  one’s technical expertise!). The sympathetic chain can  sometimes be seen on the pre-vertebral fascia deep  to the carotid artery, although the dissection itself  should not be deeper than IJV.    tion are the anterior border of the omohyoid, and the  midline of the neck in the submental triangle. The dis-  section can proceed quite quickly up the omohyoid  muscle. Occasionally a large vein is identified (some-  times after it has been cut!) but this is readily ligated.  As the dissection reaches the inferior part of the hyoid  bone, care should be taken to re-identify the hypoglos-  sal nerve as it passes into the submandibular triangle.  The dissection can now continue from the midline  along the lower border of the mandible. The mandibu-  lar periosteum can be incised to create a sharp plane of  dissection. The submental area is usually quite vascu-  lar, due to many branches of the submental vessels. The  bleeding is usually controlled with diathermy.    along the mandible, the mylohyoid muscle will come  into view. The marginal mandibular branch of the  facial nerve should be identified (if this has not already  been done) and retracted. The FVs can be ligated and  retracted superiorly to assist retraction of this nerve  (Figure 41.8). Having dealt with these structures, it  is easy to retract the mylohyoid, exposing the floor of  mouth, and enabling easy removal of the submandib-  ular gland (Figure 41.9). The lingual (superiorly) and  hypoglossal nerves (inferiorly) should be identified in  the floor of mouth and the submandibular ganglion  and duct ligated and divided. At the posterior aspect  of the gland lies the facial artery, which loops over the  posterior digastric and this requires division. If pos-  sible, when a microvascular reconstruction is taking  place, this artery should be left as long as possible to  facilitate subsequent anastomosis. All that remains is    Figure 41.8 Marginal mandibular branch of facial nerve.  The facial vessels (FV) have been ligated. DG, digastric tendon.    to join up the posterior part of the submandibular tri-  angle with the level II dissection. The tail of the parotid  can be included here, and the retromandibular vein  will need to be ligated. The specimen should be suit-  ably orientated for the pathologist.   10. Drains and closure. Meticulous haemostasis is para-  mount for this procedure - the patient should be  positioned head down to increase venous pressure to  visualize bleeding points. A Valsalva manoeuvre given  by the anaesthetist to further increase venous pressure  is also often helpful. Two large drains (size 16) should  be placed. The author routinely uses 3/0 Maxon to close  platysma, with either 5/0 Prolene or skin clips to close  the skin itself.    1. In many respect, the removal of the SCM makes the  neck dissection much easier, although adds morbidity  for the patient. With a RND or MRND (when the SCM  and IJV are included), the SCM can be cut through  superiorly and inferiorly using monopolar diathermy.  The IJV itself requires careful ligation both superiorly  and inferiorly. The author places two 2/0 linen ties with  a 3/0-silk transfixation suture between them on the IJV  being left. On the part of the vein being removed, it is  wise to place a transfixation suture as well, since the  ties sometimes come off during the dissection giving  an unexpected shock. Since it is low pressure in the  IJV, any bleeding can be temporarily arrested with  pressure. If a tie came off superiorly at the skull base,  it should still be possible to control bleeding with pres-  sure (even suturing packs in place). Once the SCM and  IJV are divided, it is easy to use the cut omohyoid mus-  cle belly to rapidly progress the dissection anteriorly.  Ideally if possible, the accessory nerve should be pre-  served ina MRND as should the marginal mandibular  nerve (Figure 41.10).    Figure 41.10 Completed MRND type with preservation of  accessory and marginal mandibular nerve (arrowed).    2. Level V can be cleared starting initially inferiorly along  the clavicle, again down to the level of the pre-vertebral  fascia. Large clips (e.g. Roberts) can be used to clamp  the fat (and transverse cervical vessels). These are ligated  as one proceeds with the dissection. At this point, care  should be taken not to inadvertently pull up the subcla-  vian vessels! This can be prevented by initially dissecting  straight down through the fat onto the pre-vertebral fas-  cia. It is also possible to damage the lung apex resulting  in a pneumothorax, although this is rare. The accessory  nerve can be dissected free and skeletonized from the fat  if this nerve is being preserved. The cervical nerves will  need to be cut to enable removal of level V, but remem-  ber that these should only be cut when they are superfi-  cial to the pre-vertebral fascia. It may be necessary to cut  the inferior belly of the omohyoid.    The principles of a more selective procedure are the same  as for the levels I-IV neck dissection described above,  although it can be technically more challenging. The dis-  section usually starts inferiorly over the omohyoid muscle  and proceeds superiorly as before. As with a levels I-IV  neck dissection, it is important to mobilize the SCM mus-  cle and take the dissection posterior to the IJV to sample  as many nodes as possible.    Surgery become more difficult in the irradiated neck, and  it is often more difficult to preserve structures, particu-  larly nerves such as the accessory nerve. Tissue planes are  distorted, fibrosis makes dissection much more difficult,  and bleeding from small vessels can also be a problem.  Furthermore, there is a greater chance of wound break-  down (Table 41.1).   Bleeding Packing, identify vessel, repair if appropriate (involve vascular surgeons if  common or internal carotid [rare])    Exploration and/or medium chain triglyceride (dietician support)  Evacuate depending on size   Minimize risk with initial choice of incision and two-layer closure  Re-suturing in theatre    Late  Shoulder pain/dysfunction Physiotherapy  Contractures Physiotherapy  : Ferlito A, Rinaldo A, Silver CE, Gourin CG, Shah JP,  Top tips Clayman GL et al. Elective and therapeutic Hamoir  e Meticulous haemostasis. M, Shah JP, Desuter G, Gregoire V, Ledeghen S,  ¢ Traction and counter-traction. Plouin-Gaudon I et al. Prevalence of lymph nodes in  ¢ Dissection ona broad front. the apex of level V: A plea against the necessity to  ¢ Beware of anatomical variations. dissect the apex of level V in mucosal head and neck  e |fyouget stuck, start dissecting elsewhere and come back. cancer. Head Neck. 2005; 27: 963-969.  * Position patient head down 7 completion to raise Lindberg R. Distribution of cervical lymph node metas-  venous pressure dae enuty Bleeding poli: tases of the upper respiratory and digestive tracts.   MacFee WE. Transverse incisions for neck dissection. Ann  Surg. 1960; 151: 279-284.    Sessions RB and Pruet CW. Standardizing neck dis-  section terminology. Official report of the Academy’s  Committee for Head and Neck Surgery and Oncology.  Arch Otolaryngol Head Neck Surg. 1991; 117: 601-605.    . Crile GW. Excision of cancer of the head and neck.    With special reference to the plan of dissection based  on one and hundred and thirty two operations.  JAMA. 1906; 47: 1780-1786.    the Tongue. With an Analysis of 197 Cases. London:  Adlard and Son; 1908.    Clayman GL et al. Elective and therapeutic neck dis-  section. Oral Oncol. 2006; 42: 14-25.    R, Shaha A et al. American Head and Neck Society;  American Academy of Otolaryngology - Head  and Neck Surgery. Neck dissection classification  update: Revisions proposed by the American Head  and Neck Society and the American Academy of  Otolaryngology - Head and Neck Surgery. Arch  Otolaryngol Head Neck Surg. 2002; 128: 751-758.    mous carcinomas of the upper aerodigestive tract.  Am J Surg. 1990; 160: 405-409.    JE, Terrell JE et al. Development and validation of  the neck dissection impairment index: A quality of  life measure. Arch Otolaryngol Head Neck Surg. 2002;  128: 44-49.    Lymphatic metastasis generally follows an orderly and  predictable pattern of progression beginning with the sen-  tinel lymph node. It has been demonstrated that the status  of the sentinel node predicts the presence of metastasis in  the remainder of the nodal basin. Lymphoscintigraphy is  now established as a reliable and minimally invasive tech-  nique of identifying the sentinel nodes in solid tumours.  Since the original description to stage patients with  cutaneous melanoma, biopsy of the sentinel lymph node  has replaced routine elective lymph node dissection in  many anatomical regions that include the head and neck.  Initial attempts at lymph node mapping using the vital  dye, isosulphan blue, failed to localize the sentinel nodes  in about 20% of cases. The introduction of the hand-  held gamma probe has improved sensitivity to over 93%.  This technique is now being increasingly used to evaluate  cancer of the breast, colon and vulva, and it is redefining  the standard of care for these treatment sites.   Head and neck squamous cell carcinomas (SCC) are  considered to have a predictable pattern of metastasis to  cervical lymph nodes in previously untreated patients.    However, clinical experience may not provide fail-safe  information with which to direct therapy for individual  patients. It has been reported that 16% of patients with SCC  of the oral tongue had ‘skip metastases’ which bypassed  what was considered to be the first echelon nodal basin.  This highlights the need for individualized localization of  sentinel lymph nodes.    The sentinel node is the first echelon node of the nodal  basin. Presence of metastasis to the sentinel node defines  the status of the rest of the nodes in the nodal basin  (Figure 42.1).    Isosulphan blue-dye technique involves injection of the  dye submucously around the tumour. The sentinel lymph  nodes are those which are stained blue. As the technique  needs visualization, it is necessary to expose the entire  nodal basin, thereby increasing the invasiveness of the  procedure. Moreover, the isosulphan blue dye has been  proven to have lower reliability than lymphoscintigraphy  (Figure 42.2).   Dynamic lymphoscintigraphy involves injection of Tc  99-labelled filtered sulphur colloid at the periphery of the  tumour. The flow of radiolabelled dye from the primary  tumour to the sentinel nodes can be visualized in real time  using a gamma camera operating in a continuous mode.  The position of the nodes where the radioactivity localizes  can be marked on the skin using a pen (Figure 42.3).   Static lymphoscintigraphy involves identifying the  nodes with increased radioactivity using a hand-held  gamma probe (Figure 42.4). The sentinel node, which is  surgically removed, is submitted for various histopatho-  logical, immunohistochemistry and molecular marker  examination for the detection of micrometastasis.    Sentinel node biopsy is indicated for early stage (T1, T2)  oral cavity SCC of oral cavity with clinically NO neck.   © Incases where the neck needs to be exposed for other rea-  sons (exposure of donor vessels for reconstructive surgery)    A total of 5 mL of Tc 99-labelled filtered sulphur colloid  is loaded in an insulin syringe. Between 1 and 2 mL of  the sulphur colloid is injected submucously around the  tumour (Figure 42.5). This is performed after isolating the  tumour with gauze. Care should be taken to avoid spill-  ing of the radioactive material. Should it happen, it should  be wiped away with the gauze. Allow the patient to rinse  the mouth with saline several times to remove any salivary  contamination. It is necessary to instruct the patient to  avoid swallowing of saliva contaminated with the radio-  active material to avoid misleading images in the gamma    camera. All the radioactive material and contaminant  should be disposed of according to the institutional radio-  active material disposal guidelines.    Position the patient on the gamma camera table similar  to that in the operation table, using shoulder bag and head  ring. This is important as the position of skin marking can  change with neck extension in the operating table.    Beginning immediately after the injections, the patient  is positioned with the injection site centred under a large  field-of-view dual-head gamma camera. A large field of  view, set at 20% window centred on the 140-keV tech-  netium energy peak and fitted with a low-energy, high-  resolution parallel hole collimator, is used to follow the  disbursement of the radionuclide from the primary site  to the cervical lymphatic. Initially, images are captured in  an anteroposterior plane to determine the laterality of the  sentinel nodes, following which the images are captured  in the lateral view (Figure 42.6). The images are captured  in a continuous mode. The transit time for drainage of the  sentinel node in oral cavity cancer is less than 5 minutes.  It is a continuous process where tracking of dye into sen-  tinel nodes can be seen on screen. The primary tumour is  seen as a large shadow, while a sentinel node is seen as a  smaller shadow. The number of sentinel lymph nodes can  vary from two to three in head and neck cancer.    The position of the sentinel node is marked externally on  the neck (Figure 42.7). This serves as a landmark for inci-  sion in the neck during the surgery. The location of the  sentinel node is marked with the guide of a pointer with    radioactive tip under gamma camera in a continuous  mode. The location where the ‘hotspot’ of the pen and that  of the sentinel node coincide is marked on the skin with  an indelible pen.    The operation is performed under general anaesthesia.  Nasal intubation is preferred to avoid interference in deal-  ing with the primary tumour in the oral cavity.    The neck must be hyperextended with the shoulders and  occiput supported with a head ring. The neck is rotated to  the contralateral side. The operating table is tipped with    a head-up tilt. The head and neck region is prepared and  draped in the standard fashion to expose the neck and oral  cavity (Figure 42.8).    Emission of radiation from the primary lesion interferes  with detection of the sentinel node using the gamma  probe, particularly if the node is situated in the region of  level I. Excision of the primary lesion in the oral cavity  before performing sentinel node biopsy in the neck helps  in eliminating this radiation interference.    A transverse neck incision is marked on the neck as in a  standard neck dissection. An incision of about 4 cm in  length is placed along this marking so as to access the  marked sentinel nodes. Occasionally, it may be necessary  to make more than one incision. However, all the incisions  should be placed in such a way that these incisions should  be later extended to perform neck dissection, should it be  necessary (Figure 42.9).    Upper and lower skin flaps are raised in the subplatys-  mal plane over the region of the marked sentinel nodes  (Figure 42.10).    Using a hand-held gamma camera, the background radia-  tion level is noted in the neck in a position away from the  sentinel nodes and primary tumour. Using the skin mark-  ing and the hand-held gamma probe as a guide, the region  of the sentinel node is explored (Figure 42.11). An increase  in count of more than threefold, the background is con-  sidered significant. This count is noted as an in vivo count.  That particular node is removed and the ex vivo count is  obtained outside the body to confirm it as a sentinel node.  Count of node-bed is noted, which should confirm that the  identified node is removed. The procedure is repeated to  remove all the marked sentinel nodes. The wound is closed  in layers. Drains are not usually required.    The excised sentinel nodes are sent for histopathologi-  cal evaluation. Step-sections of the nodes are obtained  along the hilum of the node at 3-4 mm intervals. The  tissue is processed by haematoxylin and eosin staining.  Immunohistochemistry with pan-cytokeratin antibody  or CK-14 polymerase chain reaction may be performed to  identify submicroscopic metastasis. The clinical relevance  of such lesions is yet to be determined. The feasibility of  determining metastatic status by frozen section evaluation  also needs to be determined.    Sutures are removed on day 7. The final histopathological  report is evaluated and if any node shows metastasis, for-  mal neck dissection is carried out.    Regular follow-up of every month for a year and every 2  months for the second year is done. Any suspicious neck  mass is thoroughly evaluated with ultrasound scan and  fine needle aspiration cytology as deemed necessary.    At present, there are no clear guidelines for the manage-  ment of clinically NO neck. Lymphoscintigraphy and sen-  tinel node biopsy offer the possibility of minimal invasive  management of the NO neck, avoiding undue morbidity  of surgery or radiation, as well as eliminating the risk of  regional recurrence. However, efficacy of the procedure  and long-term results need to be assessed before imple-  menting it in clinical practice.    e Sentinel node biopsy should be performed in a previ-  ously untreated patient.    e Care should be taken to avoid spillage of the dye while  injecting around the tumour.    e Instruct the patient not to swallow during injection to  prevent ingestion of the dye.    e Theposition ofthe patient underthegammacamera should  be similar to the position to be adopted in the operating  room to increase the accuracy of sentinel node marking.    e If the sentinel node is identified in level |, consider  removing the primary tumour first to avoid back-  ground radiation.    Byers RM, Weber RS, Andrews T, McGill D, Kare R and  Wolf P. Frequency and therapeutic implications of  ‘skip metastases’ in the neck from squamous cell  carcinoma of the oral tongue. Head Neck. 1997; 19:  14-19.   Giuliano AE, Dale PS, Turner RR, Morton DL, Evans SW  and Krasne DL. Improved axillary staging of breast  cancer with sentinal lymphadenectomy. Ann Surg.  1985; 222: 394-401.   Hamy A, Curtet C, Paineau J Chatal JF and Visset J.  Feasibility of radioimmunoguided surgery of colorec-  tal carcinoma using indium 111 CEA specific anti-  body and simulation with a phantom using 2 step  targeting with bispecific antibody. Tumori. 1995; 81:  103-106.   Levenback C, Burke TW, Morris M, Malpica A and Ross  MI. Potential application of intraoperative lymphatic  mapping in vulval cancer. Gynecol Oncol. 1995; 59:  216-220.   Lindberg R. Distribution of cervical lymph node metas-  tases from squamous cell carcinoma of the upper  respiratory and digestive tracts. Cancer. 1972; 29:  1446-1450.   Morton DL, Wen DR, Wong JH, Economou JS, Cagle LA,  Storm FK et al. Technical details of intraoperative  lymphatic mapping for early stage melanoma. Arc  Surg. 1992; 127: 392-399.   Pijpers R, Collet GJ, Meijer S and Otto SH. The impact  of dynamic lymphoscintigraphy and gamma probe  guidance on sentinel node biopsy in melanoma. Eur J  Nucl Med. 1995; 22: 1238-1241.    Skull base surgery developed principally throughout  the 1990s to become an established and clearly defined  surgical subspecialty. The service is team based and  includes neurosurgeons, oral and maxillofacial, ENT  and/or plastic surgeons and ophthalmologists. The team  will also include neurointensivists, neuroanaesthetists  and neuroradiologists with interventional expertise.  Neurosurgical and critical care nursing expertise and a  team coordinator are essential.   Skull base tumours generally have neural, vascular or  meningeal origins. They may also arise from bone, car-  tilage and extra-cranial tissues. Although a vast range  of different pathological entities is included within the  definition, common biological tendencies are observed  because of their anatomical location. Management of  patients harbouring skull base pathology is complex and  surgeons require in-depth anatomical knowledge - usu-  ally obtained by cadaveric dissection, and expertise may  be required in microvascular anastomosis and neural  reanimation.    In general terms, patients harbouring skull base pathol-  ogy will present with symptoms that for convenience can  be classified as aforementioned. The onset and develop-  ment of clinical features may be insidious because of  the relatively slow rate of progression of the majority of  tumours. It is crucial to be able to identify and document  the pace of progression to ensure timely intervention and  pre-empt critical neural decompensation.   Tumours affecting the skull base may be primary or  secondary lesions. Metastatic disease in the skull base  is not uncommon and biopsy may be required prior to  major surgery being undertaken in cases where there is    diagnostic doubt. The source of the primary tumour may  not be known until after the result of the biopsy.    For convenience, skull base tumours can be classified  according to primary location, e.g., anterior cranial fossa  (ACF), middle cranial fossa (MCF), posterior fossa (PF)  and those arising from the paranasal sinuses, orbit, infra-  temporal fossa and post-nasal space.    A number of factors need to be considered in the set-  ting of a multidisciplinary team meeting (MDT) in  order to establish appropriate treatment pathways for  these patients. Guidelines issued by National Institute of  Clinical Excellence (NICE) in the United Kingdom indi-  cate the required expertise. Factors to consider include the  following:   © Formal ophthalmological review may be needed and  visual evoked potentials may help assess potential for  stabilization/recovery of visual function as well as iden-  tify ‘sub-clinical’ optic nerve failure.   ® Where the lateral skull base is involved, hearing,  balance and vestibular function will need to be accu-  rately assessed and noted.    Comorbidity factors require careful evaluation. In gen-  eral terms, complications occur in up to 20% of patients  undergoing major skull base surgery. Those patients with  significant comorbidity have a higher risk of complications    and will be less likely to recover from peri-operative  systems compromise. In patients with established or  anticipated lower cranial nerve or bulbar dysfunction, tra-  cheostomy and gastrostomy will be required at an early  stage to avoid aspiration pneumonitis and ensure safe  adequate nutrition.    Detailed imaging is essential for treatment planning. As a  minimum, this will include computed tomography (CT)  and magnetic resonance imaging (MRI). Precise delin-  eation of the tumour is required and critical evaluation  of anatomically inaccessible areas is required to identify  patients who may not fulfil criteria for surgery, e.g. inva-  sion of the cavernous sinus. In some tumours, or in those  patients requiring post-operative evaluation, positron  emission tomography (PET) scanning may be required to  distinguish tumour tissue from post-operative scarring/  flaps used in reconstruction and regions displaying post-  operative hyperaemia. Angiography will delineate blood  supply and identify patients who may need pre-operative  embolization. Protocoled CT scans for intra-operative  navigation is often necessary to localize critical structures  and aid resection.    In determining options for management, it is important  to be able to assess the impact of intervention on the nat-  ural history of the pathology. Where treatment benefits  are marginal, conservative management may be in the  patient’s best interests. In general, neurological deficits are  unlikely to recover with treatment and stabilization will  be a more rational objective.   The impact of treatment on the patient’s quality of life  is a further important consideration. In general, surgery  may dramatically alter quality of life adversely in the short  and medium term. This is less evident with radiotherapy -  none the less the long-term impact of the latter may need  evaluation.    It is important to recognize that ‘cure’ of this type of  pathology may be elusive - this needs to be emphasized  in discussions held with the patient and carers. Tumour  control in the vast majority of cases will prove to be a more  realistic option.    In addition to an experienced and multi-professional  workforce, adequate theatre time, expensive ‘high-tech’  equipment and the support of a highly trained theatre  team are required. Access to neurointensive or critical  care facilities is mandatory.    Fundamental aspects of anaesthesia in skull base surgery  include maintenance of haemodynamic stability, control  of intra-cranial pressure (ICP), cerebral protection and  cranial nerve monitoring. This latter may preclude the use  of long-term muscle relaxants. Intermittent pneumatic  calf compression is used in conjunction with an agreed  policy to reduce the incidence of deep vein thrombosis  (DVT) and pulmonary thromboembolism (PTE). Careful  positioning of the head is essential to avoid compromise of  the neck veins.    Standard equipment will include an operating chair,  neurosurgical microscope and increasingly endoscopes  and appropriate stacks/screens. Micro-instruments and  non-stick bipolar forceps are essential. Image guidance  is helpful, but must not be used by the inexperienced to  compensate for a lack of anatomical knowledge and surgi-  cal expertise. High-speed drills, ultrasonic aspirators and  nerve monitors complete the list of essential equipment.  Some services have access to intra-operative MRI.    In planning surgical treatment, a clear understanding of  the pathological anatomy is required. Whilst the oper-  ating surgeons may be familiar with normal skull base  anatomy, the pathological process may distort this. This  facilitates planning of the access required, tumour resec-  tion and reconstruction of the skull base.    It is fundamental that adequate access to the pathology  is realized. This may involve the use of craniofacial oste-  otomies although with experience their use is rationalized  and tailored to the individual patient. A short straight line  of sight to the pathology is necessary to create space for  surgical manoeuvres and avoid brain retraction. Access  should not compromise reconstructive options, e.g., pres-  ervation of the superficial temporal and supraorbital ves-  sels. Damage to the temporal muscle should be avoided  unless its resection is mandatory. Ideally, osteotomies  should be pedicled, if post-operative radiotherapy is  planned. Endoscopic surgery can be employed on its own  or in addition to open surgery (endoscopic assisted) in  selected individuals and specific pathologies.    In the planning process, the overall strategic approach to  the tumour must be determined. The following need to be  considered.   © The requirement for temporary vascular occlusion, e.g.  internal carotid artery. Intra-operative mini Doppler  may assist in confirming post-manipulation patency  and identify vessels in spasm.   © Spinal drainage - a spinal drain may enhance brain  relaxation, but the amount of cerebrospinal fluid (CSF)  drainage must be carefully controlled by the anaesthetist.   ® Steroids, Mannitol and withdrawal of CSF from the  basal cisterns and ventricles may also assist with brain  relaxation.    Exposed brain surfaces must be kept moist and where  retractors are used, non-stick patties or equivalent should  protect the brain. Meningiomas and schwannomas adja-  cent to the brain will usually have an arachnoidal plane,  within which the dissection should be carried out.  Damage to the pia should be avoided. Vascular structures  are generally dissected parallel to the encased structure  and should only be divided after dissection has confirmed  that they supply the tumour. Tumour adherent to perfora-  tors should be left in situ - tumour eradication should not  be preferred to preservation of neurovascular structures.   Dissection en bloc is the ideal with high-grade tumours  to avoid tumour spillage. With larger tumours, this may  not be possible due to anatomical constraints — in this situ-  ation a so-called modified en-bloc resection is performed.  The use of the operating microscope is essential in critical  areas such as the optic chiasma and cavernous sinus.    Reconstruction of the skull base is critical to avoid post-  operative infection and CSF leak.   © Repair basal dural defects with vascularized convexity  dura or a vascularized pericranial or galeal-pericranial  flap passed via a ‘letterbox’ approach through the con-  vexity dura.   ® Tissue glue is helpful to control suture holes and  re-enforce suture lines, but will not secure an inad-  equate repair.   © Small bone defects do not generally need reconstruction  but larger defects, particularly over the orbital roof, may  need a bone graft, mesh or free tissue transfer to support  the dural repair and prevent pulsating exophthalmos.   © The majority of middle fossa defects can be recon-  structed with a pedicled temporalis muscle graft.  Extensive defects may require free tissue, e.g. rectus  abdominis, particularly if the temporalis muscle is  devascularized in the resection.   ® Central skull base - bone not required in isolated cen-  tral skull base defects. In more posterior defects par-  ticularly in older patients, reliance cannot be placed on  pericranial flaps; galeo-pericranial flaps are preferred.   ® Orbit - orbital roof reconstruction prevents pulsating  exophthalmos. Isolated lateral wall defects may not  need reconstruction.   @ ‘Dead space’ may allow accumulation of post-operative  clot and may be a focus for infection and allow brain  herniation. In the central skull base, this may cause  traction injury to the optic apparatus. Free tissue recon-  struction is usually required in extensive defects.    It is relatively unusual to require free tissue transfer to  reconstruct the skull base. The relative indications include  the following:    There are a number of options that can be considered.  The choice of flap will depend on the requirement for  bulk to obliterate dead space or lining to close a basal  defect without altering the intra-cranial volume. For the  former, a wide variety of muscle or musculo-cutaneous    flaps are suitable, e.g. rectus abdominis/latissimus dorsi/  anterolateral thigh. For the latter, in our practice, the  most frequently used flap is radial forearm for central  skull base defects. This versatile flap is used without the  cutaneous component to produce a thin fascial flap on a  long vascular pedicle.    Infection is the most dreaded complication of skull base  surgery. When this occurs in the setting of an inadequate  primary repair, control will only be possible when vascu-  larized tissue is introduced to create a barrier between the  intra- and sub-cranial regions.   CSF pathway problems are the next most frequent com-  plication. Whilst the majority settles with temporary CSF  drainage, a persistent CSF leak will require further sur-  gery and hydrocephalus may necessitate placement of a  shunt.   General medical complications including respiratory  tract infection, post-traumatic epilepsy, urinary tract  infection and poor nutrition are not uncommon. These are  best treated after prompt recognition in a neurointensive  care or critical care unit.    The three cases discussed have been selected to illustrate  different tumour sites, pathology reconstructive tech-  niques and management difficulties.    This is a difficult tumour to control. The ideal is total  resection (Simpson Grade 1) but around the skull base,  this may be precluded by extensive basal dural involve-  ment and proximity to critical neurovascular structures.  In general, patients with visual failure and those with  proptosis resulting in ophthalmological complications  will require craniofacial resection and reconstruction.  In our series of patients, the majority (92%) presented  with proptosis and the orbit and MCF were involved in  71%. Whilst technically benign, there is a propensity for  this tumour to cross anatomical barriers, invade adja-  cent structures and recur despite initial surgery consid-  ered to be complete.   The conventional surgical strategy includes preserva-  tion of vision, improvement of aesthetics and prevention  of the inevitable ophthalmological complications of the  untreated primary process.    In most cases, a frontotemporal or pterional craniotomy  will be required and lateral/superior orbitotomies may  enhance access to the intra-orbital tumour and resection  of the bone around the superior orbital fissure and optic  canal under direct vision. It is probable that invaded bone  in the vault and skull base will require removal. In cases  where the temporalis muscle is invaded, this will require  resection. Imaging findings may dictate that the superior  orbital fissure is decompressed together with the foram-  ina rotunda and ovale. Infiltrated periorbita will then be    resected. The optic canal will usually require radical bony  decompression and soft tissue compressing the optic nerve  will require removal. In patients who have required resec-  tion of more than one orbital wall, an orbital reconstruc-  tion will be required. In these cases, the use of surgical  guides and patient specific implants significantly improves  the accuracy of the reconstruction and decreases intra-  operative surgical time (Figures 43.1 through 43.3). When  these aids are not available, split calvarial bone grafts and/  or titanium mesh can be utilized (Figures 43.4 and 43.5).    Sphenoid wing meningioma en plaque. (a) Pre-operative proptosis right eye. (b) Axial computed tomography (CT)    (a) Planed resection with surgical guide in situ. (b) Defect following resection of tumour, optic nerve and superior    (a) Custom made PEEK implant in situ. (b) Post-operative appearance demonstrating excellent cosmesis with  preservation of sight and eye movement.    (a) Harvesting split inner table calvarial grafts. (b) Reconstruction of orbital walls.    (a) Contoured titanium mesh on a mirrored model. (lb) Pre-contoured mesh in situ.    A significant proportion of malignant tumours consid-  ered for craniofacial resection will originate from the  paranasal sinuses. Various factors have to be taken into  account to assess local resectability and include involve-  ment of the brain, dura, orbital structures, nasal cavity,  temporal/infratemporal/pterygopalatine fossa and skin.  The adjoining structures can be considered as specific  compartments and involvement of these compartments  will mandate partial/complete resection of the respective  compartments.   This patient presented with proptosis and ophthalmo-  plegia due to an abdominal type adenocarcinoma involv-  ing the right maxillary/ethmoid sinuses/nasal cavity/  orbit extending superiorly through the cribriform plate  to involve the dura, but not the brain and posteriorly to  involve the infratemporal fossa (Figure 43.6). Access was  obtained via a modified Weber-Fergusson incision, coro-  nal flap, soft-tissue nasal swing and bifrontal craniotomy  (Figure 43.7). (Lip split marked for access to the poste-  rior maxilla/infratemporal fossa, but not utilized; infe-  rior dental/lingual nerves traced to skull base with early  coronoidectomy). He underwent a craniofacial resection,  which included a bifrontal craniotomy, extended maxil-  lectomy with infratemporal fossa clearance, orbital and  nasal exenteration and ACF resection including the dura.  Vascularized pericranial flap was utilized to line the floor  of the ACF and separate the cranial contents from the  nasal cavity; maxilla and orbit reconstructed with com-  posite fibula and anterolateral thigh free flaps (Figures  43.8 through 43.12).    The excisions margins were clear of tumour and he  received post-operative radiotherapy due to the extent  and adverse histological features of the tumour. He  remains well and free of recurrence 18 months following  surgery.    Interventions with palliative intent are considered to alle-  viate unpleasant symptoms and enhance/maintain quality  of life. These often take the form of pharmacological inter-  ventions, radiotherapy and psychosocial support. Surgery,  however, can have an important role to play in selected  individuals to achieve similar aims.   This patient presented with a new metastatic deposit  from a thyroid carcinoma in the left orbital apex/sphenoid  wing causing significant pain, proptosis and decreasing  vision (Figure 43.13). The tumour was considered radio-  resistant, as the spinal metastasis had not responded to  radiotherapy. The patient was otherwise well, lived inde-  pendently and continued to work.   Following discussion at the MDT, the patient under-  went a frontotemporal craniotomy, superior/lateral orbi-  totomy and excision of the tumour including the affected  temporal bone, temporalis muscle and decompression of  the optic nerve and superior orbital fissure (Figure 43.14).  The defect was reconstructed with a custom made poly-  etheretherketone (PEEK) implant and the resections were  performed with a surgical guide (Figure 43.15a). The  patient made an uneventful recovery and was discharged  home 3 days following surgery, completely symptom free    Figure 43.6 (a) Pre-operative appearance. (b) Coronal magnetic resonance imaging scan.    (a) Mid-facial defect following resection of  tumour; inferior dental/lingual nerves traced to skull base. (b)    (a) Post-operative three-dimensional CT scan demonstrating bony reconstruction. (b) Early post-operative  appearance.    (a) Pre-operative appearance with proptosis.  (b) Axial MRI demonstrating the lesion.    with intact vision and eye movements (Figure 43.15b). The  patient returned to work 3 weeks later and died of dissem-  inated disease 6 months later, with no recurrence of her  orbital symptoms.    (a) Resection margins outlined with the sur-  gical guide. (b) Defect following resection of tumour.    This patient highlights the potential difficulties in  deciding the appropriate treatment in complex cases -  balancing the surgical morbidity versus quality of life,  which in this case was enhanced despite the limited  post-operative course.    Patients are becoming aware of these treatments and  frequently request their use in preference to surgery.  Surgeons must be able to provide reasoned argument for  the pros and cons of these forms of irradiation in tumour  control.    Figure 43.15 (a) Custom made PEEK implant in situ. (b)  Appearance 2 weeks post-op.    e Skull base surgery should only be contemplated with  the appropriate skill mix in a multidisciplinary team.   e Many skull base tumours are slow growing, and clini-  cal and imaging surveillance play a key role in patient  management.   e Sound applied anatomical knowledge is essential to  link sub-cranial with intra-cranial dissection.   e The use of appropriate access osteotomies may facili-  tate cerebral protection by minimizing brain retrac-  tion whilst maintaining a wide corridor of access to the  pathology.   e Sub-total tumour resection, particularly in benign and  low-grade malignant tumours will frequently provide  adequate tumour control, provide relief from symp-  toms and minimize morbidity.   e The key elements in reconstruction are the isolation of  intra-cranial contents from the nasal cavity and parana-  sal sinuses and appropriate support for the frontal and  temporal lobes if required. Autologous tissue is the pre-  ferred reconstructive option.   e Follow-up protocols will depend on tumour biology -  recurrence is expected with certain tumours including  chordoma and meningioma.   e Surgeon's objectives and technical achievement need  to be aligned with the expectations of patients and  their carers.    Cantu G, Solero CL, Miceli R, Mattana F, Riccio S, Colombo  S, et al. Anterior craniofacial resection for malignant  paranasal tumours: A monoinstituitional experience  of 366 cases. Head Neck. 2012; 34: 78-87.   Cushing H and Eisenhardt L. Meningiomas. Their classi-  fication, regional behaviour, life history and surgical  results. Springfield, IL: Charles C Thomas; 1938.   Evans HL, Ayala AG and Romsdahl MM. Prognostic fac-  tors in chondrosarcoma of bone. A clinic-pathologic  analysis with emphasis on histological grading.  Cancer. 1977; 40: 818-831.   Ganly I, Patel SG, Singh B, Kraus DH, Bridger PG, Cantu G,  et al. Craniofacial resection for malignant paranasal  sinus tumours: Report of an international collabora-  tive study. Head Neck. 2005; 27: 575-584.   Honeybul S, Neil-Dwyer G, Lang DA, Evans BT, Ellison  DW. Sphenoid wing meningioma en plaque: A clini-  cal review. Acta Neurochirur. 2001; 143(8): 749-758.   Honeybul S, Neil-Dwyer G, Lang DA, Evans BT, Weller  RO, Gill J. The extended transbasal approach: A  quantitative anatomical and histological study. Acta  Neurochirurgica. 1999; 141(3): 251-259.   Howard DJ, Lund VJ and Wei WI. Craniofacial resec-  tion for tumours of the nasal cavity and paranasal  sinuses: A 25-year experience. Head Neck. 2006; 28:  867-873.    Kleihues P, Burger PC and Scheithauer BW. The new WHO  classification of brain tumors. Brain Pathol. 1993; 3:  255-268.   Lund V, Stammberger H, Nicolai P and Castelnuovo P.  European position paper on endoscopic management  of tumours of the nose, paranasal sinuses and skull  base. Rhinol Suppl. 2010; 22: 1-143.    National Institute of Health and Clinical Excellence. Improving  Outcomes for People With Brain and Other CNS Tumours -  The Manual. London: National Institute for Health &  Clinical Excellence; 2006. Available at www.nice.org.uk   Ringel EK Cedzich C and Schramm J. Microsurgical tech-  nique and results of a series of 63 spheno-orbital  meningioma-en-plaque. Neurosurgery. 2007; 60: 214-222.    Surgical removal of stones in the distal submandibular duct  Surgical removal of stones in the proximal submandibular duct   Sublingual gland excision for ranula or excision biopsy  Sublingual gland excision for malignant tumour  Surgery of the minor salivary glands    The most frequent indications for excision of the subman-  dibular gland are when a calculus is present within the gland  hilum and cannot be retrieved endoscopically or when the  gland is the site of chronic infection or when a benign or  malignant tumour is present. Only 10% of salivary tumours  arise in the submandibular gland and 60% of these will be  pleomorphic adenomas. The remaining 40% will be malig-  nant. Except in advanced malignancy, the tumours rarely  extend beyond the capsule of the gland and so excision of  the submandibular gland is the definitive surgical treat-  ment. For advanced malignant tumours with spread beyond  the capsule, more radical clearance of the submandibular  triangle is required, often in continuity with a neck dissec-  tion. When a pre-operative diagnosis of a benign tumour  can be reasonably and confidently established by computed  tomography (CT) and ultrasound-guided fine needle aspi-  ration cytology or preferably fine needle core biopsy and  the tumour is in the superficial part of the submandibular  gland partial excision of the gland is possible. This has the  merit of preserving gland function and reduces the risk of  damage to the lingual and hypoglossal nerves.    There are only two indications for the removal of the  sublingual gland. The first is in the management of a ran-  ula and the other is when a tumour is present. The sublin-  gual gland is a very rare site of tumour, but almost all of  them will be malignant, the majority being adenoid cystic  carcinomas. The most frequent reason for operating on  the minor salivary glands is for mucocoele or for tumour.  Nearly 10% of salivary tumours arise in the minor glands  and about 50% of these will be malignant.    When there is a history suggestive of obstruction, plain  radiographs (mandibular occlusal and oblique lateral  views) are appropriate as the majority of submandibular  stones are calcified. A sialogram should not be performed  unless a calculus has been ruled out on plain film as the  sialogram itself might displace the stone proximally, mak-  ing surgery more difficult. For the investigation of chronic  infection, a sialogram is invaluable. It will show the extent  of the destruction of the acinar cells and the post-stimu-  lation emptying film will demonstrate residual function.    If the gland is not functioning, it should be removed as an  elective procedure to prevent further episodes of infection.   When a mass is present either in the submandibular  gland or the sublingual gland, a CT scan or a magnetic  resonance imaging (MRI) scan is indicated. The scan  should include the neck so that any associated lymph-  adenopathy is also imaged. For suspected minor salivary  gland tumours, if they occur within the lips, cheeks or  floor of the mouth, simple excision biopsy is the investiga-  tion of choice. However, for tumours arising on the hard  palate, imaging with a CT or MRI scan is mandatory to  assess the depth of the tumour.    Open surgical biopsy of a suspected submandibular gland  tumour is contraindicated. If the tumour is contained within  the capsule of the gland, open biopsy will spill tumour cells  into the surrounding tissue planes. As the majority will be  benign pleomorphic adenomas, their straight forward exci-  sion will be compromised. If the tumour is malignant, then  the hope of cure will have been compromised. Fine needle  aspiration biopsy appears to be safe but is unreliable because  of sampling error in salivary gland pathology, but ultra-  sound-guided fine needle core biopsy is useful if available.   For suspected minor gland tumours arising in mobile  soft tissues (lips, cheeks and floor of the mouth), excision  biopsy will often be the only treatment required. If the  tumour proves to be a high-grade malignancy, further-  more extensive surgery might be required together with  post-operative radiotherapy when indicated. The situation  is different when a tumour arises from the hard palate. In  this situation, an incisional biopsy is mandatory as the  diagnosis will have a direct influence on the extent of the  subsequent surgery.    Wherever facilities are available, a first attempt at endo-  scopic or Dormia basket retrieval should be attempted (see  Chapter 45). However, on occasion this is either not available  or is unsuccessful in which case open surgery is required. If  the stone lies within the lumen of the duct distal (anterior) to  the point where the duct crosses the lingual nerve, it is a safe  procedure to open the duct and remove the stone. For stones  more proximal, great care must be taken to avoid damage to  the lingual nerve and often it may be wise to remove the sub-  mandibular gland together with the stone from an external  approach.    In a co-operative patient, the operation is readily per-  formed under local anaesthesia. If co-operation is in doubt,  a general anaesthetic should be used. If the operation is    to be performed under local anaesthesia, 2% lignocaine  hydrochloride with 1:80,000 epinephrine (adrenalin)  is used. A lingual nerve block plus local infiltration suf-  fices. Care must be taken not to infiltrate too much solu-  tion immediately over the duct as this can easily distend  the floor of the mouth and make it difficult to identify the  duct. It is also important not to perforate one of the sublin-  gual veins as this will result in a large haematoma.    The first stage is to pass a stay suture into the floor of the  mouth around the duct proximal to the position of the  stone. This prevents the stone from being displaced back-  wards during the operation. The ends of the suture are left  long and should be held in artery forceps. Gentle traction  on the suture will then lift the duct upwards making it  more accessible in the floor of the mouth (Figure 44.1).   An incision is made in the mucosa along the line of the  duct overlying the stone. The blade is used in a gentle strok-  ing fashion gradually becoming deeper until the wall of the  duct is opened. The duct itself is seen as a pale grey struc-  ture with an overlying capillary network (Figure 44.2).   It is often helpful to steady the duct with dissection for-  ceps while incising longitudinally through its wall. Often  the calculus is seen through the duct wall and the overly-  ing incision immediately releases it. If the stone is large  and there has been scarring and fibrosis, it may be adher-  ent to the lining of the duct. In this situation, fine stay  sutures can be inserted into the duct wall on each side of  the stone and these sutures can be used to retract the walls.  The calculus can be gently mobilized and freed with the  careful use of a fine artery clip or small dental excavator  (Figure 44.3).   Once the calculus has been released, cloudy mucinous  saliva will often be released from the duct proximally.    Figure 44.1 Stay suture around the submandibular duct  proximal to the site of the stone.    A linear incision is made in the floor of the  mouth to expose the submandibular duct.    The duct should be gently irrigated with sterile saline  or water both proximally and distally to ensure that any  further epithelial casts or gravel are removed. If these  are retained, they readily act as foci for further stones to  form (Figure 44.4).   The stay sutures are removed and the mucous mem-  brane of the floor of the mouth is closed with two or three  resorbable sutures. No attempt should be made to close the  duct walls as this would result in scarring and stricture  formation leading to further obstruction (Figure 44.5).    Access to the posterior floor of the mouth is difficult in  the conscious patient and for this reason general anaes-  thesia is preferred. Once the patient is on the operating    Figure 44.6 Incision in the floor of the mouth for removal  of a stone at the hilum of the submandibular gland.    table, it is helpful to infiltrate the floor of the mouth with  local anaesthetic containing epinephrine (adrenalin) as  this helps to reduce bleeding. Care must be taken not to  perforate one of the sublingual veins.    An assistant is essential. The operator should stand on the  contralateral side. A mouth prop is inserted between the  molar teeth on the side of the stone. The assistant grasps  the tongue with a swab or alternatively a sharp pointed  towel clip can be used. The tongue is retracted forward  and away from the side of the stone. An incision is made  through the mucosa of the floor of the mouth laterally  from the third molar region forward and medial to the  sublingual gland (Figure 44.6).   The sublingual gland is then retracted laterally using  one or two stay sutures revealing the submandibular duct  on its deep surface. Using careful blunt dissection, the  duct is traced posteriorly identifying the lingual nerve  passing immediately deep into the duct running from the  lateral border of the tongue towards the third molar tooth  (Figure 44.7).   Once the duct and the lingual nerve have been identi-  fied, they must be carefully separated and the duct traced  posteriorly into the hilum of the submandibular gland. At  this point the lingual nerve lies very superficially and is  ‘tethered’ to the gland itself through the parasympathetic  ganglionic fibres (Figure 44.8).   The assistant should apply firm pressure in the subman-  dibular region in order to elevate the hilum of the gland and  the proximal duct upwards above the level of the mylohyoid.  At this point, the stone is readily palpable. A longitudinal    Figure 44.7 Following retraction of the sublingual gland  the lingual nerve can be identified deep to the submandibular  duct.    Figure 44.8 Posteriorly the lingual nerve ascends towards  the skull base crossing the duct as it enters the hilum of the sub-  mandibular gland. (A) Facial artery; (B) lingual nerve and subman-  dibular gland; (C) submandibular duct; (D) sublingual gland.    incision is made through the duct wall and the stone is  teased out using a small excavator (Figure 44.9).   The duct is then carefully irrigated in order to wash out  any associated ‘gravel’. No attempt is made to close the duct  wall. Careful use of the diathermy ensures haemostasis.  All stay sutures are removed and the mucosa of the floor of  the mouth is closed with two or three resorbable sutures.    As the stone and obstructed gland is likely to be infected,  a 3-day course of antibiotics is given. Routine analgesia is  used and the patient should be encouraged to eat citrus  fruit or to chew gum in order to encourage salivary flow.    Figure 44.9 The hilum of the gland is incised to release the  stone.    The operation is performed under general anaesthesia.  The patient is placed supine on the operating table with  moderate neck extension and the chin rotated to the oppo-  site side. It is helpful to have head-up tilt of the table as  this reduces venous engorgement. Following routine skin  preparation and draping, the incision is mapped out. The  incision line should be infiltrated with conventional den-  tal local anaesthetic containing 2% lignocaine hydrochlo-  ride and 1:80,000 epinephrine (adrenaline). This results  in some vasoconstriction which limits capillary ooze and  helps to define tissue planes.    The incision should run within a natural skin crease in  the neck at least 3 cm below the lower border of the man-  dible in order to avoid damage to the mandibular branch  of the facial nerve as it loops down below the lower bor-  der of the mandible (Figure 44.10). It should be at least  7 cm long. The lower the incision in the neck, the better  the post-operative cosmetic result, but incisions lower  than 3 cm make the operation slightly more difficult as  the operator must dissect upwards to reach the subman-  dibular triangle.   The incision is made with either a No. 15 blade or with  a fine diathermy needle or ceramic blade while the assis-  tant puts tension across the incision line. The incision is  made directly down to platysma. The subcutaneous fat is  stripped with firm pressure with a swab from the under-  lying muscle for approximately 1 cm on each side of the  incision as this facilitates a layered closure. The underlying  platysma is then incised to the full extent of the skin inci-  sion, again using either a blade or diathermy.    Figure 44.10 Incision marked out in a natural skin crease  in the neck.    The assistant can now retract the wound margins using  ‘cat paws’ or Allis forceps applied to the cut edge of the  platysma (never the skin edges!). The underlying invest-  ing layer of the deep cervical fascia is next divided, prefer-  ably with scissors, after the fascia is first tented outwards  with toothed forceps. Often the fascia consists of a series of  separate laminae like an onion skin, but occasionally it is  composed of a single thicker sheet. Again the fascia should  be divided along the full length of the incision to avoid the  operative field becoming even smaller (Figure 44.11).   Posteriorly, the fascial incision approaches the angu-  lar tract where the deep cervical fascia splits to form the  investing layer that has just been incised and the deeper  layer that forms the floor of the submandibular triangle  containing the submandibular gland.   The marginal mandibular branch of the facial nerve  normally runs on the deep aspect of the investing layer  of fascia, although, occasionally, it lies between the pla-  tysma and the fascia. Great care must be taken to pro-  tect this branch. Even with an incision as low as 3 cm  below the lower border of the mandible, the nerve may  be encountered when the fascia is divided. If it is seen, it  should be carefully mobilized and gently retracted with  the upper part of the flap.   The delicate capsule overlying the gland is then lifted  with toothed dissection forceps and opened with scissors.  The loose connective tissue is separated with scissors to  expose the surface of the gland (Figure 44.12). The anterior  facial vein which lies in the connective tissue overlying the  submandibular gland is clamped, divided and tied.   From now on, the dissection continues as close to the  surface of the gland as possible. In the case of chronically  infected glands, there is frequently extensive fibrosis and  care and patience is required to maintain this plane. For all  tumours contained within the submandibular gland cap-  sule, the operation should proceed in the plane just super-  ficial to the capsule as it is an effective barrier between  the tumour and adjacent structures. When the tumour  is known to be benign and lies superficially within the  gland then only that part of the gland needs to be excised  using a careful extracapsular dissection. For malignant    tumours that have extended beyond the capsule, a full  submandibular clearance, usually as part of a neck dissec-  tion, and often including the periosteum of the lower and  inner aspect of the mandible, is needed (Figure 44.13).   The anterior pole of the superficial lobe of the sub-  mandibular gland is first mobilized and retracted  upwards with Allis forceps (Figure 44.14). This reveals  the posterior belly of the digastric which is then gently  retracted downwards with a small Langenbeck retractor.  This then exposes the facial artery which emerges from  behind the stylohyoid muscle and passes upwards and  forwards to enter the deep surface of the submandibu-  lar gland. The artery is then clamped, divided and tied.  Great care must be taken to secure the proximal ligature.  As the vessel is divided, it retracts out of site and, if the  ligature slips, the bleeding end of the vessel can be very  difficult to identify.   The course of the facial artery is variable. Often it deeply  penetrates the substance of the gland to emerge again at  its upper border. Sometimes the artery lies in a groove in  the deep aspect of the gland. The dissection continues to  mobilize the anterior pole of the superficial lobe of the  gland which is then gently retracted posteriorly. During  this dissection, a number of small arteries and veins will    be identified entering the gland. These should be carefully  clamped, divided and tied or diathermized according to  their size. As the dissection continues posteriorly along  the lower border of the mandible, the facial artery and  anterior facial vein are encountered as they hook around  the lower border. These vessels are again clamped, divided  and ligated.   Sometimes when the facial artery runs in a groove on  the deep aspect of the submandibular gland, it can be  preserved without division at the lower edge of the gland  and again at the lower border of the mandible. However,  although this is technically possible, there is little advan-  tage other than to show off one’s technical expertise.   At this stage in the operation, the anterior pole of  the superficial lobe of the gland can be retracted pos-  teriorly to reveal the groove between the superficial  and deep lobes of the submandibular gland. The pos-  terior border of the mylohyoid lies within this groove.  It is gently freed with scissors and then retracted for-  ward with a Langenbeck retractor. The deep lobe of the  gland can now be mobilized either with a finger or by  opening the blades of the scissors applied to the surface  of the gland. On the deep aspect of the deep lobe, one  or two small veins may be encountered running from    Division of the deep cervical fascia following  skin incision and division of the platysma.    Exposure of the submandibular gland  revealing branches of the facial vessels.    The lower pole of the submandibular gland  is mobilized and retracted upwards.    the gland through the underlying hyoglossus muscle  into the lingual veins. If these veins are not tied off or  adequately diathermized, troublesome bleeding may be  encountered.   The submandibular salivary gland can now be pulled  downwards revealing the V-shaped lingual nerve (Figure  44.15). The apex of the V is the point at which the para-  sympathetic fibres tether the lingual nerve to the salivary  gland. Occasionally, the sublingual ganglion can be iden-  tified on the surface of the gland. It is very important to  identify the V of the lingual nerve and its parasympathetic  fibres as the latter must be transacted to free the gland.  As these fibres are cut, the lingual nerve springs upwards.  Finally, the submandibular duct is clamped, divided and  ligated as far forward as possible with just enough remain-  ing to drain the sublingual gland. A thin layer of loose  connective tissue remains in the gland bed overlying the  hypoglossal nerve (Figure 44.16).   The wound is inspected for any bleeding points, a vac-  uum drain inserted and closed in layers using a subcu-  ticular suture to close the skin. The wound edges may be  reinforced with skin closure tapes.    Figure 44.15 The submandibular gland is pulled down-  wards revealing the V-shaped lingual nerve prior to division of  the parasympathetic nerve fibres.    Figure 44.16 The hypoglossal nerve lies in the floor of the  gland bed.    The vacuum drain is removed when drainage has slowed,  usually at 24 hours. The subcuticular stitch is removed at  about 10 days.    Three cranial nerves are at risk during removal of the sub-  mandibular salivary gland: the mandibular branch of the  facial nerve, the lingual nerve (a branch of the third divi-  sion of the trigeminal nerve) and the hypoglossal nerve. A  neck incision at least 3 cm below the lower border of the  mandible and careful surgical technique will avoid dam-  age to the facial nerve.   When chronic infection and subsequent fibrosis have  occurred, it is sometimes difficult to identify the lingual  nerve and the deep aspect of the deep lobe may be tethered  to the hypoglossal nerve. At these stages of the operation,  the surgeon must be convinced that these structures have  been identified before using any sharp dissection.   Meticulous haemostasis is required throughout the  operation as many vessels entering and leaving the sub-  mandibular gland are only apparent when the gland is  under traction and as soon as they are divided the vessels  retract into the adjacent muscle planes. Ligation or dispos-  able titanium vascular clips are safer than diathermy in  this situation. Carelessness with these vessels results in  extensive haematoma in the neck.    The operation may be performed under general anaesthesia  or local anaesthesia. Ifa general anaesthetic is used, it is help-  ful to infiltrate the floor of the mouth with a local anaesthetic  containing vasoconstrictor before any incision is made.    For simple excision of the sublingual gland, a linear inci-  sion is made in the floor of the mouth parallel to and just  lateral to the submandibular duct. Care must be taken not  to extend the incision posteriorly beyond the first molar  tooth so as to avoid damage to the lingual nerve. The inci-  sion should open the sac of the ranula to allow the muci-  nous contents to be aspirated.    The submandibular duct is now carefully identified and  retracted medially. Stay sutures passed through the mar-  gins of the mucosa are helpful to aid retraction (Figure  44.17). Using blunt dissection with scissors, the lingual  nerve is identified.    The sublingual gland which lies adjacent to the inner cortex  of the mandible is then mobilized and its multiple ducts,  which drain into the submandibular duct, divided care-  fully in order not to damage the duct itself (Figure 44.18).    The anterolateral part of the sublingual gland may be  attached to the periosteum of the mandible by fibrous tis-  sue and this too must be divided (Figure 44.19). Following  removal of the gland, the mucosa of the floor of the mouth  is loosely closed with two or three resorbable sutures.    Damage to the lingual nerve posteriorly or the subman-  dibular duct medially is avoided by careful surgical tech-  nique. Meticulous haemostasis is required to avoid a  post-operative haematoma in the floor of the mouth.    Although only a rare site for a salivary gland neoplasm, the  majority of such neoplasms will be malignant and there-  fore removal should encompass a clear margin of normal  tissue of at least 1 cm in all dimensions. This normally  includes the adjacent floor of the mouth and mylohyoid  muscle, a cuff of ventral tongue and a rim resection of the  mandible. If the mandible is edentulous, removal of the  inner table only is often sufficient. Each tumour should be  managed on its merits according to its size and infiltration  into adjacent anatomical planes.    Because of the vascularity of the floor of the mouth, it is  helpful to use a cutting diathermy for the soft-tissue inci-  sions (Figure 44.20). Depending upon the position of the    Figure 44.20 Sublingual tumour resection necessitating  wide excision with a margin of normal tissue.    sublingual gland and the size of the tumour, it may be  necessary to take a section of the lingual nerve with the  specimen.   The mandibular alveolus is approached from the buccal  aspect. A bur is used to cut the bone horizontally below  the level of the tooth roots. The lingual line of section  must lie below the level of the mylohyoid insertion (Figure  44.21). Final separation of the alveolus is made with a fine  osteotome.   The line of the dissection is then continued across the  floor of the mouth deep to the mylohyoid. The mobi-  lized alveolus and sublingual gland within the floor of  the mouth must be gently elevated and the hypoglos-  sal nerve, just below the mylohyoid, must be identi-  fied and freed. The dissection is then continued to join  up with the mucosal incision in the ventral tongue  (Figure 44.22).   The buccal mucosal flap is used to cover the mandibu-  lar bone. The mucosal defect in the floor of the mouth  is closed either by mobilizing adjacent soft tissue or  a pack soaked in Whitehead’s varnish may be sutured  over the defect which granulates and epithelializes below  the pack.    The ensuing complications will depend on how radical  the excision has been and what adjacent structures have  been resected or damaged. The proximal stump of the  submandibular duct should be loosely sutured to the oral  mucosa at the back of the operation site. It will form a new  opening into the floor of the mouth and submandibular  gland obstruction is not a problem. Lingual anaesthesia  from loss of the lingual nerve and tongue paralysis, if the  hypoglossal nerve has been included in the specimen, are    Figure 44.21 Three-dimensional excision of the sublin-  gual gland including the adjacent alveolar bone.    major problems. Both of these nerves can be reconstructed  by grafting at the time of the tumour excision, although  because of the poor prognosis of such tumours, this is  often not executed.   The surgeon is sometimes asked to provide specimens of  minor glands to confirm the diagnosis of Sjogren’s syn-  drome. The biopsy should be taken from the inner aspect  of the lower lip. The incision should be made in the vertical  plane just through the mucosa. The lip is then retracted    and the assistant places a finger on the outer aspect of the  lip, everting the submucosa into the wound. A minimum  of three minor glands are identified and excised. They can  be seen as pale yellow glistening ‘grains of rice’ within  the connective tissue of the submucosa. Haemostasis is  obtained and the mucosa closed with a single resorbable  suture.    When a patient presents with a mobile mass in the sub-  mucosa of the mobile soft tissues, the assumption should  be that it is a neoplasm until proved otherwise. Many of  these will be benign pleomorphic adenomas and open  incisional biopsy would result in tumour seeding into the  adjacent tissues. For this reason, a simple excision biopsy  of the minor gland is the appropriate management for  all such masses. The excision is performed in the extra-  capsular plane and even for tumours that prove to be  malignant, this will often prove to be sufficient as these  tumours do not infiltrate the gland capsule until late in  their development.    The detailed pathology of masses and ulcers arising on  the hard palate prior to surgery is all important and an  incisional biopsy is essential before definitive surgery  is undertaken. The differential diagnosis of persistent  ulcers arising on the hard palate includes acute necro-  tizing sialometaplasia (Figure 44.23), adenoid cystic  carcinoma, squamous cell carcinoma and antral carci-  noma. The definitive management of these conditions  will all be very different. Even a small adenoid cystic  carcinoma will involve at least a partial maxillectomy,  whereas a pleomorphic adenoma requires no more than  excision with a narrow margin of mucosa and dissection  in the subperiosteal plane. Low-grade mucoepidermoid  tumours will require a local palatal fenestration and a  1-cm mucosal margin.    This technique is appropriate for pathology such as pleo-  morphic adenoma (Figure 44.24), neurofibromas or  haemangiomas. Although the operation can be readily  performed under local anaesthesia, it is often kinder to use  a general anaesthetic as bleeding from the hard palate can  be distressing for a conscious patient. In this situation, the  patient is positioned supine on the operating table with a  sand bag under the shoulders and a head down tilt of the  table. The surgeon sits at the head of the table. The palate is  infiltrated with 2% lignocaine with 1:80,000 epinephrine  (adrenalin).   The mucosal margin is mapped out with ink (Figure  44.25). A 5-mm margin is adequate. The incision is made  down to the bone using a fine cutting diathermy needle.  The specimen is then freed in the subperiosteal plane with a  Howarth’s periosteal elevator or Mitchell’s trimmer.   Although benign, long-standing pleomorphic adenomas  can result in pressure resorption of the underlying palatal  bone and there may be a concavity in the palate (Figure  44.26). However, it is important to realize that such benign  tumours will never penetrate the periosteum.    Figure 44.26 Following the subperiosteal dissection the  concavity of the palatal bone due to pressure resorption is seen.    The defect may be left to heal by secondary intention,  although it should be protected by a Whitehead’s varnish  pack or by a preformed acrylic appliance, relieving the  area of resection in order to accommodate some peri-  odontal pack as a dressing (Figure 44.27). The pack or  plate should be retained for about 10 days by which time  the area will be granulating. Some large defects may take  several weeks to heal and in such cases a removable plate  should be utilized to protect the area. The plate must be  kept scrupulously clean and removed and rinsed after all  meals. A chlorhexidine mouth wash should be used to  rinse when the plate is removed for cleaning.    For all low-grade malignant tumours, palatal fenestration  with a 1-cm mucosal margin is indicated. The operation is  performed under general anaesthetic with the patient and  surgeon positioned as mentioned earlier.    Following mapping of the 1-cm mucosal margin and  the diathermy incision, a dental bur is used to cut through  the palatal bone at the margins of the incision. The exci-  sion specimen can then be gently elevated and any under-  lying structures, such as the nasal septum or antral wall,  can be divided with heavy scissors.   Whenever possible, an immediate reconstruction  should be undertaken. For small defects, a palatal rota-  tion flap may be suitable. The palatal flap should be  mapped out parallel to the dental arch and is based  on the greater palatine artery. In order to avoid dam-  age to this vessel, the incision should stop 1 cm anterior  to the greater palatine foramen (Figure 44.28, see also  Chapter 17).   The flap is raised in the subperiosteal plane and rotated  to cover the fenestration defect. It needs to be firmly  sutured into position with non-resorbable sutures as there  isa tendency for the flap to pull back to its anatomical posi-  tion (Figure 44.29). The sutures should be retained for 2  weeks. The donor site defect is covered with a Whitehead’s  varnish pack.   For more lateral palatal defects, a buccal advancement  flap used to close oro-antral communications can be uti-  lized. The flap must be broad-based and it should extend to  the full depth of the buccal sulcus (Figure 44.30).   The periosteum on the deep aspect of the flap is incised  with a sharp blade parallel and close to the base of the  flap. This relieving incision through the unyielding peri-  osteum allows the flap to be advanced on to the palate  (Figure 44.31).    Great care must be taken not to incise beyond the peri-  osteum as a button hole through the flap will compromise  the blood supply. It is also important to ensure that the  periosteal relieving incision extends to the full width of the  flap. Failure to do this results in the flap failing to advance  as it remains tethered by the unyielding periosteum.   The palatal margins of the fenestration defect must  be undermined and the mobilized buccal flap is meticu-  lously sutured to the palatal mucosa with everting mat-  tress sutures. Non-resorbable sutures must be used and  they should be maintained for 2 weeks to ensure healing  (Figure 44.32).    Posterior full-thickness palatal defects are conveniently  closed with buccal fat pad flaps as described in Chapter 17.  For central palatal defects, bilateral buccal fat pads can be  used.    For all aggressive malignant tumours, particularly ade-  noid cystic carcinomas, partial or total maxillectomy  followed by radiotherapy including the skull base is  indicated. When a maxillectomy has been undertaken,  the defect is reconstructed with a vascularized hip graft  (Chapter 28) or a fibular flap (Chapter 27). An alterna-  tive is to reconstruct the defect with an implant retained  obturator (Chapter 14).    When removing submandibular stones, it is impor-  tant to irrigate the duct in order to remove any ‘gravel’  remaining in the duct system.   When excising the submandibular gland, the lingual  nerve must be fully visualized and the parasympathetic  fibres tethering the nerve to the gland must be severed  in order to free the gland.   The only effective treatment for a ranula is excision of  the related gland which is nearly always the sublingual  gland. Occasionally, the submandibular gland can be  responsible.   The majority of sublingual gland tumours are malig-  nant and wide surgical excision and post-operative  radiotherapy are essential.   Pre-operative diagnosis of a palatal gland tumour is  essential. Benign tumours require local excision with a  very narrow cuff of normal mucosa, low-grade tumours  require palatal fenestration and high-grade tumours  require radical maxillectomy.    Cawson RA, Gleeson MJ and Eveson JW. Pathology and  Surgery of the Salivary Glands. Oxford: Isis; 1997.   McGurk M. Surgical release of a stone from the hilum of  the submandibular gland. Int J Oral Maxillifac Surg.  2005; 34: 208-210.   Seward GR. Anatomic surgery for salivary gland calculi.  Oral Surg Oral Med Oral Pathol. 1968; 25: 670-678.   Shaheen OH. Removal of the submandibular gland. In:  Carter D, Russell RCG, Pitt HA (eds.), Rob and  Smith’s Operative Surgery. London: Butterworths; 1976.  pp. 362-368.    Sialolithiasis accounts for approximately 50% of major sal-  ivary gland disease. The incidence of symptomatic sialoli-  thiasis is between 27.5 and 59 cases per million population  per year.   The presence of a salivary calculus usually results  in mechanical obstruction of the salivary duct, caus-  ing repeated swelling during meals, which can remain  transient or be complicated by bacterial infections.  Until recently, recurring episodes necessitated open sur-  gery with calculi that lay in the proximal duct or gland  requiring sialoadenectomy despite its attendant risks (see  Chapters 44 and 46).   During the past 18 years, minimally invasive and non-  surgical techniques for the removal of salivary calculi have  been developed. The basis for this approach resides in the  fact that salivary glands have been shown to have signifi-  cant reparative potential. Scintigraphic studies before and  after removal of a submandibular calculus have shown  that the gland can recover. In addition, the duration of  obstructive symptoms does not influence the amount of  recovery observed (Figure 45.1a and b).   While a variety of techniques have been investigated,  those which have progressed beyond the initial trials and  remain in clinical practice include basket retrieval and  microforceps retrieval, both of which can be performed    under either endoscopic or radiological control. Intra- and  extracorporeal shock wave lithotripsies have also assumed  a continuing role, as has gland-preserving surgery for sub-  mandibular calculi and an endoscopically assisted form  for parotid stones.    Following the successful introduction of lithotripsy  for renal calculi in the 1980s, the technique has been  applied to several other areas of the body including, with  the development of specialized machines, the salivary  glands.    At the present time, the devices which generate the shock  wave are either piezoelectric (Piezolith 2501; Richard Wolf,  Knittlingen, Germany) or electromagnetic (Minilith;  Storz Medical, Tagerwilen, Switzerland) (Figure 45.2).    A number of selection criteria have been developed for  this technique (Table 45.1), which have led to it principally  being used in the management of fixed parotid stones.    Figure 45.1 (a) Pre-treatment sialogram showing presence  of obstruction associated with poor ductal architecture. (b)  Post-treatment sialogram showing improvement in glandular  architecture.    Figure 45.2 Salivary lithotripter with patient in treatment  position for a parotid stone.    In addition, where present, acute sialoadenitis must first  be treated with antibiotics.    Treatment is performed on an outpatient basis. After  ultrasonographic localization of the stone (Figure 45.3),  shock waves are delivered to a maximum per visit (3000  piezoelectric, 7500 electromagnetic). In general, a series of  three sessions separated by 4-12 weeks are required.   Following successful fragmentation, pieces of calculus  migrate distally and exit the duct either spontaneously  (Figure 45.4) or as a result of adjuvant measures (massage,  sialogogues) or techniques (dilatation of ostium, papil-  lotomy, endoscopic or basket retrieval).   Common, reversible complications include mild swell-  ing of the gland (60%-70%), self-limiting ductal haem-  orrhage (40%-55%) and petechial skin haemorrhage  (40%-55%), while acute sialoadenitis is rare (1.5%-5.7%).   Success rates are generally expressed in terms of cure (stone  and symptom free), partial success (residual stone without  symptoms) and failure (residual stone and symptoms).    In the five published series with over 100 cases, the overall  cure rates vary from 29% to 63%, whereas 56.7% to 100%  are rendered stone or symptom free (Table 45.2).   The cure rate is significantly better (34.2%-69.3%) for  parotid (Table 45.3) than for submandibular (29.0%-  41.1%) stones (Table 45.4). Similarly, the percentage of  patients with neither stones nor symptoms is higher for  parotid cases (68.6%-100%) than for submandibular cases  (56%-100%).   In a long-term (10-year) follow-up study of subman-  dibular stones, one-third of patients remained stone free,    one-third still had residual fragments but were symptom  free and one-third required additional intervention.    The cure rate for parotid stones is significantly greater than  that for submandibular stones. Several authors have reported  an association between the size of the stone and the stone-  free rate, while others have not. This association is not seen  repeated in the case of partial success.    The development of micro-endoscopes has enabled  sialoendoscopy for both diagnostic and interventional  purposes. In intracorporeal shock wave lithotripsy, a  lithotripsy probe is passed along the salivary duct, under  endoscopic guidance, to be adjacent to or in contact with  the stone surface.   Initial studies in this area centred on the use of electrohy-  draulic and pneumatic lithotripsy. Electrohydraulic intracor-  poreal lithotripsy (Calcitript; Storz Medical) was successful  in fragmenting the calculus in 60%-70% cases. A flexible  endoscope together with the shock wave probe were intro-  duced into the duct and advanced until the probe was 1 mm  away from the sialolith. The shock waves were generated by  a sparkover at the tip of the 600-j1m probe. Pneumobalistic  lithotripsy used a LithoClast (Electro Medical Systems,    Study Year Lithotripter No. of cases Cured  Partial success  —_ Failure    Study Year Lithotripter Parotid cases Cured  Partial success  Failure     Study Year Lithotripter Submandibular cases Cured  Partial success  Failure     Nyon, Switzerland). This equipment consists of a central unit,  connected to a compressed air source, producing a pressure  of 3 bar at the handpiece. The handpiece generated ballistic  energy and converted it into shock waves which were applied  directly to the stone via the probe. Using this equipment, in  the working channel of a 2.1-mm endoscope, stone-free rates  of up to 60% were reported. However, both techniques have  been abandoned because of the high risk of unwanted effects  such as ductal perforation and nerve damage.   Later studies investigated the use of laser lithotripsy  and several systems have been evaluated in vitro and in  vivo. Unfortunately, the Nd-YAG (1064 nm; LASAG-AG,  Belp, Switzerland) and Alexandrite (755 nm; Dornier  Medizintechnik, Germany) lasers were unsuitable because  of inadequate fragmentation. In the case of the Exicmer laser  (308 nm; Technolas Laser Technologie, Germany), stone-  free rates of up to 91.6% were reported, but were associated  with a high rate of ductal perforation and its use in humans  is inadvisable. The Rhodamine-6G-Dye-laser (595 nm;  Lithoghost, Telemit-Company, Munchen, Germany), how-  ever, proved successful. This had the added advantage of  using a novel spectroscopic feedback technique which ana-  lysed the reflected laser light to distinguish between calculi  and soft tissue, so minimizing damage to the duct. Its use  was associated with complete removal of stones in 46% of  cases after between one and three treatment sessions.   All of these techniques required a papillotomy to enable  the endoscopically controlled equipment to access the duc-  tal system. In addition to this, the techniques often require  expensive equipment and are relatively time-consuming  for the success rates achieved. As a result, intracorpo-  real shock wave lithotripsy is currently of limited clinical  importance.    The initial attempts at endoscopically guided stone retri-  eval used flexible endoscopes. Unfortunately, these were  difficult to manoeuvre, fragile, provided only poor images  and were difficult to sterilize. This situation improved with  the use of semi-rigid endoscopes, although the diameter    of the device (relative to the lumen of the duct) resulted  in difficulty in progressing along the duct and ductal  tears. Rigid endoscopes proved most successful (Figures  45.5 and 45.6) and have developed progressively from the  initial 2.7-mm-diameter arthroscopes, which required  a papillotomy to facilitate ductal entry, to one (Marchal  sialoendoscope; Karl Storz, Tuttlingen, Germany) which    measures 1.3 mm in diameter and contains an optic fibre  of 6000 pixels, a rinsing channel of 0.25 and a working  channel of 0.65 mm for instrumentation.   Clinical and radiographic assessment of prospective cases  is essential, as exclusion criteria for the technique include  narrow ducts, ductal strictures and intra-parenchymal loca-  tion of stones. In addition, acute sialoadenitis should be  treated with antibiotics prior to intervention.   In the technique, the endoscope is introduced into the  ductal system and progressed until the sialolith is identi-  fied. The stone is then removed using suction, basket or  microforceps. If the stone is large, then fragmentation by  microforceps or laser lithotripsy is required to facilitate  its removal. While the first is time-consuming, the latter  is associated with the previously detailed problems asso-  ciated with laser lithotripsy, although further advances  may address these issues. Post-operative antibiotics have  been advocated, as have stenting of the duct with a 2-mm  polyethylene tube, although the value of the latter is  questionable.   Overall success rates of more than 80% have been  reported. However, the success rates are directly related to  the size of the stone with one study reporting a 97% cure  rate for stones smaller than 3 mm and 35% for those larger  than 3 mm.    Radiological techniques have been used to investigate the  salivary glands since 1900, when Charpy first described  the injection of mercury into the salivary ducts in order  to demonstrate salivary gland anatomy. Sialography is still  widely practised in the diagnosis of obstruction, sialoade-  nitis and Sjogren's syndrome. It remains the most sensitive  method for detecting salivary stones and strictures within  the ductal system of the major salivary glands.   In recent years, its role has been developed and extended  into interventional radiological techniques in the salivary  ducts to treat ductal obstruction. Interventional sialogra-  phy has thus become one of several new minimally inva-  sive techniques within the armamentarium of the clinician  seeking to treat one of the most common salivary gland  complaints, salivary gland obstruction, without resorting  to surgery.   Salivary gland obstruction may be due to either extra-  ductal or intra-ductal causes. Intra-ductal causes are most  common and principally include salivary calculi and duct  stenoses. A recent analysis of the incidence of salivary  ductal obstruction in a series of more than 1300 sialo-  grams undertaken for patients with obstructive symptoms  showed an obstruction in 64% of the investigated cases, of  which 73% had salivary calculi and 23% had a stricture.  This highlights the greater incidence of stones (Figure  45.7), but also illustrates the very real problem of sali-  vary duct stenosis (Figure 45.8). This study also showed    Figure 45.7 Submandibular sialogram showing a stone in  the proximal part of the main duct.    Figure 45.8 Parotid sialogram showing two diffuse  strictures, one at the entry to the hilum of the gland and one  more distally placed near the division of the main duct with a  secondary branch.    that duct strictures were far more common in the parotid  glands of middle-aged women and may be, in around 7%,  bilateral.   Interventional sialography has developed methods for  treating both eventualities using ideas taken from other  areas of intervention. Ductal calculi may be extracted by  capture with devices such as small collapsible Dormia  baskets, where these have been used to extract biliary and  ureteric stones (Figure 45.9). These are introduced into the  ductal system within fine catheters and deployed to cap-  ture the stone once they have been positioned around or  beyond the stone. Salivary duct strictures are amenable to  dilatation by balloon catheters in a similar way to vascular  stenoses or strictures developing within the ureteric sys-  tem or within haemodialysis fistulas.    Sialography and ultrasound examinations form the pre-  requisite imaging for case assessment prior to intervention  in the salivary ducts. Sialography successfully distin-  guishes salivary calculi from strictures, and ultrasound  successfully distinguishes stones from soft mucous plug  debris, since a stone will show a bright area within the sali-  vary duct with an acoustic shadow behind it, whereas soft  debris shows a similar appearance but no acoustic shadow.   Sialography and ultrasound also localize a stone or stric-  ture, give its dimensions, identify multiple stones and help to  identify if a stone is mobile. Stones within the main parotid  and submandibular ducts are amenable to extraction using  this technique, but cannot normally reach stones within the  submandibular hilum since the Dormia basket cannot pass  beyond the genu of the duct. Mobility of the stone on the  pre-operative sialogram is a good prognostic factor, since it  indicates that the stone is not fixed or fibrosed to the duct  wall, which would prevent its extraction. Sialograms also  allow assessment of the condition of the proximally placed  gland. However, importantly, only sialography allows one to  assess the width of the duct running distally from a stone  to the duct orifice. This is crucially important if the stone is to  be withdrawn down this distal duct, since there must not be  too great a mismatch between the size of stone and the duct.  It would be sensible to avoid extraction of stones more than  25% greater in width than the width of the narrowest section  of the distal salivary duct. Care should be exercised in case  selection at this point — ifa large stone is captured in a basket  but is too large to be withdrawn down the relatively narrow  duct, then the basket will become impacted in the proximal  duct and will almost certainly require surgical release. This is  an important complication, which can be avoided with sen-  sible treatment planning. Larger and very proximal stones  are best treated first by extracorporeal shock wave lithotripsy  to break down the stone into more manageable pieces. If a  stricture is identified distal to the stone to be removed, then    planning will be required to dilate this area of duct stenosis  prior to stone extraction, using an angioplasty balloon.   Sialography also plays a key role during intervention.  During interventional sialography, the pre-operative sial-  ogram is used to confirm the exact nature and location of  the obstruction and to guide the placement of the inter-  ventional tool in relation to the obstruction.   One noted advantage of minimally invasive techniques  has been the ability to carry out treatment under local  anaesthesia, avoiding conventional surgery under general  anaesthetic and therefore enabling treatment of patients  with more complex medical conditions that might other-  wise preclude intervention. Treatment under local anaes-  thesia is additionally more time-efficient, does not require  inpatient hospital admission and is generally associated  with lower morbidity.   Local anaesthesia is achieved for intervention in  the parotid gland by infiltrating the cheek around the  Stenson's duct papilla with 2% lignocaine and by instilling  local anaesthetic into the parotid duct to create some topi-  cal anaesthesia of the duct wall. For interventional pro-  cedures in the submandibular ductal system, an inferior  nerve block accompanied by a lingual nerve block is very  effective.    A technique for stone extraction under fluoroscopic radio-  logical guidance was first demonstrated by Briffa and  Callum in 1989, and described the extraction of a small  stone from the submandibular duct. An angioplasty bal-  loon catheter was inserted into the salivary duct, the  balloon slid proximal to the stone and inflated, then with-  drawn to the orifice of Wharton's duct, trapping the stone  and drawing it up to the orifice. Following this, similar  procedures were reported using interventional catheters  normally used for vascular work, such as vascular snares  and graspers to trap salivary stones and extract them  from the salivary ducts, but most of these subsequent case  reports and small case series have reported greatest suc-  cess with Dormia baskets. In these papers, success rates of  between 60% and 100% have been reported.   The technique for stone removal from the parotid and  submandibular ducts using a Dormia basket technique  under fluoroscopic x-ray guidance and local anaesthesia  is a relatively simple procedure with a high success rate  and low morbidity. Following treatment planning, on the  basis of clinical examination and pre-operative imaging,  the patient is given a suiTable local anaesthetic and a sialo-  gram is performed. The duct orifice is gently dilated with  lachrymal duct and Nettleship dilators to sufficient diam-  eter to receive a 3-French Dormia basket catheter. The  Dormia basket catheter is inserted in the closed position  and guided into position under radiological control. The  catheter tip is normally required to pass beyond the stone,  into the proximal salivary duct (Figure 45.10). Once in this    Figure 45.10 Inter-operative submandibular sialogram  showing the basket inserted beyond the stone.    position, the basket is opened and withdrawn across the  stone to capture it. This can be confirmed under imag-  ing control (Figure 45.11). The stone is captured and then  withdrawn to the papilla, where a small papillotomy inci-  sion is often needed to deliver the stone (Figure 45.12). An  immediate post-operative sialogram is helpful to check for  any residual stones.    Salivary duct strictures are believed to develop secondary  to previous duct wall irritation and inflammation, as may  follow the presence of a stone, local trauma or infection.  They are normally found within the main excretory duct  and 75% are located in the main duct of the parotid gland,  making these far more common in this situation than in  the submandibular system. A recent study also showed  these to be more common in middle age and in women.   This technique offers a non-surgical option for those  patients developing symptoms of obstruction as a result  of duct stenosis, and for relieving strictures distal to a  stone prior to stone extraction. Angioplasty balloons are  available in widths suiTable for dilation of salivary ducts,  which normally range in diameter from 1 to 2 mm. The  aim of the procedure is to dilate the duct to slightly greater  than its normal calibre and to break the circumferential  bands of fibrous tissue forming within the duct wall.   The patient is prepared in the same way as for stone  extraction, using a pre-operative sialogram to identify the  nature and position of the stenosis. A local anaesthetic  is given, the duct orifice dilated manually with dilator  instruments and a pre-operative sialogram performed.  Immediately, without moving the patient, the balloon    Figure 45.11 Inter-operative sialogram showing the  basket, with stone trapped within it, being withdrawn forward  to the orifice of Wharton's duct.    Figure 45.12 Papillotomy is performed to release a stone,  trapped in a Dormia basket, from the submandibular duct.    catheter is inserted into the duct. The lateral sialographic  view is used to guide the balloon catheter into position  along a guide-wire which, together with the balloon cath-  eter, is inserted into the duct orifice and moved gently  but firmly down the duct until it passes through the most  proximal area of strictured duct. The balloon is positioned  centrally within the stricture and inflated fully for several  minutes to ensure good dilation (Figure 45.13). Tight ste-  nosis may require several inflations. The balloon is then  deflated fully and withdrawn forward to the next, more  distal stricture if present. The procedure is repeated, if  necessary, until all the stenoses are satisfactorily dilated.  A post-operative sialogram is used to check satisfactory  duct calibre before the duct is finally irrigated.    Post-operative care  Following a salivary intervention, the patient is advised to    keep well hydrated and to stimulate the gland with sialo-  gogues and self-massage to ensure that the operative site    Figure 45.13 Post-operative view following balloon duc-  toplasty for two strictures of the parotid duct (see Figure 45.7  for pre-operative appearance). Note the filling defect repre-  senting mucous plug against the inferior duct wall within the  dilated hilum.    remains patent. Intervention in the salivary ducts is normally  accompanied by some degree of local oedema, particularly  following balloon ductoplasty. The effect of the local oedema  may be to cause compression of the duct and a temporary  return of gland swelling, especially at mealtimes. The patient  needs to be counselled to expect this for several days. Post-  operative antibiotic prophylaxis is not always needed, but  may also be appropriate if infection is suspected.    To date, our experience of this technique at this centre has  included 443 interventional radiologically guided salivary  gland treatments for benign obstruction; 252 for salivary  stone extraction and 194 balloon ductoplasties. Patients  included 190 males and 253 females ranging in age from 8  to 85 years, with an average age of 48 years.   In 252 cases of salivary stones, 96 (38%) were in the  parotid glands and 156 (62%) in the submandibular glands,  which is a rather different distribution to that normally  quoted (normally around 80%-90% in the submandibular  duct system), but probably reflects a different patient group  who are keen to avoid surgery, especially a superficial  parotidectomy, which carries the risk of facial nerve palsy.  Successful stone clearance was achieved in 77% (194/252)  of the study group, partial clearance was achieved in 8.3%  (that is, some but not all stones were removed) and in the  remaining 14.7% (37/252) the procedure failed to remove  the intended stone. This was primarily due to an immobile  stone (adherent to the duct wall) or due to the inability to  capture the stone due to an unfavourable position within a  secondary duct or side branch.   A total of 194 salivary duct strictures were diagnosed  and treated, generally with a higher average age of 51 years    and showing a distinct predilection for females (male/  female ratio = 1:1.87). Balloon ductoplasty achieved elimi-  nation of duct strictures in 78.4% (152/194), whereas 11.8%  (23/194) showed some residual stenosis on post-operative  sialogram. The procedure was not completed success-  fully in 5.2% (10/194) of the group, primarily due to the  density of the stenosis which prevented passage of the  balloon. Degree of final dilatation was not recorded in  nine patients (4.6%).    Increased awareness has led to a demand from the pub-  lic for less invasive surgical options to treat conditions  such as salivary gland obstruction. Conservative man-  agement with minimally invasive techniques has come  about through technological advances across a range of  fields, with many techniques borrowed from other areas  of medicine and offers a low-morbidity treatment option.  Radiology has followed a similar path and now offers a  choice of radiologically guided techniques for treating  both salivary stones and strictures. These techniques com-  pliment other new modalities such as extra- and intra-  corporeal lithotripsy, sialoendoscopy and limited-access  surgery, such that they may be used in isolation or as part  of a combined multimodal approach to treatment.    Blaine D and Smith Frable MA. Removal of a parotid duct  calculus with an embolectomy catheter. 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Interventional sialogra-  phy: A single-center experience. Cardiovas Intervent  Radiol. 1997; 20: 331-336.   Escudier MP, Brown JE, Drage NE and McGurk M.  Extracorporeal shockwave lithotripsy in the manage-  ment of salivary calculi. Br J Surg. 2003; 90: 482-485.   Escudier MP and McGurk M. Symptomatic sialoadenitis  and sialolithiasis in the English population, an esti-  mate of the cost of hospital treatment. Br Dent J. 1999;  186: 463-466.   Guest P, Maciag A and Buckenham T. Non-operative removal  of a parotid duct stone with a balloon angioplasty cath-  eter. Br J Oral Maxillofac Surg. 1992; 30: 197-198.   Iro H, Dlugaiczyk J and Zenk J. Current concepts in diag-  nosis and treatment of sialolithiasis. Br J Hosp Med.  2006; 67: 24-28.   Iro H, Zenk J, Waldfahrer F Benzel W, Schneider T and Ell  C. Extracorporeal shock-wave lithotripsy of parotid  stones. Results of a prospective clinical trial. Ann Otol  Rhinol Laryngol. 1998; 107: 860-864.   Isacsson G, Isberg A, Haverling M and Lundquist P. Salivary  calculi and chronic sialoadenitis of the submandibu-  lar gland: A radiographic and histologic study. Oral  Surg Oral Med Oral Pathol. 1984; 58: 622-627.   Kelly IMG and Dick R. Technical report: Interventional  sialography: Dormia basket removal of Wharton's  duct calculus. Clin Radiol. 1990; 43: 205-206.   Kim R, Strimling A, Grosch T Feider DE and Veranth JJ.  Nonoperative removal of sialoliths and sialodocho-  plasty of salivary duct strictures. Arch Otolaryngol  Head Neck Surg. 1996; 122: 974-976.   Marchal F, Dulguerov P, Becker M Barki G, Disant F. and  Lehmann W. Specificity of parotid sialendoscopy.  Laryngoscope. 2001; 111: 264-271.   Marchal F and Dulguerov P. Sialolithiasis management:  The state of the art. Arch Otolaryngol Head Neck Surg.  2003; 129: 951-956.   Marchbank N and Buckenham T. Removal of a sub-  mandibular duct calculus with a vascular snare.  Dentomaxillofac Radiol. 1993; 22: 97-98.   McGurk M, Escudier MP and Brown E. Modern manage-  ment of obstructive salivary gland disease. Ann R  Australas Coll Dent Surg. 2004; 17: 45-50.    McGurk M, Escudier MP and Brown JE. Modern  management of salivary calculi. Br J Surg. 2005; 92:  107-112.   McGurk M, Escudier MP and Brown JE. Modern manage-  ment of salivary calculi. Br J Surg. 2005; 92:107-112.   Ngu RK, Brown JE, Whaites EJ Drage N, Ng S and Makdissi  J. Salivary duct strictures: Nature and incidence in  benign salivary obstruction. Dentomaxillofac Radiol.  2007; 36: 63-67.   Nixon P and Payne M. Conservative surgical removal of a  submandibular duct calculus following interventional  sialography. Clin Radiol. 1999; 54: 337-338.   North E. Submandibular sialoplasty for stone removal and  treatment of a stricture. Br J Oral Maxillofac Surg.  1998; 36: 213-214.   Ottaviani F, Capaccio P, Rivolta R, Cosmacini P, Pignataro  Land Castagnone D. Salivary gland stones: US evalu-  ation in shock wave lithotripsy. Radiology. 1997; 204:  437-441.   Poirier P and Charpy A. Traite Danatomie Humaine, Vol. 4.  Paris: Masson et Cie; 1900.   Sharma R, Al-Khalifa S, Paulose K and Ahmed N. Parotid  duct stone - Removal by a dormia basket. Journal  Laryngol Otol. 1994; 108: 699-701.   Yoshino N, Hosokawa A, Sasaki T and Yoshioka T.  Interventional radiology for the non-surgical removal  of sialoliths. Dentomaxillofac Radiol. 1996; 25:  242-246.   Zenk J, Bozzato A, Winter M Gottwald F and Iro H.  Extracorporeal shock wave lithotripsy of submandib-  ular stones: Evaluation after 10 years. Ann Otol Rhinol  Laryngol. 2004; 113: 378-383.   Zenk J, Hosemann WG and Iro H. Diameters of the main  excretory ducts of the adult human submandibu-  lar and parotid gland: A histologic study. Oral Surg  Oral Med Oral Pathol Oral Radiol Endod. 1998; 85:  576-580.   Extensive deep lobe and other parapharyngeal tumours  Transpharyngeal approach to the deep lobe    The parotid gland is subject to acute ascending bacterial  infection from the oral cavity. Provided the infection is  controlled with antibiotics, the gland will usually make  a complete functional recovery. In a few cases, the gland  becomes chronically infected with recurrent acute flare-  ups leading ultimately to sialectasis and duct changes.  Chronic infection is particularly common when salivary  flow rates are reduced, such as in Sjogren’s, syndrome  or following radiotherapy. In this situation, it is best to  remove the superficial lobe of the parotid and to tie off the  main duct as far distally as possible. It is not usually neces-  sary to remove the deep lobe, which accounts for only 20%  of parotid mass, as this undergoes spontaneous atrophy  following superficial lobectomy and duct tie.   Calculi in the parotid duct system are uncommon.  The majority impact is at the parotid papilla and is readily  released by papillary dilatation with lachrymal probes or fine  bougies. Failing this, a papillotomy can be performed under  local anaesthesia. Calculi in the intra-glandular part of the  duct are usually located at the junction of the main duct and  the first-order tributaries, the stone mimicking a staghorn  calculus is seen in the renal pelvis (see also Chapter 45).   The majority of salivary tumours (75%) are found in  the parotid gland. The overwhelming majority present as  slow-growing painless masses within the parotid capsule.  Of these tumours, 85% will be benign, mostly pleomor-  phic salivary adenomas. When skin fixation, ulceration or    fungation, facial nerve weakness or lymphatic metastasis is  present, and the tumour is clearly malignant. The absence  of these signs does not exclude malignancy. The majority  of malignant parotid tumours are clinically indistinguish-  able from benign tumours.   In recent years, there has been a move to more conser-  vative procedures and in particular extracapsular dis-  section. However, it remains essential that any surgeon  dealing with parotid pathology remains competent in the  technique of facial nerve dissection and formal parotidec-  tomy. These techniques are required when operating for  malignancy, tumour recurrence (benign and malignant)  and deep lobe tumours.    Routine surgical biopsy is not indicated. The majority  of intrinsic parotid masses will be pleomorphic adeno-  mas. These tumours are tense and poorly encapsulated.  Rupture, either at the time of biopsy or surgery, leads to  widespread spillage of clumps of cells resulting in multiple  recurrences which may be very difficult to control. If the  tumour remains intrinsic within the parotid at the time  of surgery, the exact histological diagnosis is unlikely to  influence the definitive surgical procedure. However, if the  tumour is obviously malignant and has extended beyond  the anatomical boundaries of the parotid, open surgical  biopsy is indicated.    Fine needle aspiration biopsy has been widely advocated  in the pre-operative diagnosis of parotid masses. Although  it is safe, oral pathologists find it difficult to make a defini-  tive diagnosis based on a few aspirated clumps of cells,  because the architecture of the tumour is lost, many parotid  tumours are heterogenous in appearance and the aspirated  sample may not be representative. Furthermore, there is the  risk of sampling error although this is reduced when using  ultrasound guidance. The newer technique of fine needle  core biopsy, particularly when performed using ultrasound  guidance, offers hope of more accurate diagnosis.    Conventional sialography is the investigation of choice in  chronic inflammatory disease, autoimmune disease and  duct obstruction. The post-stimulation emptying film is  most valuable as it is a good measure of function and will  often determine if surgical excision is indicated.   For the imaging of parotid masses, either computed  tomography (CT) scanning or magnetic resonance imag-  ing (MRI) are equally useful. MR imaging avoids the  use of ionizing radiation, but CT is better tolerated by  patients. Both techniques give a good anatomical image of  the region, but can neither reliably demonstrate the plane  of the facial nerve nor confidently distinguish intrinsic  malignant tumours from benign.   Ultrasound imaging is indicated in acute parotid swell-  ings as it will reliably demonstrate obstruction and collec-  tions of pus. In chronic infection, it will show advanced  sialectasis and duct dilatation. It will also characterize cal-  culi if they are calcified. Warthins tumours are echo poor  and show posterior acoustic enhancement whereas pleo-  morphic adenomas are echogenic.    Although readily performed under local anaesthesia, the  operation must be performed carefully in order to avoid  subsequent stricture formation. A fine metal probe is  passed through the papilla into the parotid duct. Using  the probe as a guide, one blade of a pair of sharp pointed  scissors is inserted into the duct and the wall of the duct  is laid open. The cut should be extended posteriorly until  the point of the scissors enters the dilated part of the duct  proximal to the site of obstruction. A 6-0 resorbable suture  is used to sew the cut edge of the duct lining on to the adja-  cent mucosa of the cheek. This results in the formation ofa  funnel-like opening of the duct on to the cheek and avoids  subsequent stricture formation.    The operation is performed under general anaesthe-  sia. The patient is positioned supine with moderate neck    extension and the head turned away from the operative  side. Head-up tilt on the table helps to prevent venous con-  gestion and ooze. Some anaesthetists are willing to mod-  erately lower the blood pressure, which reduces arteriolar  and capillary bleeding.   The hair in front of the ear is either shaved or gathered into  a tuft which can be taped down on to the skin of the cheek.  The area is infiltrated with conventional dental local anaes-  thetic containing 2% lignocaine hydrochloride and 1:80,000  epinephrine (adrenaline). The external auditory meatus is  plugged with a small piece of Vaseline-impregnated tulle to  prevent blood entering the meatus and irritating the drum.  The surface markings of the parotid duct are marked on the  skin of the face at the start of the operation and can be read-  ily transposed to the surface of the parotid fascia once the  flap has been raised. A line is drawn from the lowest point  of the alar cartilage to the angle of the mouth. This line is  bisected and the midpoint is joined by a straight line to the  most posterior point of the tragus. The line is then divided  into three equal parts. The middle section corresponds to the  position of the parotid duct (Figure 46.1).    The incision starts in the hairline running downwards and  backwards to the junction of the pinna and the temple. The  incision then follows the pre-auricular attachment of the  pinna skimming across the free edge of the tragus, follow-  ing the attachment of the lobe posteriorly and then swinging  gently down into a neck crease. Alternatively, the incision  behind the attachment of the earlobe may be extended pos-  teriorly into the hairline as with a face-lift incision. This  variation results in a less visible scar, but surgical access to  the parotid region is slightly more difficult. The incision is  made either with a No. 15 blade or preferably with a very fine  diathermy needle or ceramic blade. The incision is made  through the skin just into the underlying fat.    The flap is raised either using a scalpel or by blunt dis-  section with scissors over the surface of the investing    layer of the deep cervical fascia which in this region  splits to encapsulate the parotid (Figure 46.2). In this  situation, the dissection can be deep to the superficial  musculo-aponeurotic system (SMAS) as this layer will  be returned to its anatomical position at the end of the  operation. At the superior and anterior margins of the  parotid gland, great care must be taken not to damage  branches of the facial nerve which in these areas become  very superficial. The flap must be raised just beyond the  anterior border of the parotid. The flap is held forwards  by suturing the flap to the head drapes with mattress  sutures.    The duct is identified where it emerges from the anterior  border of the parotid. The surface marking of the duct is  transferred on to the fascia. The fascia is incised along the  line of the duct and, by careful blunt dissection, a search is  made for the duct which is pinkish grey and covered with a  fine capillary network. The branch of the facial nerve sup-  plying the upper lip runs parallel with the duct either on  its surface or a few millimetres superior to the duct. If the  duct is not readily identifiable, it is useful to pass a fine  IV cannula through the parotid papilla into the duct. This  splints the duct and it can be easily palpated within the  parotid (Figure 46.3).    Once the duct has been identified at the anterior border  of the parotid gland, it is fairly simple and rapid to follow  it back into the substance of the gland. With fine scissors,  the tissues overlying the duct are progressively separated  and divided. Stay sutures through the edges of the dissec-  tion are used to retract the parotid. Provided the dissec-  tion continues in the plane immediately above the duct  and the branch of the facial nerve to the upper lip is kept  in sight, there is no risk to other branches which at this  point have fanned out. Several fine intercommunicating  branches will be encountered crossing the surface of the  duct. Tributaries of the posterior facial vein are carefully  clamped, divided and tied.   Once the calculus has been reached, it can be palpated  through the duct wall. A longitudinal incision is made in  the duct wall and the calculus is carefully teased out of  the duct (Figure 46.4). The duct is then carefully irrigated  proximally and distally with sterile saline or water to flush  out any associated ‘gravel’ which if retained acts as a focus  for recurrent stone formation (Figure 46.5).    No attempt should be made to suture the duct wall as this  results in stenosis. The stay sutures are removed and the    parotid capsule closed with resorbable sutures. A small  vacuum drain is inserted under the skin flap to avoid hae-  matoma formation and the flap is closed in two layers.    As the parotid gland is likely to be infected proximal to the  site of the calculus, antibiotics are administered for 3 days  post-operatively. The drain is removed at about 24 hours  and the skin sutures are removed after 5 days.    Apart from anaesthesia in the territory of the skin flap,  there are few complications. As the fascia forming the  capsule of the parotid gland is closed, salivary fistula and  Frey’s syndrome do not occur. The paraesthesia gradu-  ally resolves as the cutaneous sensory fibres regenerate  from the periphery. If a face-lift incision has been uti-  lized, healing is normally excellent and after 6 months the  scar becomes almost invisible. However, if a conventional  lazy-S incision has been used, hypertrophic scarring  sometimes occurs in the cervical extension of the incision.  For this reason, patients should be followed up carefully  for the first 6 months so that, if hypertrophic changes are  seen, the scar can be treated appropriately. Weekly infil-  tration with triamcinalone acetonide will usually prevent  further scarring.    Treatment of parotid tumours is classically by superficial  lobectomy for all tumours within the superficial lobe and  total parotidectomy for all tumours within the deep lobe.  Such deep lobe tumours should never be approached from  the pharyngeal aspect even when they present as lateral  pharyngeal masses. The facial nerve, if not macroscopi-  cally invaded by malignant tumour, is preserved in all  cases. For small tumours arising in the superficial lobe,  careful extracapsular dissection may be undertaken (see  Chapter 45).    The key to successful parotid surgery is the observation of  the two following anatomical features (Figure 46.6):    1. The parotid gland has two lobes (superficial and deep)  united by an isthmus. The parotid gland is not embryolog-  ically a bilobed structure, but its developmental relation-  ship to the facial nerve results in the two surgical lobes   2. The facial nerve and its branches are surrounded by  these lobes, invested in loose connective tissue. The  facial nerve, except when invaded by tumour, does not  enter the substance of the gland.    The following are four anatomical landmarks leading  to the identification of the trunk of the facial nerve as it  leaves the stylomastoid foramen (Figure 46.7):   2. Just deep to the cartilaginous pointer is a reliable bony  landmark formed by the curve of the bony external meatus  and its abutment with the mastoid process. This forms a  palpable groove leading directly to the stylomastoid fora-  men. Unfortunately, this groove is filled with fibrofatty  lobules that often mimic the trunk of the facial nerve,  which can lie as much as 1 cm deep to this landmark.    Figure 46.6 Development of the parotid gland to engulf  the branches of the facial nerve.    Figure 46.7 Anatomical landmarks leading to the iden-  tification of the facial nerve trunk. 1 cartilagenous external  meatus; 2 parotid gland; 3 sternocleidomastoid muscle; 4 tip  of the mastoid process; 5 styloid process; 6 posterior belly of  digastric muscle.    3. The anterior superior aspect of the posterior belly of the  digastric muscle is inserted just behind the stylomastoid  foramen.   4. The styloid process itself can be palpated superfi-  cial to the stylomastoid foramen and just superior to  it. The nerve is always lateral to this plane and passes  obliquely across the styloid process. A branch of the  post-auricular artery is usually encountered just lateral  to the nerve.    The operation is performed under general anaesthesia. The  patient is placed supine with a sand bag or pad under the  shoulder on the side of the operation. The neck is moder-  ately extended and the head is turned to the opposite side.  The table is tilted ‘tilted’ to reduce venous engorgement.  The anaesthetist should be requested to drop the blood  pressure to reduce capillary and artereolar bleeding. The  incision line is infiltrated with lignocaine hydrochloride  and 1:80,000 epinephrine (adrenaline).    The incision starts in the temporal region and passes infe-  riorly in the pre-auricular crease, crossing the base of the  tragus and passing posteriorly behind the lobe of the ear.  It then either extends posteriorly into the hairline as in a  face lift or alternatively swings down inferiorly from the  mastoid to continue in a neck crease. The incision may be  made either with a No. 15 blade or with fine needle dia-  thermy or a ceramic blade. The skin flap may be raised  in the plane of the pre-parotid fascia, but if it is raised  superficial to the SMAS, this layer can be mobilized as  a separate exercise and used to cover the raw surface of  the parotid avoiding much of the cosmetic deformity and  the incidence of Frey’s syndrome. The flap is held forward  by suturing the margins of the flap to the adjacent head  drapes (Figure 46.8).    Figure 46.8 Flap elevated to expose the superficial lobe of  the parotid gland.    The routine use of a nerve stimulator as a guide to the  position of the facial nerve is not advocated as it may be  misleading due to tissue conduction or fatigue of the nerve.  The blood-free plane anterior to the cartilaginous meatus  is opened up by blunt dissection with scissors. This leads  down to the base of the skull just superficial to the sty-  loid process and the stylomastoid foramen and defines the  depth of the dissection. This plane is then gently opened  up in an inferior direction by blunt dissection until the  trunk of the facial nerve is seen. It is usually possible to  preserve the posterior branch of the great auricular nerve  if care is taken to avoid dissecting too deep to the earlobe.   With large posterior tumours, this plane may be diffi-  cult to open up. In this situation, it is helpful to identify  the posterior belly of the digastric muscle in the cervical  extension of the incision. The anterior border of the sterno-  cleidomastoid muscle is mobilized and retracted inferiorly  to display the digastric muscle beneath it. This manoeu-  vre necessitates sectioning the great auricular nerve. The  posterior belly of the digastric muscle is traced upwards  and backwards to its insertion on to the mastoid process  which lies immediately below the stylomastoid foramen,  thus leading the operator to the facial nerve from below  (Figure 46.9a and b).   Very rarely, most often after recurrent infection with  fibrosis or previous radiotherapy, the trunk of the facial  nerve cannot be confidently identified. In this situation,  the peripheral branches of the nerve at the anterior border  of the parotid are identified and traced centrally towards  the stylomastoid foramen.    Once the facial nerve trunk has been identified, the super-  ficial lobe of the parotid can be ‘exteriorized’ by opening  up the plane in which the branches of the facial nerve run  between the two lobes using blunt dissection. Initially, as  it leaves the stylomastoid foramen, the trunk of the facial  nerve turns abruptly to become more superficial and also  divides into the larger zygomaticofacial trunk and smaller  cervicofacial trunk. The five main branches of the nerve  are then followed centrifugally through the parotid until  the superficial lobe is completely freed. This part of the  operation is performed using fine scissors, opened up in  the plane of the facial nerve branches, with care always  taken to identify the nerve fibre before dividing parotid  tissue (Figure 46.10a and b). During the lower part of the  dissection, branches of the posterior facial vein will be  encountered immediately deep to the marginal mandibu-  lar branch of the facial nerve. Great care must be taken  when vascular clamps are applied to these branches to  avoid damaging the facial nerve. If the superficial paroti-  dectomy is being performed for chronic infection, the  duct should be tied off as far forward as possible to prevent  recurrent ascending infection.    Figure 46.9 (a) Identification of the facial nerve trunk.  (b) Identification of the facial nerve trunk at the insertion of  the posterior belly of the digastric muscle into the mastoid  process.    When the tumour lies within the tail of the parotid gland,  there is no necessity to dissect all the branches of the facial  nerve nor to remove the entire superficial lobe. Once the  main division of the nerve trunk has been identified, only  the cervicofacial trunk needs to be followed and the infe-  rior part of the superficial lobe is mobilized and ultimately  removed.   Similarly, if the tumour lies above the level of the  meatus, only the zygomaticofacial trunk should be dis-  sected and the corresponding part of the superficial lobe  is removed.    Figure 46.10 (a) Completed dissection of the facial nerve  following superficial parotidectomy. (b) Anatomical landmarks  following superficial parotidectomy.    If the tumour lies in the deep lobe of the gland, a con-  ventional superficial parotidectomy is performed as  described. Next, the branches of the facial nerve are mobi-  lized and lifted on nylon tapes to enable the deep lobe to  be freed around its margins and removed by dropping it  downwards (Figure 46.11). As this space is wedge-shaped  with its apex superior, it is almost invariably possible to  do this. The deep lobe is covered by a capsule (the deep  layer of the deep cervical fascia which splits to envelope  the parotid) and is surrounded by the parapharyngeal  fat. Thus, it is relatively easy to mobilize the deep lobe  by blunt dissection either with scissors or with a finger  (Figure 46.12). Only very rarely it is necessary to perform    Figure 46.11 Mobilization of the branches of the facial  nerve to gain access to the deep lobe.    Figure 46.12 Mobilization of the deep lobe of the parotid  gland.    a mandibulotomy (either vertical subsigmoid or angle) to  gain access to the deep lobe.    Following the removal of the parotid, the blood pres-  sure is returned to normal and the head-up tilt returned  to horizontal. All bleeding points must be meticulously  controlled. A vacuum drain is inserted under the flap and  the wound carefully closed in two layers (Figure 46.13).  A firm pressure dressing will help to prevent any collec-  tion of blood or saliva under the flap.    The pressure dressing, if used, is removed at about 12  hours and the vacuum drain at 24 hours if the wound is  no longer draining. Skin sutures are removed after 5 days.    Permanent facial nerve paralysis following superficial or  total parotidectomy is very rare, except when branches of  the facial nerve have been deliberately sacrificed. When the    Figure 46.13 Two-layer closure with a single vacuum  drain prior to the application of a pressure dressing.    facial nerve or its branches are sacrificed as a result of mac-  roscopic tumour involvement, an immediate nerve graft  may be undertaken using conventional microneural tech-  niques. Temporary weakness due to neuropraxia occurs  in approximately 20% of operations, but recovers usually  within 6 weeks.   Anaesthesia of the skin flap slowly resolves as the sen-  sory nerves regenerate from the periphery over a 4-month  period. Anaesthesia of the earlobe due to sectioning of  the great auricular nerve can be troublesome particularly  when the subject has pierced ears. Recovery can take up to  18 months and may not be complete. Furthermore, a pain-  ful amputation neuroma can develop on the stump of the  sectioned nerve and requires excision.   Frey’s syndrome (gustatory sweating) is a regular sequel  to parotidectomy occurring in more than half the patients  if looked for carefully. The only effective way to control the  symptoms if troublesome is to map out the area of sweat-  ing and then infiltrate the subcutaneous plane with botu-  linum toxin. This will need to be repeated at intervals of  4-6 months.   Other rare complications, such as sialocoele or salivary  fistula, occasionally follow parotidectomy. Both compli-  cations are managed conservatively and resolve sponta-  neously after days or weeks. Very rarely, a parotid fistula  persists despite attempts at surgical closure. In this situa-  tion, post-operative radiotherapy will destroy any residual  functioning glandular tissue and allow the fistula to close.   Parotidectomy can result in a significant cosmetic defect  with hollowing of the facial contour behind the man-  dible. Where this is likely to be a problem, the superficial  part of the sternocleidomastoid muscle can be mobilized,  transacted inferiorly and swung up to cover the defect  (Figure 46.14). The flap must be anchored in place with non-  absorbable sutures as it tends to pull down into the neck.    The superficial SMAS can be elevated as a separate  flap if the skin flap is raised in the subcutaneous layer    Figure 46.14 Sternocleidomastoid muscle flap turned up  to restore the cosmetic defect following parotidectomy.    (Figure 46.15a). On completion of the parotidectomy, the  SMAS layer can be mobilized to cover the defect behind  the mandible by suturing its free edge posteriorly to the  anterior border of the sternocleidomastoid muscle and  periosteum of the zygomatic buttress (Figure 46.15b).  This will also partially advance the skin flap and excess  tissue may need to be trimmed. Great care must be taken  when a tumour lies very superficially within the parotid.  Mobilizing the SMAS flap can very easily rupture the  tumour capsule and it is better to buttonhole the flap  overlying the tumour rather than risk rupture. The evi-  dence suggests that not only does the use of the SMAS  flap improve the cosmetic result, but it also dramatically  reduces the incidence of Frey’s syndrome.    Spillage of a benign pleomorphic adenoma should not  occur if a formal parotidectomy is undertaken. However,  the following are four circumstances where even with  meticulous surgical technique this can happen:    1. Extremely large pleomorphic adenomas occupying the  entire superficial lobe making mobilization of the gland  difficult. In this circumstance, it may be better to dissect  the facial nerve from the periphery.   2 Tumours that are intimately associated with branches of  the facial nerve requiring very delicate dissection along  the capsule of the tumour to release the nerve.   3. Tumours with lobular extensions extending beneath the  mastoid, zygomatic arch or mandible.    If rupture does occur, an extremely careful inspection  of the wound must be undertaken and the area thoroughly    Figure 46.15 (a) Area of undermined superficial musculo-  aponeurotic system (SMAS) flap. The ‘hinge’ is indicated by the  dotted line. (b) Re-attachment of the SMAS flap to the zygo-  matic buttress and sternocleidomastoid muscle.    irrigated. The circumstances should be discussed subse-  quently at the head and neck cancer multidisciplinary  team (MDT) meeting for consideration of prophylactic  post-operative radiotherapy to prevent multiple recur-  rences due to tumour seeding.    In a small proportion of cases, the subsequent histo-  pathological diagnosis will be of malignancy. Provided  the tumour was intrinsic to the parotid and the tumour  was not ruptured during parotidectomy, no other surgery  is necessary or desirable. Each case should be discussed  at the MDT meeting and considered for post-operative  radiotherapy. In general, all high-grade tumours should  be treated with radiotherapy and also those where there is  any doubt about the margins being clear.   Patients with advanced disease with extension beyond  the parotid capsule into adjacent tissues or with lymphatic  metastasis should be treated by a sound oncologic tech-  nique according to the specific circumstances (Figure  46.16a and b). Often this will include mandibular resection,  clearance of the infratemporal fossa and neck dissection  and on occasion resection of the temporal bone (Figure  46.17a and b). If any of the branches of the facial nerve  are functioning pre-operatively, they may be preserved as    (a) Malignant parotid tumour with cervical  metastasis. (b) Total parotidectomy and neck dissection with  preservation of the facial nerve.    evidence suggests that radical sacrifice of the facial nerve  does not improve survival.    On occasion, very extensive deep lobe parotid tumours  develop with minimal signs and symptoms. In such cir-  cumstances, a transpharyngeal approach using a lower lip  split and mandibulotomy with mandibular swing will give  adequate access to the deep lobe and infratemporal fossa.    (a) Recurrent high-grade mucoepidermoid  carcinoma causing intractable pain. (b) Radical tumour resec-  tion including the mandibular ramus and temporal bone.    Although this approach is mostly used for large extrap-  arotid masses, it is occasionally indicated for the excep-  tional tumour arising in the deep lobe (Figure 46.18).  After anaesthetic induction, an elective tracheostomy is  performed as there can be considerable swelling in the  oropharynx post-operatively.    A skin crease incision is made from the level of the hyoid  bone and extended forward towards the chin point. At  this point, the incision is continued either around the  chin point or vertically in the midline. The decision is dic-  tated according to the local anatomy. In patients with a  pronounced chin cleft, it is best to use a midline vertical  incision and for those with a well-developed chin button  dictate it is preferable to incise around this (Figure 46.19).  The lower lip is split in the midline, but a notch should be  incorporated in the incision line at the vermillion border.  These help with the aligning of the vermillion border at  skin closure and also acts as a Z-plasty to prevent tethering  of the lower lip.    After retraction of the sternocleidomastoid muscle poste-  riorly, the carotid sheath is isolated and traced upwards  to the skull base. Vascular slings are placed around the    Computed tomography scan showing an  extensive deep lobe tumour requiring a transpharyngeal  approach.    internal and external carotid arteries in case either vessel  is ruptured later in the operation and urgent control is  required. Often it is sensible to clamp, divide and ligate the  external carotid at this stage.   The dissection is then continued forward deep to the  submandibular salivary gland. It must be carefully freed  from the underlying hyoglossus and mylohyoid muscles,  whilst remaining attached to the lower border of the  mandible.   The surgeon should then return to the chin incision and  expose the buccal aspect of the mandible from the midline  back to the premolar region carefully isolating the mental  nerve as it exits the foramen between the premolar roots.   The mandibulotomy is then marked running between  the first premolar and canine teeth (Figure 46.20). Two  microplates are then adapted to the buccal aspect of the  mandible and the screw holes drilled. The plates are then  carefully put aside, care being taken to mark them for  position and orientation.   The mandibulotomy cut is then made with a reciprocat-  ing saw. Great care must be taken between the two adja-  cent teeth so as not to damage the roots. It may be wise  to cut just through the buccal cortex with a bur and con-  tinue the mandibulotomy with a very fine osteotome at    Exposure of the mandible and application  of the first manipulate prior to mandibulotomy.    this level. The mandible is then retracted laterally and the  mucosal incision extended posteriorly along the floor of  the mouth medial to the submandibular duct. The incision  should extend up the anterior pillar of the fauces to the  upper pole of the tonsil.   During this stage of the operation, the lingual nerve and  the hypoglossal nerve must be identified. The hypoglossal  nerve can be readily displaced medially and protected, but  it may be difficult to release the lingual nerve sufficiently.  In this case, the nerve should be cleanly divided with a  blade and the ends tagged, so that an anastamosis can be  performed at the end of the operation.   At this stage of the operation, the parapharyngeal space  can be opened through the incision and the tumour mobi-  lized and delivered by blunt dissection.    Following meticulous haemostasis, a vacuum drain is  inserted into the parapharyngeal space. The intra-oral inci-  sion is closed in at least two layers with the mucosa being  closed with everting mattress sutures as it is important to  achieve a watertight closure to prevent the formation of an  orocutaneous fistula. At this stage, the lingual nerve should  be repaired with micro neural techniques if it has been  previously divided. Once the floor of the mouth has been  repaired, the previously adapted microplates are screwed  into their previously drilled holes and mandibular conti-  nuity is restored without any disturbance to the occlusion.   The skin incision is closed in two layers. Great care must  be taken with the lip closure. The orbicularis muscle should  be repaired with resorbable sutures before commencing  a two-layered closure of the skin. It is very important to  achieve perfect alignment of the vermillion as failure to  achieve this result in a very unsightly scar. The drain is  removed usually at 24 hours and the skin sutures at 7 days.    The greatest risk with this operation is the development  of an orocutaneous fistula. Watertight closure of the  mucosal incision is vital. Should a fistula develop, it is  worth returning the patient to the operating theatre and  resuturing the mucosa where it is leaking. If this is done,  the drainage through the neck will close spontaneously.    Damage to the teeth adjacent to the mandibulotomy  can be prevented by careful technique at the time of  the operation. The lingual nerve repair will normally  give useful function, but sensation almost never returns  completely. The patient should have been warned of this  pre-operatively.    e Surgical biopsy of an intrinsic parotid tumour carries a  severe risk of seeding tumour cells into the adjacent tis-  sues and rarely affects the definitive surgical procedure.   e Although embryologically composed of a single lobe,  the parotid gland consists of two surgical lobes sepa-  rated by the facial nerve which is enclosed in loose con-  nective tissue.   e The trunk of the facial nerve is very constant anatomi-  cally. It should be identified before any facial nerve dis-  section, except when a centripetal approach is to be  used. The anatomical landmarks are 100% reliable.   e The great majority of deep lobe tumours may be safely  removed without dividing the mandible.   e Preserving the SMAS and re-attaching it at the end of a  parotidectomy improve the cosmesis and dramatically  reduce the incidence of Frey’s syndrome.   e The only reliable way of controlling Frey’s syndrome is  the subcutaneous infiltration of botulinum toxin into  the affected area.    Cawson RA, Gleeson MJ and Eveson JW. Pathology and  Surgery of the Salivary Glands. Oxford: Isis; 1997.   Norman JedeB and McGurk M. Colour Atlas and Text of the  Salivary Glands. London: Mosby- Wolfe; 1995.   Seifert G, Miehlke A, Haubrich J and Chilla R. Diseases of  the Salivary Glands. Stuttgart: Georg Thieme Verlag;  1986.   Seward GR. Anatomic surgery for salivary calculi. Part V.  Calculi in the extraglandular part of the parotid duct.  Oral Surg Oral Med Oral Pathol. 1968; 25: 810-816.   Seward GR. Anatomic surgery for salivary calculi. Part VI.  Calculi in the intraglandular part of the parotid duct.  Oral Surg Oral Med Oral Pathol. 1968; 26: 18.    Extracapsular dissection (ECD) is an example of the  general move towards minimally invasive procedures.  Historically, pleomorphic adenomas in the parotid  gland have had a reputation for tumour recurrence.  Consequently, an approach was adopted towards superfi-  cial or total conservative parotidectomy.   The reputation for pleomorphic adenomas having a  propensity to recurrence is largely undeserved. The rea-  son for this is that in the 1930s, when the high incidence  of recurrence was noticed, these lesions were thought to  be hamartomas and not true neoplasms. They were called  pathological adenomas. Consequently, it was an accept-  able practice to enucleate these lesions after opening the  capsule, in essence an intra-capsular dissection. It was  soon realized that a significant number recurred. In  response, a number of surgeons started to develop new  techniques to deal with these parotid lumps and with  the seminal work of Patey and Thakray in 1958, the tech-  niques of superficial parotidectomy (SP) and total con-  servative parotidectomy became the universal standards  of care for the wrong reason, but correct result. The inci-  dence of recurrence dropped with this change, thus rein-  forcing the intellectual and scientific bases underpinning  these techniques.   However, in the late 1940s, before the debate had been  resolved in favour of superficial and total parotidecto-  mies, general surgeon Alan Nicholson at the Christie  Hospital, Manchester, UK was continuing with his own  local dissection technique. By the late 1950s, when the  debate was settled in favour of SP, Nicholson had 10  years of experience with the ECD technique without  evidence of recurrence. Consequently, he continued  with this technique and was followed in turn by other    surgeons both at Guy’s Hospital, London, UK and  Erlangen, Germany where over 1200 cases of benign  parotid tumours have been treated by ECD. In reality,  surgeons have been dissecting benign tumours in an  extracapsular plane ever since the conservative paroti-  dectomy technique was conceived because the tumour  surface is in direct contact with one or more branches  of the facial nerve in 60% of the cases. Two recent sys-  tematic reviews and meta-analysis have supported the  role of ECD in benign parotid tumour management  with significantly reduced risk of temporary facial nerve  weakness and Frey’s syndrome in ECD compared to SP.  Albergotti et al.,! in an analysis of 1882 patients, found  similar rate of tumour recurrence (1.5% ECD vs. 2.4%  SP) and permanent facial nerve paresis with ECD and  SP. On the other hand, Foresta et al.? analyzed a total of  2562 patients and suggested significantly reduced risk of  tumour recurrence and permanent nerve weakness with  ECD. The evidence is now beginning to favour ECD as a  viable and safe technique in the management of benign  parotid tumours against the long-held views supporting  more extensive traditional surgical techniques.    ECD is only appropriate for benign tumours of the  parotid gland. It has no application in submandibular  gland because the morbidity of ECD and submandibu-  lar gland removal are the same. There is no facial nerve  to complicate the equation. But the basic principle of a  conservative extracapsular resection is applicable to  pleomorphic adenomas of the junction of hard and soft  palate. Resection of bone on the hard palate or soft-tissue    aponeurosis to form a nasal fistula is completely unjusti-  fied (see Chapter 44).   Every effort should be taken to avoid inadvertent ECD  of a salivary malignancy. This error of patient selection,  which has probably delayed general acceptance of the  technique of ECD, happens rarely and only occurs with  very low-grade lesions masquerading as benign lumps.  Clinically, it is difficult to discern these tumours when  they are small, as they have not had time to declare  themselves. Consequently, it is the small apparently  benign parotid lumps that present a challenge, not the  2 or 3-cm diameter lesions. Also, small lumps are easily  missed on fine-needle aspiration so that normal benign  tissue is sampled inadvertently. Therefore, small parotid  tumours should be approached with caution and if ECD  is being considered, the cytological evidence should be  checked carefully. Also, it is a very simple matter with  these small 8-15-mm lesions to continue to ECD with a  margin around the lesion of 1 cm if required. A conven-  tional parotidectomy is also an option but is not normally  required from an oncological perspective as most patients  with malignant parotid lumps get adjuvant radiother-  apy because of the proximity of the facial nerve and the  inability to achieve a 5-mm margin.   The ideal lesion is a well-defined lump, 2-6 cm in diam-  eter, in the superficial portion of the parotid gland, the  circumference of which can be defined by palpation. With  time and experience, most parotid lumps irrespective of  their position are amenable to the ECD technique.    Although there is evidence that some clinicians can discern  benign from malignant tumours in over 90% of cases by  clinical examination alone, it is prudent to undertake fine-  needle aspiration cytology assessment as it is a simple tech-  nique that can improve the diagnostic rate even further.   The role of imaging in benign superficial parotid  tumours is debatable, but reconnaissance is never wasted.  Imaging is open to individual preference. With increas-  ing experience, the surgeon will tend to reduce the use of  imaging. It has increasing application as the tumour is less  easy to inspect digitally.    Hypotensive anaesthesia is not necessary for ECD.  Haemostasis is a surgical responsibility, not an anaesthetic  one. Ifa paralyzing agent is used, it should be short acting as it  is important that the patient is not paralyzed during the sur-  gery. Continuous nerve monitoring does no harm and may  rescue the tired or distracted surgeon from a misadventure.  The patient’s neck is extended as it makes the parotid  gland more prominent, this can be done by placing a small  pack beneath the nape of neck. A nasal endotracheal tube  is used as an oral tube, by opening the mouth, makes it    difficult to draw the mandible forward which is neces-  sary when the tumour is wedged between the ramus of the  mandible and the mastoid process. The patient is supine  with the operating surgeon on the same side as the tumour  with the head turned away. The drapes are placed to leave  the ipsilateral face exposed for facial twitching is the ulti-  mate indicator of proximity to the facial nerve.   It is important that the surgeon is comfortable, usually  sitting with adequate support of the arms. Most surgeons  use some degree of magnification for this procedure, such  as surgical loupes.    A bloodless field is achieved by infiltrating the pre-  auricular tissues with 20-30 mL of 1:200,000 epinephrine  solution. This provides a dry surgical field and hydro-  dissects the subcuticular tissues from the parotid fascia.  The solution is injected early in the procedure so it has  time to induce adequate vasoconstriction.   The proposed incision should be marked; it is useful to put  superficial scratch marks or skin staples on either side across  this incision line in order to relocate the skin flap. This is par-  ticularly so around the lobe of the ear, which has an annoy-  ing habit of becoming distorted after surgery. The standard  approach for ECD is a pre-auricular incision with cervical  extension along a natural skin crease. But with experience  the length of incision can be reduced and tailored to the  individual lump. When commencing ECD, the advice is to  use the same extent of exposure as traditional SP.   Shaving the patient’s hair has no impact on healing; it  can be swept back and tied or taped away so it is kept out  of the surgical field.    The skin is raised in a plane immediately superficial to the  parotid fascia. This is a shining white plane, which is easy  to identify and follow forward until the fibres of the pla-  tysma muscle are encountered. The lobe of the ear should  be freed from the mastoid process and both the skin flap  and the ear are retracted with sutures. At this point, the  great auricular nerve should be identified as it runs over  the sternomastoid muscle and in approximately 60% of  cases of ECD it can be preserved.   When the skin flap has been raised, the clinical features  of the tumour are checked once again. If the lump is clearly  mobile and there are no features of tethering to suggest  malignancy, then ECD can proceed. A new approach that  has transformed the approach to the parotid lump, espe-  cially those towards the posterior aspect of the parotid and  wedged between the mandible and mastoid is to approach  the procedure like an upper neck dissection. The posterior  skin flap is developed to expose the sternomastoid muscle  (with the deep cervical fascia intact). Then, longitudinal  incision is made along the anterior border of the muscle  (1 cm from its edge). The fascia is carefully lifted off the    muscle and followed down its deep surface to the accessory  nerve. The parotid is released and can be rotated anteri-  orly. What was wedged between the ramus and mastoid is  freely visible and easy to access. In all cases, apart from a  very superficial tumour on the lateral surface of the parotid,  this rotation approach should be used. It is perfect for the  Warthin’s tumour in the distal aspect of the tail of the gland.   Once exposed, the periphery of the tumour is marked  in ink and a cruciform incision drawn across the surface  (Figure 47.1). It is very important that this incision extends  for at least 1 cm beyond the tumour margin as it improves  access to the tumour. Four artery clips are attached to the  centre point (Figure 47.2) and used to provide upward ten-  sion whilst the parotid fascia is incised along the cruci-  form lines.   The key to ECD is finding a safe plane in which to dis-  sect. This is done by drawing the normal parotid tissue  away from the tumour revealing tissue planes 2 or 3 mm  wide of the tumour capsule. The rule is that no instru-  ment should be used to retract the tumour. If it no longer  has a cushion of protective normal tissue, it can only be  retracted by finger pressure, but retractors can be used to  hold back the normal parotid tissue. The artery clips are  left attached to the parotid fascia and continually used as  retractors. It cannot be emphasized more strongly that the    retraction must be on the normal parotid tissues adjacent  to the tumour and never on the tumour itself.   The process of dissection in the safe plane is identical to  that used in SP when exposing the trunk of the facial nerve.  The closed end of a pair of blunt-tipped scissors or artery  clip is pushed gently through thin sections of parotid tissue  and opened with upward pressure to part the parotid tissue.  It is imperative that no tissue is cut without seeing the scis-  sors through the fascia. In this way, a facial nerve branch  is readily identifiable. If a branch of the facial nerve enters  the surgical field, it is traced forward for a short distance  (5-10 mm) to reveal its position and if in close contact with  the capsule is dissected from the tumour. If the tumour  arises from below the facial nerve in the deep lobe of the  parotid gland, then all that is required is that the branches  of the facial nerve are dissected off the tumour capsule or  periphery and the ECD continues as normal with dissec-  tion around the periphery of the lesion until it is free. This  situation is no different from that encountered in SP.   Another important point is to work slowly around the  periphery of the tumour. If at any point the dissection  becomes difficult, the surgeon should move to another  area of the tumour. One should avoid working in the  bottom of a hole. If this is the case, the cruciate incision  should be extended to improve exposure. Extending the  incision allows the parotid lump to be delivered up and  improves access immediately.   It is not necessary to search for the facial nerve; an  unseen nerve is a safe nerve. It is the dissection of the  nerve and inadvertent trauma that produces facial nerve  damage. Once the tumour is delivered, the parotid fascia is  re-approximated along the lines of the cruciform incision  and closed with multiple, interrupted, resorbable sutures.  This restores the contour of the cheek, eliminates any  dead space within the parotid gland and the closed fascia  and also minimizes the risk of Frey’s syndrome. The skin  flaps are closed in two layers over a suction drain and a  mastoid-type pressure dressing is applied.    The pressure dressing is left in situ for 24 hours. It is  important that it is taken down the next day in order to  check on the perfusion of the helix. It is mostly possible to  discharge the patient home on the first post-operative day  or on occasions, on the same day.    The risk of tumour rupture is the same as SP (1%-3%). If  such an event occurs, the operation should be stopped.  A clean sucker should be used to suction up any spilt  tumour. The sucker should then be discarded. The tear  in the tumour capsule should be closed with surgical tis-  sue glue in the first instance. Liga clips or sutures tend to  aggravate the situation by making the tear even bigger.    The operative field should be thoroughly washed with  sterile water. The operation is then recommenced but  the tumour is no longer handled at all. If this routine is  followed and contamination is minimal, then the risk of  recurrence is about 8% at 15 years. If gross contamination  of the wound is encountered, then the risk of recurrence  is increased and the possibility of adjuvant radiotherapy  should be discussed at the multidisciplinary meeting and  indeed with the patient.    The parotid gland is a vascular structure and the risk  of post-operative haematoma is always present. There  does not seem to be any greater or lesser risk with ECD.  Meticulous haemostasis should be achieved through-  out the procedure and also small bleeding points should  be identified and carefully cauterized. A suction drain  is an option and should be used if a lot of dissection has  occurred in the parotid. The one essential item is a pres-  sure dressing. This is a formal mastoid dressing; without it,  the risk of sialocoele and haematoma is raised.    With ECD, the incidence of transient facial nerve injury  is reduced from 20% to 8% and permanent damage  is the same as SP (1.4% vs. 1.2%). Most of the surgical  techniques deployed in ECD are also used routinely in  traditional parotid surgery. The fundamental difference,  however, is that in traditional surgery the threat of nerve  injury drives the surgeon to find and proceed to a facial  nerve dissection. The procedure of SP is an inaccurate  description of the procedure. In contrast, ECD is not a  nerve dissection but a tumour dissection procedure. The  facial nerve is not routinely identified and explored in  ECD; the act of leaving the nerve untouched within the  parotid tissue reduces the incidence of transient nerve  injury. The management of facial nerve injury applies  to all parotid surgery; the transacted nerve should be  repaired directly.    Pressure dressings are important in reducing the inci-  dence of sialocoeles and also in their management. If it  occurs the incision line must not be reopened, it should be  managed by regular needle aspiration, pressure dressings  and salivary suppressants. Initially, it may require aspi-  ration every 2 or 3 days but gradually the frequency will  reduce and the sialocoele will resolve spontaneously over  10 days. Once the skin flap has re-attached to the parotid  fascia and the pressure around the sialocoele is greater  than that in the duct system, the saliva will preferentially  flow down the duct.    The transected parotid duct is treated the same for any  type of parotid surgery. The duct should not be tied in the  process of removing a benign parotid tumour unless it is  absolutely essential. Tying the parotid duct increases the  risk of sialocoele formation.    The incidence of Frey’s syndrome is less than 5% follow-  ing ECD because the re-approximated parotid fascia is a  barrier to neural infiltration compared to the incidence of  26% with SP.    Traumatic neuromas are more common with SP than ECD.  This is due to the limited exposure of the parotid gland  with ECD; the greater auricular nerve can be avoided in the  dissection in over 60% of cases. There are no established  ways of avoiding a traumatic neuroma once the nerve is  transected. There are numerous anecdotes and suggestions  in the literature but none proven to be effective.    The incidence of recurrent tumour following ECD is iden-  tical to that for SP about 1%-2% at 10 years. The median  time to recurrence is 7 years.   e Check the clinical features of the tumour once the skin  flap is raised to ensure that ECD is appropriate.   e If you cannot see through the tissue do not cut it, if you  always do this, you will never cut a nerve.   e Do not work in a hole, extend the cruciate incision if  needed. If it is getting difficult at one site in the dis-  section, then stop and move around the tumour and  comeback later — it will be easier then.   e The Warthin’s tumour is an ideal case for surgeons learn-  ing this procedure because it is not a true neoplasm so  fear of recurrence is absent and most Warthin’s tumours  lie in the tail of the parotid, well away from the facial nerve.  Remember to release the parotid and rotate it forward.   e Time spent applying an effective pressure dressing is  well spent; it will reduce the likelihood of haematoma  and sialocoele formation.   e If during an ECD, the surgeon becomes uneasy with the  surgical environment then the operation can be drawn  to a close by re-approximating the cruciform incision  with 3 or 4 simple sutures. The surgeon can revert to  the SP. Nothing is lost in this approach.    1. Albergotti WG, Shaun BA, Nguyen MD, Zenk J and  Gillespie MB. Extracapsular dissection for benign  parotid tumours: A meta-analysis. Laryngoscope.  2012; 122: 1954-1960.   2. Foresta E, Torroni A, Di Nardo F, de Waure C,  Poscia A, Gasparini G, et al. Pleomorphic adenoma  and benign parotid tumors: Extracapsular dissection  vs superficial parotidectomy - Review of literature  and meta-analysis. Oral Surg Oral Med Oral Pathol  Oral Radiol. 2014; 117: 663-676.    Bailey H. Treatment of tumours of the parotid gland with  special reference to total parotidectomy. Br J Surg.  1941; 28: 337-346.    Donovan DT and Conley JJ. Capsular significance in  parotid tumour surgery: Reality and myths in lateral  lobectomy. Laryngoscope. 1984; 94: 324-329.   George KS and McGurk M. Extracapsular dissection - A  minimal resection for benign parotid tumours. Br J  Oral Maxillofac Surg. 2011; 49: 451-454.   Janes RM. The treatment of tumours of the salivary gland  by radical excision. Can Med Assoc J, 1940; 43:  554-559.   McFarland J. Three hundred mixed tumours of the salivary  glands, of which sixty-nine recurred. Surg Gynecol  Obstet. 1936; 63: 457-468.   McGurk M and Combes J (eds.). Controversies in the  Management of Salivary Gland Disease. Oxford, UK:  Oxford University Press; 2013.   Patey DH and Thackray AC. The treatment of parotid  tumours in the light of a pathological study of paroti-  dectomy material. Br J Surg. 1958; 55: 447-487.    Thyroid lobectomy and total thyroidectomy are some of the  most common head and neck procedures. Broadly speaking,  these are performed for two basic reasons - either there is a  confirmed or high enough suspicion for pathology to merit  surgical removal or the patient suffers from the overall size  of the gland. The latter may cause compressive symptoms or  disfigurement leading the patient to seek surgical care.   In cases of pathology, relevant workup should be done  including fine needle aspiration biopsy and imaging  including ultrasound, computed tomography (CT) or  thyroid nuclear scans. Having an accurate diagnosis is  helpful, though not always possible, in determining the  specific procedure to be done as well as the management of  regional nodes. Patients undergoing thyroidectomy should  also have basic biochemical workup for thyroid function.  Those with overactivity should be medically controlled  prior to surgery and should be offered the options for com-  plete medical management where appropriate. Patients  who have compressive symptoms or potential airway com-  promise should have careful pre-operative planning with  an anaesthetist adept at airway management including  fibre-optic techniques.    The thyroid gland is a prominent bilobed endocrine gland  which on average weighs approximately 20 g and occupies  the space between the thyroid cartilage and fifth to sixth  tracheal rings just deep to the strap muscles. It has a tenu-  ous capsule around the entire gland, which is surrounded  by the deep visceral fascia of the neck. Embryologically,  this structure arises at the foramen cecum at the tongue    base from the endodermal layer of the first and second  pharyngeal pouches. It descends to the adult position in  the neck by the sixth to seventh week of gestation. The  proximal tract normally degenerates, but in cases when  it does not, a thyroglossal duct cyst may arise along this  path. Occasionally the thyroid fails to fully descend in the  neck and ectopic thyroid tissue may be found anywhere  along the course of the thyroglossal duct from the tongue  base down to the hyoid bone.   The vascular supply to the thyroid gland is composed  of paired superior and inferior thyroid arteries and veins  and a lone middle thyroid vein on both sides. The superior  thyroid artery arises from the external carotid artery and  enters the superior pole from a supero-lateral direction  along with the accompanying vein. The inferior artery  arises from the thyrocervical trunk off of the first portion  of the subclavian artery. On occasion, a thyroid ima vessel  is present which enters the thyroid isthmus on its course  from the subclavian artery. The middle thyroid veins enter  laterally from the internal jugular system and have no  accompanying arterial supply.   Anatomically relevant nerves in the region include the  bilateral external branch of the superior laryngeal nerve,  which provides motor function to the cricothyroid mus-  cle, and the recurrent laryngeal nerves, which are respon-  sible for the remaining intrinsic laryngeal muscles. Both of  these are branches of the vagus nerve. The external branch  of the superior laryngeal nerve travels with the superior  pole vessels to enter the cricothyroid muscle and is not  always visualized during surgery. As a result of their being  dragged inferiorly during embryologic development, the  recurrent laryngeal nerves follow a more circuitous route.  The left recurrent laryngeal nerve (RLN) courses around  the ligamentum arteriosum to approach the larynx from  below along the tracheo-oesophageal groove, whilst    the right side travels around the subclavian artery after  branching from the vagus. In less than 1% of individuals,  a non-recurrent nerve is present on the right side second-  ary to atypical formation of a retro-oesophageal subcla-  vian artery.   Finally, the parathyroid glands must be acknowledged  during surgery of the thyroid. Residing on the posterior  surface of the thyroid gland, they each weigh approxi-  mately 50 mg and reside on the posterior surface of the  thyroid gland. The majority of the population has four  parathyroids and some have more. Identification requires  attentive searching, as they are quite small and can blend  in, especially in a bloody field. The parathyroid glands  are usually of caramel colour that differs from adjacent  fatty tissue. The superior parathyroids are derived from  the fourth pharyngeal pouch and are usually found at the  level of the cricoid cartilage. The inferior counterparts are  somewhat more variable given their greater distance trav-  elled during development due to their origin at the third  pharyngeal pouch.    Prior to bringing the patient to the operating room, mark-  ing is done in the pre-operative area with the patient stand-  ing upright in order to aid in identification of the neck  crease that most easily allows the incision to heal whilst  permitting sufficient surgical access. The patient is then  brought to the operating room positioned supine. With  administration of general anaesthesia, the patient is orally  intubated with a neural integrity monitor (NIM) tube. The  anaesthetist typically uses an endoscopic-assisted tech-  nique in order to allow the surgeon to confirm accurate  placement of the tube’s monitoring surfaces. The NIM  tube is recommend in all cases to aid in the preservation  of the recurrent laryngeal nerve, but by no means can it  be considered a panacea for identifying or preserving the  nerve. Anatomic identification and strict technique are the  primary means by which the nerves ought to be identi-  fied and protected. The continuous neural monitoring  provides an adjunct with which to confirm security of this  vital structure.   Once the patient is intubated and all monitors applied,  the patient is positioned with the neck extended using  either a soft shoulder roll or positioning the head of bed  in an extended position. Avoid overzealous neck exten-  sion or a position that leaves the patient positioned with  the patient’s head unsupported. In patients with a large  body habitus, especially when combined with a short,  thick, neck, it can be helpful to tape down the chest with  foam tape applied to the table with a caudad vector. Also,  during tucking of the arms, gentle traction can be applied  inferiorly to bring the shoulders down and provide better  exposure of the neck.    Figure 48.1 Nerve monitor apparatus is set up and moni-  tored by a technician at a console in the operating room.    The thyroidectomy patient population can often be quite  image conscious particularly with regards to neck scars.  Exposure is therefore limited to what is necessary. Usually  a 4-5 cm horizontal incision set symmetrically between  the sternocleidomastoid muscles is sufficient. For small  volume glands, incisions as small as 3 cm will accommo-  date the procedure and generally results in a more pleasing  scar to the patient (Figures 48.2 and 48.3). As mentioned,  the marking is done pre-operatively and placement within  a favourable neck crease is now confirmed with the neck in  extension. A Colorado tip electrocautery on a low setting  is used to make the incision. The use of the electrocautery  ensures haemostasis. A continuous smooth and expeditious  movement minimizes thermal injury. Sub-platysmal flaps  are raised superiorly to the thyroid notch and inferiorly to  the sternal notch. Traction sutures are used to hold back  the flaps as they provide reasonable mobility during later  dissection in contradistinction to large, rigid retractors.    The superficial fascia is divided between the anterior jug-  ular veins and the midline of strap muscles is identified.    Figure 48.2 incisions as small as 2.5 cm may be used for  smaller volume glands and when the patient has favourable  neck anatomy.    Figure 48.3 A traditional Kocher-style incision extending  from sterno-cleido-mastoid (SCM) to SCM may be required for  large goiters. Horizontal division of the strap muscles in these  cases will also facilitate access.    The middle cervical fascia, which encapsulates the strap  muscles, is divided in order to expose the underlying thy-  roid. The use of Ligasure dissection helps to speed this  portion of the procedure and render the dissection blood-  less (Figure 48.4). The sternohyoid and sternothyroid strap  muscles are then dissected off the gland. In rare cases  transection of the strap muscles are required to facilitate  exposure (Figure 48.3). The vast majority of time, the thy-  roid can be easily exposed by gentle retraction by tenting  up the muscle in a supero-lateral direction whilst simulta-  neously retracting the gland using Kittner dissectors in a  motion that rolls the gland out of the wound (Figure 48.5).  This traction-counter traction reveals the layer of visceral  fascia as a ‘fluff of tissue that can be mostly bluntly dis-  sected off the thyroid capsule. Attention should be paid  to the superior aspect where muscle is not as easily lifted  free in order to ensure complete dissection of the gland  towards the superior pole.   Capsular dissection is continued widely in order to mobi-  lize the gland. The middle thyroid vein (or veins) are usually    Figure 48.4 After sub-platysmal flaps have been raised,  they are retracted with sutures. Ligasure is used to divide the  strap muscles at midline.    Figure 48.5 The right thyroid lobe is exposed with blunt  dissection aided by retractors providing counter traction in a  supero-lateral fashion.    identified early on in the dissection and can be ligated with  ties or surgical clips. The specific sequence of the opera-  tion progresses and any tethering vessels that follow can  be directed by how the gland dissection and can be ligated  with ties or surgical clips. It is particularly helpful to allow  an element of improvisation in cases of large goitres when  visibility is limited. However, by freeing the gland broadly  with continuous wide dissection eventually the next logi-  cal step presents itself. For most cases, though, the superior  pole is the first area to be addressed. With the muscle freed  from the gland, the superior pole of the can be visualized  and mobilized with a combination of blunt dissection and  use of bipolar electrocautery to divide small vessels and  attached fascia tethering the thyroid. Extra attention is paid  to make a clean dissection between the superior thyroid and  the cricothyroid space. A pair of Kittner dissectors can then  be used on either side of the superior pole to bring the ves-  sels easily into view. A clear dissection of the superior artery  and veins before ligating them will help to prevent injury to  the external branch of the superior laryngeal nerve. Use of    a right-angle dissector is useful in aiding the visualization  and ligation of the vessels.   At this point, the dissection is brought inferiorly.  Continuous use of the bipolar for fine dissection and  gentle blunt dissection is used. It is important to avoid  picking up the gland itself, as this almost surely will cause  bothersome, persistent bleeding, which impedes prog-  ress. As the gland begins to mobilize, a portion of it can  be brought out of the wound bed and retracted gently by  hand in order to aid in further dissection (Figure 48.6).  The superior parathyroid glands can usually be identified  as the dissection is carried inferiorly. These tend to pop  out clearly if strict capsular dissection is done. With the  use of fine forceps, the fascia of the parathyroids can pro-  vide traction for dissection off the thyroid gland without  undue trauma to the parathyroids or their vascular supply.  It is especially crucial to look for and preserve any para-  thyroid glands in cases of total thyroidectomy. If there is  any concern based on the course of dissection or colour  change in these glands, consideration should be given to  autotransplantation.   The inferior pole can be approached next. There are usu-  ally multiple branches of the inferior pole vessels entering  the gland and therefore it is important to carefully dissect  each to achieve a clean field (Figures 48.7 and 48.8). In sim-  ilar fashion to the superior vessels, a right-angle dissector is  used to cleanly dissect these vessels before they are ligated.  This will prevent inadvertent injury to the recurrent    Figure 48.7 The gland is retracted inferiorly and the supe-  rior pole vessels are ligated using silk suture passed under the  vessels in this case.    Figure 48.8 The inferior pole vessels are shown being  exposed and ligated with silk suture. Alternatively, these can  be taken with stainless steel clips or haemostatic devices.    laryngeal nerves. The median portion of trachea can then  be exposed inferiorly to establish a plane of dissection.   The recurrent laryngeal nerve is identified prior to pro-  ceeding with the lateral-to-medial dissection. On the left  side, the nerve tends to follow a fairly predictable course  paralleling the tracheo-oesophageal groove as the nerve  courses superiorly towards the larynx after wrapping  around the ligamentum arteriosum. The right side, on  the other hand, tends to approach the larynx from a more  inferolateral direction after passing under the ipsilateral  subclavian artery. Additionally, a non-recurrent nerve is  present in approximately 0.5% of the population on the  right side. Volumes have been written on the anatomic  landmarks for identification of the RLN. We find that the  nerve can generally be found within approximately 10 mm  of the inferior parathyroid gland. Alternatively, the nerve  can be searched for distally near the cricothyroid joint as  it enters the larynx. This knowledge, along with careful  blunt dissection will allow the RLN to be found. Rarely is  blind nerve probing with the neural monitor necessary. In  cases where the NIMs monitor is used, confirmation of the  position of the nerve can be done by using the nerve probe.   At this point, the only attachment remaining in order  to free the gland is Berry’s ligament. This structure must  be divided to free the thyroid from the trachea. Gentle  medial traction of the gland is provided. The key is to  avoid pulling too enthusiastically. This can cause two  problems. First, the nerve can be pulled up within the fas-  cia and become very difficult to differentiate from fascia  as it arborizes distally. Second, aggressive traction makes  it more likely for the smaller vessels in the area to tear and  bleed, which compounds the problem of visually tracking  the nerve. Thus, we dissect the tenuous Berry’s ligament  using bipolar cautery and right angle dissector where nec-  essary to maintain a plane above the RLN. The dissection  here is brought towards the trachea and completed by  joining the plane inferiorly where the tracheal fascia has  been exposed previously. Dissection is finished by freeing  the thyroid isthmus towards the contralateral paramedian  trachea.   If a total thyroidectomy is being performed, the oppo-  site lobe is dissected at this point. The previously dissected  lobe can be delivered from the neck and used to apply trac-  tion for the opposite side. Alternatively, it can be tucked  back in situ in order to provide an unobstructed view as  dictated by surgical progress (Figure 48.9).   For closure, a small suction drain is placed deep to the  strap muscles. The muscles are then re-approximated with  two to three resorbable sutures. The platysma is sutured  with 3-0 Vicryl sutures and skin closure is achieved with  5-0 monofilament subcuticular sutures. A single Steri-  Strip applied along the wound provides a neat closure and  comes off painlessly after several days.    Lobectomy patients may be managed either as outpatients  or admitted for 24 hours depending on patient preference.    Figure 48.9 The gland has been completely removed in  this image with the surgical bed revealing intact RLN bilater-  ally. These can be confirmed using nerve monitoring.    For total thyroidectomies, patients are admitted for  24-hour observation. During that time, they are monitored  continuously for any airway problems or vocal changes that  may indicate injury to the recurrent laryngeal nerve. Also,  oral calcium is provided at a dosage of 3 g elemental calcium  daily. The patients are also discharged on this dosage for  1 week. During the hospital stay, calcium levels are moni-  tored every 8 hours. Every patient has an endocrinology  consultation as an inpatient as well in order to establish  continuity of care with the appropriate provider.    Given the associated anatomy with thyroidectomy, a brief  discussion of management of thyroglossal duct cysts is  given here. As mentioned, this benign lesion will pres-  ent either in adults or children as a soft, mobile, midline  mass that moves superiorly during swallowing. It results  from persistence of the tract as the thyroid descends from  the foramen cecum during embryologic development. The  treatment is surgical excision of the duct, known as the  Sistrunk procedure.   Pre-operative workup is relatively straightforward.  Testing of the cyst itself is not commonly required as the  thyroglossal duct cyst is a clinical diagnosis (Figures 48.10  and 48.11). If there is an acute infection of the cyst, then  medical management with antibiotics to resolve the inflam-  mation is indicated. Also, the presence of normal thyroid tis-  sue should be confirmed by ultrasound or some other means  of imaging to ensure that the patient’s only thyroid tissue  does not reside within the cystic tract to be excised, thus ren-  dering the patient hypothyroid.    The operative setup for the Sistrunk procedure mirrors  that of the thyroidectomy with regards to patient posi-  tioning. The NIM monitor need not be used during this    Figure 48.10 Lateral view of a small thyroglossal duct cyst  and the corresponding sagittal computed tomography (CT)  image.    Figure 48.11 This patient with a large thyroglossal duct  cyst demonstrates the elevation of the mass during tongue  elevation due to its epithelial tract associated with the hyoid.    operation, as the recurrent laryngeal nerves should not  be approached. A horizontal incision is made through  skin over the prominence of the mass paralleling the  hyoid bone. The incision is deepened to a sub-platysmal  layer. Care must be taken here as the mass may widen  the platysmal diastasis leaving only a thin layer of fascia  covering the cyst. Every effort is made to avoid rupture  of the cyst since this will make complete excision more  difficult. The sub-platysmal flaps are elevated supe-  riorly and inferiorly in order to allow exposure of the  entire mass.   The midline is identified and the strap muscles are  divided at this point and finely dissected off the cyst wall  (Figure 48.12). Lateral and inferior dissection is per-  formed first in order to clearly define the surgical plane  and begin to mobilize the specimen. Next, the hyoid  gland is palpated and electrocautery used to cut down on  the medial portion of the bone (Figures 48.13 and 48.14).    Figure 48.12 Initial dissection of the thyroglossal duct  cyst with exposure of the cyst deep to the infrahyoid strap  muscles.    Figure 48.13 Sistrunk procedure showing dissection of  the epithelial tract towards the hyoid which has been exposed  in order to include the central portion in the specimen.    The medial portion of the sternohyoid and thyroid hyoid  as well as the suprahyoid muscles is divided in order to  expose the hyoid for osteotomy. Division of the midline  segment of hyoid is a mandatory part of the procedure  as the cystic tract can be tenuously fused to the posterior  surface. The risk of recurrence is elevated if the hyoid  is not taken. In addition, removal of the midline hyoid  allows for easier retraction and a more thorough superior  dissection. A periosteal elevator is used to dissect soft  tissue off the hyoid circumferentially such that a 2-3 cm  portion may be osteotomized. The hyoid immediately  adjacent to the tract should not be dissected along on its  deep margin. Rather, the deep sub-periosteal dissection  should only be performed lateral to the tract in order to  avoid interruption of the lining. At this point, the bone  cut can be made with a heavy scissors or fine fissure bur.    Figure 48.14 Intraoperative images of the second patient  demonstrates the dissection of a large thyroglossal duct cyst.    Once the osteotomy is complete, the specimen is fur-  ther mobilized and dissection continued using bipolar  dissectors along the plane. Exposure of the most supe-  rior aspect of the dissection can be aided in several ways.  A Kocker clamp may be applied to the hyoid in order to  provide traction and the bulk of the specimen can be  delivered through the neck incision. This manoeuvre  is facilitated by bimanual manipulation with one fin-  ger placed transorally at the tongue base. This should  reveal whatever remaining tract remains up to the fora-  men cecum. After the entire lining is dissected, it is  divided at the base of tongue and delivered as one  specimen.   Closure is achieved in a fashion similar to the thyroid-  ectomy. Strap muscles are re-approximated with resorb-  able sutures and layered closure is performed. Depending  on the size of the cyst and anticipated dead space, a suction  drain is placed until output is minimal. Post-operatively,  patients may be admitted for 24-hour observation or man-  aged as outpatients.   - Maintain the dissection outside the thyroid capsule  to avoid excessive bleeding.   - Avoid excessive retraction of the lateral thyroid  lobe when dissecting one the recurrent laryngeal  nerve to avoid traction injury to the nerve.   - Delay definitive surgery for an infected thyroglos-  sal duct cyst, await resolution of the infection.   - Thyroglossal duct cysts are not always precisely in  the midline.   - Dissection of the duct tract towards the foramen  caecum can be difficult as a distinct duct is rarely  seen rather a cone of tissue should be excised.   - Before excising, ectopic thyroid tissue always  establish the presence of functioning thyroid tis-  sue elsewhere.    American Thyroid Association Guidelines Taskforce on  Thyroid Nodules and Differentiated Thyroid Cancer,  Cooper DS, Doherty GM, Haugen BR, Kloos RT,  Lee SL, Mandel SJ et al. Revised American Thyroid  Association management guidelines for patients  with thyroid nodules and differentiated thyroid can-  cer. Thyroid. 2009; 19: 1167-1214.   Dadan J and Nowacka A. A journey into the past cysts of  the thyroglossal duct. Wiad Le.   Organ GM and Organ CH. Thyroid gland and surgery of  the thyroglossal duct: Exercise in applied embryol-  ogy. World J Surg. 2000; 24(8): 886-890.   Sistrunk WE. The surgical treatment of cysts of the thyro-  glossal duct tract. Ann Surg. 1920; 71: 121-122.  Toniato A, Mazzarotto R, Piotto A, Bernante P, Pagetta C  and Pelizzo MR. Identification of the nonrecurrent  laryngeal nerve during th yroid surgery: 20-year    The management of vascular anomalies has been confusing  for surgeons because of an illogical and largely descriptive  nomenclature that has reflected a lack of understanding of  the biology of these lesions.   In 1982, the clinical behaviour and endothelial cell  characteristics of vascular lesions were analyzed and an  elegantly simple biologic classification system was pro-  posed (Table 49.1). Vascular lesions were categorized  as either haemangiomas or vascular malformations.    Haemangioma (infantile) Slow flow:  Haemangioendothelioma Capillary (CM)  Angiosarcoma Lymphatic (LM)  Venous (VM)  Combined (CLM, CVM, LVM, CLVM)  Fast flow:    Abbreviations: AM, arterial malformation; AVF, arterial venous fistula;  AVM, arteriovenous malformation; CLM, capillary-  lymphatic malformation; CLVM, capillary lymphatico-  venous malformation; CVM, capillary venous  malformation; LVM, lymphaticovenous malformation.   Source: Reproduced from Kaban LB and Mulliken JB. In Kaban LB and   Troulis MJ [eds.], Pediatric Oral and Maxillofacial Surgery.  Philadelphia, WB Saunders, 2004. With permission.    Haemangiomas are tumours of endothelial cell origin  and vascular malformations are structural abnormali-  ties of blood vessels lined by normal endothelial cells  (Table 49.2).    The first and most crucial step in evaluating a patient with  a maxillofacial vascular anomaly is to determine whether  the vascular lesion is a tumour or a malformation.   Newborn, infant and childhood photographs are  reviewed with the parents to determine if the lesion was  present at birth, as well as the rate of growth. History and  physical examination provide an accurate diagnosis in  more than 90% of patients with vascular lesions.   Magnetic resonance imaging (MRI) with gadolinium  is the standard, initial imaging technique for diagnosis of  vascular anomalies.    The standard of management is observation, reassurance  of the parents and excision of the fibrofatty tissue and  abnormal skin after involution when the child is 8-12  years of age. It may be helpful, in cases where there is fam-  ily pressure for immediate operation, to show the parents  photographs of a similar tumour during proliferation and  involution. For psychological reasons, a well-localized,    Rapid proliferation in the first 4 weeks of life. Proliferating  phase may last until 12 months  Slow regression at 12 months to 12 years (involuting phase)   Involuting phase: the skin becomes pale, particularly in the  centre of the lesion   Involuted phase: (after 12 years) normal skin is restored in 50%  of children. The remainder have some laxity, discolouration,    2 A pale spot or telangiectatic or macular stained area may be present at birth at the site where the haemangioma will proliferate.   > The intra-osseous lesions called haemangiomas in the oral surgical literature are most commonly low flow venous malformations. However,  primary vascular tumours, such as haemangioendothelioma, haemangiopericytoma and angiosarcoma do occur in bone.   © For example, depression of the outer cortex, nasal deviation, orbital enlargement and minor hypertrophy of the maxilla or mandible are occasion-  ally noted in the presence of, or after involution of, a large cutaneous facial haemangioma.    disfiguring haemangioma can be excised, even if not fully  involuted, before the child starts school.    © Intra-lesional steroids. For haemangiomas less than 2cm  in diameter, serial intra-lesional steroid injections  (3-5-mg/kg triamcinolone) are performed through  a 25-gauge needle. Usually, three to five injections at  6-8-week intervals are required to accelerate involution  (Figure 49.1). Intra-lesional injections can be used for  upper eyelid haemangiomas with caution.   ® Systemic corticosteroids (for destructive, function  impairing or life-threatening lesions). Prednisolone, at    a dosage of 2-3 mg/kg per day, is administered once a  day for 2 weeks. If there is a response, the drug is contin-  ued and slowly tapered and withdrawn at about 10-11  months of age. Haemangiomas in the involuting phase  do not respond to steroids.   Interferon alpha-2a or -2b or vincristine (in cases  unresponsive to corticosteroids). Interferon is admin-  istered daily, at a dosage of 3 million units/m? subcu-  taneously. Transient side effects of interferon therapy  include fever and a flu-like syndrome at the start of  treatment (most patients), neutropenia, skin necro-  sis and skin rash. Interferon can adversely affect the  central nervous system in infants by producing spastic  diplegia. This is potentially reversible upon cessation  of therapy; careful clinical observation is required  during treatment.   Treatment with B-blockers such as propranalol has been  shown to decrease the size of haemangiomas or lead to  total regression of the lesion. Recommended regimen  is 1-2 mg/kg once per day per os for 6-12 months. In  cases where the lesion disappeared 2 months after the  initiation of propranalol have been reported. Side effects  include nausea, symptomatic blood pressure decrease,  somnolence, asthma and gastrointestinal symptoms.  Use of propranalol for the treatment of infantile hae-  mangioma was approved by the FDA in 2014.    Figure 49.1 Infantile haemangioma. (a) A newborn infant  with normal facial appearance, except for a small discoloura-  tion at the lower end of the philtral column. (b) At 4 months of  age, the lesion shows rapid growth (proliferative-phase hae-  mangioma) and superficial ulceration. (c) Frontal photograph  at 6 years of age after three intra-lesional triamcinolone injec-  tions and excision at the involuting phase. (From Kaban LB and  Mulliken JB., In Kaban LB and Mulliken JB [eds.], Pediatric Oral  and Maxillofacial Surgery, WB Saunders, Philadelphia, 2004.  With permission.)    © Surgical excision (Figure 49.2). In 2002, the strategy of  circular excision and purse-string closure for haeman-  giomas was introduced.   © Staged resection is often necessary for labial haeman-  giomas because they cause distortion in three dimen-  sions. The mass is de-bulked by excising involved  mucosal and submucosal tissue, usually in a transverse  axis. Excision at the vermilion-cutaneous junction  should be delayed, and vertical incisions on the skin  should be avoided.    ® Ulceration is common for infantile haemangiomas,  especially for those on the lip. These ulcerated areas  should be treated by frequent cleaning and application  of topical antibiotic ointment. Occasionally, debride-  ment is required, followed by dressing changes. If the  ulcer fails to heal with local measures, treatment with  steroids is indicated.   © Bleeding can usually be controlled by local pressure.  Embolization is rarely used for uncontrollable bleeding  from deep, extensive haemangiomas.   ® Steroid therapy may cause temporary growth retarda-  tion and decreased appetite.   @ Large cutaneous haemangiomas can cause life-  threatening congestive heart failure and anaemia.   © Thrombocytopenia due to platelet entrapment in large  haemangiomas may cause bleeding. This is managed  with steroid therapy. Platelet transfusions are not  beneficial.    The first step in the care of a patient with a vascular mal-  formation is to determine whether it is a slow- or fast-flow  lesion. Complete resection is not possible in most cases,  hence the possibility of uncontrollable bleeding during  operation and the likelihood of recurrence. Occasionally,  a well-localized, low-flow venous malformation (VM) of  the jaw can be resected.   When slow-flow malformations without direct intra-  osseous involvement cause secondary bony distortion,  orthodontic treatment and orthognathic surgical proce-  dures can be carried out safely without the fear of exces-  sive bleeding. Fast-flow lesions usually produce bony  destruction and extractions or orthognathic surgery are  prohibitively dangerous. In combined vascular anomalies,  management is based on the characteristics of the pre-  dominant, deeper malformation.    Circular excision of a haemangioma. (a) Involuting-phase haemangioma of the left cheek. A circular or ovoid inci-  sion is planned to include all the altered skin. In the proliferating phase, this includes damaged and ulcerated skin. In the involuted  phase (as in this case), it includes atrophic skin and fibrofatty residuum. Minimal subcutaneous undermining is required. (b) A run-  ning, intra-dermal purse-string suture (4-0, 5-0 polydioxanone) is placed along the wound edge. (c) The suture is tightened to gather  the edges and appose the wound margin. A gauze wick is placed if a small opening remains. The wound is covered with an absor-  bent dressing. Alternatively, the edges may be closed with percutaneous sutures in the axis of relaxed skin tension. (d) After several  months of healing and remodelling, a decision is made to accept a small circular scar or to revise it. Clinical appearance of the patient  3 years post-operatively. (From Kaban LB and Mulliken JB., In Kaban LB and Mulliken JB [eds.], Pediatric Oral and Maxillofacial Surgery,  WB Saunders, Philadelphia, 2004. With permission; Mulliken JB et al., Plast Reconst Surg, 109, 1544-1554, 2002. With permission.)    Capillary malformations rarely present major problems  for the oral and maxillofacial surgeon (Figure 49.3).    Pulsed dye laser: 50%-75% of patients will notice  improvement with between 2 and 20 sequential treat-  ments (lightening of the lesion) under general anaesthe-  sia or local anaesthetic cream.   Excision and skin grafts or flaps: These are occasionally  used in cases where the skin is very thick and the laser  is unsuccessful.   Orthognathic surgery for skeletal overgrowth and distortion:  Maxillary and mandibular overgrowth is common    when there is staining of the overlying facial skin and  mucosal lining. In patients with dentoalveolar distor-  tion, osteotomies can be performed without fear of  excessive bleeding (Figure 49.3).   © Impaired vision. Involvement of the eyelids can be asso-  ciated with elevated intra-ocular pressure and glaucoma  (V1-V2 distribution).    VM are the most common type of vascular anomaly.  They occur in a spectrum, from isolated skin or mucosal  varicosities to localized spongy masses, to large complex  lesions permeated throughout tissue planes.    © Sclerotherapy: For large VMs with localized venous  ‘lakes’, direct injection of absolute (100%) ethanol  (sclerozing agent of choice in the United States) by an  interventional radiologist is indicated. This requires  general anaesthesia with real-time fluoroscopic guid-  ance. Usually several sessions are necessary to shrink  a large VM. Ethiblock (Ethicon, Hamburg, Germany),  a radiopaque mixture of ethanol, contrast agent and  amino acids, is also used in Europe. Small oral mucosal  venous malformations can be sclerozed with injection  of 1% sodium tetradecyl sulphate.    ® Intermittent swelling, pain and fever are a com-  mon problem encountered in venous and combined  lymphatic-venous lesions. Such lesions increase in size  in relation to viral illness, trauma, adjacent (odonto-  genic) or intra-lesional infection and clotting. In these  patients, it is difficult to distinguish between cellulitis,  intra-lesional abscess, thrombophlebitis and phlebo-  thrombosis. A local source for infection, such as cari-  ous teeth, peri-apical abscess or peri-coronitis must be  excluded. Administration of the appropriate antibiotic  (usually penicillin or clindamycin in the maxillofa-  cial region) is begun. A drainage procedure is carried  out only for an obvious abscess. Aspirin anticoagula-  tion therapy may be useful in cases of venous malfor-  mation enlargement, if there are no local or systemic  sources of infection and when there are tender phlebo-  liths. In patients who respond to aspirin, indefinite    administration of this antiplatelet drug to prevent  intra-lesional clotting should be considered.   ® Localized or systemic coagulopathy may result in major  haemorrhage spontaneously or during an operation in  large VMs. Disseminated intra-vascular coagulopa-  thy can be caused by stasis and turbulence associated  with the venous malformation. This is a consumptive  coagulopathy. Prothrombin (PT) and partial thrombo-  plastin times (PTTs) are often normal; thrombin time  and levels of fibrin split products and fibrinopeptide  may be elevated, with decreased fibrinogen and platelet  levels. Heparin treatment is instituted when indicated  and only when the coagulopathy is corrected are sur-  gical procedures feasible. Another approach is to begin  giving heparin followed by antifibrinolytic therapy with  e-aminocaproic acid. Failure to address this chronic  consumptive coagulopathy will result in uncontrollable  bleeding during a procedure.   ® Systemic sepsis related to local infection with hae-  matogenous spread. In these cases, hospital admission,  blood cultures and intravenous antibiotic therapy are  necessary.   ® Recanalization of extensive venous malformation after  sclerotherapy is a recognized occurrence. Repeat of  sclerotherapy in this situation can be dangerous and  cause local blistering, deep ulceration, full-thickness  skin necrosis, nerve damage, haemolysis, haemoglobin-  uria and potential renal toxicity and cardiac arrest.   © Bleeding after teeth extractions is controlled by pack-  ing with pledgets consisting of microfibrillar collagen  (Avitene, Davol, Warwick, RI) wrapped in oxidized cel-  lulose sheets (Surgicel, Ethicon, Someville, NJ). These  are held in place with 2/0 chromic catgut figure-of-eight  sutures across the sockets. Extractions should be per-  formed after sclerotherapy.   @ Painful expansion secondary to injury, partial resection  or endocrine changes (e.g. puberty, pregnancy, birth  control pills). This may be the first evidence of the lesion.    Lymphatic malformations (LMs) are classified as macro-  cystic or microcystic. Macrocystic (called cystic hygroma  in the past) occur below the mylohyoid muscle in the  neck most frequently in front of the sternocleidomastoid  muscle (Figure 49.5). Microcystic commonly involves the  tongue, the floor of the mouth, the cheek, the lips and the  mandible.    ® Sclerotherapy with ethanol, OK-432 (attenuated  Streptococcus pyogenes) or 1% sodium tetradecyl sul-  phate for macrocystic LM.   ® Intra-lesional injections of bleomycin have been  described with encouraging results.    (a) Frontal and (b) lateral photograph of a teenage boy with dermal capillary malformation in the distribution of  the second and third division of the trigeminal nerve. This is also a frequent finding in the Sturge-Weber syndrome that includes a  capillary malformation of the V1 or V1-V2 trigeminal areas, choroidal vascular ectasia and leptomeningeal vascular anomalies. (c)  Intra-oral photograph shows malocclusion due to excessive vertical growth of the maxillary alveolus on the right side. (d) Lateral  cephalogram demonstrates the long lower face height and bimaxillary dentoalveolar protrusion. (e) Panoramic radiograph shows  the hypertrophy of the mandibular body on the right side. Orthognathic surgery could be performed without risk of bleeding,  since the malformation did not extend into the bone. (f) Frontal, (g) lateral and (h) intra-oral photographs after three-piece Le Fort |  osteotomy, bilateral mandibular osteotomies and genioplasty. (From Kaban LB and Mulliken JB., In Kaban LB and Mulliken JB [eds.],  Pediatric Oral and Maxillofacial Surgery, WB Saunders, Philadelphia, 2004. With permission.)    (a) Frontal (‘worm’s eye’) view of a patient with venous malformation of the mandible. (b) Panoramic radiograph  shows lytic changes in the bone. (c) Computed tomographic (CT) scan with contrast demonstrates the large malformation extending  into the soft tissues. (d) Intra-operative photograph. Well-localized low flow vascular malformations can be treated with resection  without the risk of excessive bleeding. (e) Panorex 1 year post-operatively and (f) submental view of the patient one year post-  operatively. (From Kaban LB and Mulliken JB., In Kaban LB and Mulliken JB [eds.], Pediatric Oral and Maxillofacial Surgery, WB Saunders,  Philadelphia, 2004. With permission.)    (a) Infant at 2 weeks of age with a left submandibular lymphatic malformation (LM). (b) Magnetic resonance imaging  (MRI) T2 with gadolinium shows a macrocystic LM with homogenous enhancement that involves the anterior neck triangle. (c) Intra-  operative photograph. Excision was performed through combined submandibular-intra-oral (sublingual) approach. The malforma-  tion extended to the floor of the mouth. During the course of the dissection, the lingual and hypoglossal nerves were identified and  preserved. (d) Specimen. (e) Frontal; (f) submental and (g) intra-oral view at 9 years of age.    @ Excision of cervical macrocystic LM with neck  dissection approach. Complete excision may not be  achieved as typically LMs in the neck extend deep  into the parapharyngeal space with carotid artery and  nerves adherent on the LM walls.   © Patients with large microcystic cervicofacial LM require  serial, staged surgical excisions of the floor of the mouth  and submandibular tissues.   ® Orthognathic surgery after soft tissue excision to mini-  mize recurrence and manage malocclusion and distor-  tion of the maxillofacial skeleton (Figure 49.6).   ® Intra-lesional bleeding or bleeding from the irregular  surface of microcystic LM in the morning upon awak-  ening, possibly due to the increased venous pressure of  sleeping supine.   e Airway obstruction when LM is located in the floor of  the mouth or the tongue.   © Sudden expansion often occurs coincidently with upper  respiratory tract infection.    A clinical staging system for arteriovenous malformations  (AVMs) that is helpful in predicting the natural history  has been introduced (Table 49.3).   The current strategy for management of AVMs is arte-  rial embolization for occlusion of the nidus (centre of the  AVM) of the malformation, followed 24-72 hours later by  surgical excision. The surgical goal is complete resection  of the AVM nidus and involved overlying tissue, although  this is often not possible.    © Superselective arterial embolization is performed by  an interventional radiologist. The principle is to oblit-  erate the nidus of the malformation with emboliza-  tion materials (Table 49.4). Thus, inflow to the AVMs  is reduced with low risk of collateral flow development.  Superselective embolization may be performed elec-  tively and followed by resection or it may be required  as a life-saving procedure in the presence of acute  bleeding. Proximal vessel embolization is contrain-  dicated because of the rapid development of collateral  flow to the nidus of the AVM. Post-embolization angi-  ography is obtained to ensure reduced blood flow in the    Figure 49.6 (a) Frontal, lateral and intra-oral photographs of a 13-year-old girl with a cervicofacial LM, mandibular prognathism  and open bite, secondary to the progressive mandibular distortion. Lateral cephalogram and panorex show obtuse mandibular plane  angle and anterior open bite. (b) Frontal, lateral and intra-oral photographs, lateral cephalogram and panorex 5 years post-treatment.  The patient underwent resection of the LM, Le Fort | osteotomy, bilateral mandibular osteotomies and genioplasty. (From Padwa BL,  In: Kaban LB and Troulis MJ [eds.], Pediatric Oral and Maxillofacial Surgery, WB Saunders, Philadelphia, 2004. With permission.)    Pink-bluish stain, warmth and arteriovascular shunting by continuous Doppler scanning or  20-MHz colour Doppler scanning   Same as stage | plus enlargement, pulsations, thrill, and bruit and tortuous, tense veins   Same as stage II plus either dystrophic skin changes, ulceration, bleeding, persistent pain or    Reproduced from Mulliken JB et al., Curr Probl Surg., 37,520, 2000. With permission.    Irvine, CA, USA)  Acrylic glue  Silky thread  Stainless steel  Platinum coils    malformation and the AVM is examined for clinical  improvement (skin colour, size, pulsation).  Intra-osseous direct puncture of the AVM with plati-  num coils or other embolization materials may be  used to supplement superselective embolization or in  cases where further vessel embolization is not feasible  (Figure 49.7).   A 16-gauge needle trocar is placed directly through the  bone or alveolus intra-orally using direct fluoroscopy.  Placement of the trocar into the AVM nidus is con-  firmed by an arteriogram.   Through the trocar, an 18-gauge catheter is placed using  a guide wire.   Embolization material is injected directly into the nidus  through the catheter.   This procedure can be repeated for multiple varices of  the AVM.   Partial or complete surgical resection of soft tissues  or bone is performed 1-3 days after embolization.  Embolization does not decrease the extent of resection.  Hypervascularity makes haemostasis difficult intra-  operatively, even after embolization. Intra-operative  embolization must be available. All small arteries that  supply the AVM should be ligated except the main,  proximal arteries.   Teeth extraction after AVM embolization (Figures 49.7  and 49.8). In patients with intra-osseous malformation  in the tooth-bearing portions of the maxilla and man-  dible, teeth may be removed 24-48 hours after emboli-  zation insertion. The sockets are packed with Avitene  and surgical pledgets and oversewn. Once the sockets    heal and the wounds are completely mucosalized, the  malformations often become quiescent and remain in  Shobinger stage I. This is probably because the irritant  of mobile teeth constantly being compressed by occlusal  forces and perhaps chronic low-grade inflammation are  eliminated.    threatening. Even a single tooth extraction associated  with an AVM can result in exsanguinating haemorrhage.  Pre-operative embolization is performed to prevent this  complication. Intra-operative bleeding is managed with  urgent embolization or haemostatic materials such as  Surgicel, Avitene, suturing and pressure. However, local  haemostatic measures may be insufficient to control the  bleeding. Prolonged intubation to secure the airway and  blood transfusions may be necessary.   Unfortunately, AVMs are not usually well localized  and recurrence with expansion of vessels deep or at the  periphery of the resection occurs in a high percentage  of patients. For these patients, embolization is palliative  and re-operation may not be feasible.   Development of collateral vessels and flow to the nidus  of the malformation occurs especially after proximal  ligation or embolization.    (a) Frontal and (b) intra-oral photographs of a 10-year-old girl with arteriovenous malformation (AVM) of the right  hemimandible. The patient had noted swelling and intra-oral bleeding at the right mandible 2 months prior to her initial visit.  Physical examination revealed enlargement of the right hemimandible, warmness of the area on palpation, but no tenderness and  no discolouration of the overlying skin. A loud bruit was auscultated by stethoscope examination of the right submandibular region  anda thrill was palpated. The teeth were mobile and depressible. (c) Three-dimensional computed tomography (CT) angiogram (3D-  CTA) demonstrates the supply of the malformation from branches of the enlarged right (R) external carotid artery (R internal maxil-  lary, R facial artery) and the left facial artery. No contribution of the right internal carotid artery is identified. Drainage of AVM (stage  II-III) is via innumerable large venous varices that drain into an enlarged right internal jugular vein. (d) Sagittal section of CT scan  shows the lytic AVM that involves and expands the right hemimandible including the ascending ramus. (e) Frontal and (f) intra-oral  photograph 3 years after the patient’s initial visit. She underwent multiple, urgent and scheduled embolizations with platinum coils  and extraction of posterior mandibular teeth on the right side. (g) Panorex before intervention shows the large AVM that appears as  a multi-loculated radiolucent lesion extending from the first premolar to the sigmoid notch. The mandibular 12-year molar is floating  in the radiolucency and there is resorption of the 6-year molar. The second premolar tooth bud is also displaced and there is thinning  of the inferior border cortex. (h) Panorex 3 years after the initial visit shows the intra-osseous coils and the filling of the cavity with  bone. After the treatment, the AVM became quiescent (stage |).    Figure 49.8 (a) Panorex of a 17-year-old boy who experienced excessive bleeding after an unsuccessful attempt to extract the  left lower wisdom tooth. The procedure was aborted and the patient was referred to hospital. The radiograph shows a radiolucent  area in the left mandible extending from the left first molar to the middle of the ramus above the lingula posteriorly. There is resorp-  tion of the third and second molar roots and the distal root of the first molar. (b and c) Axial sections of MRI T1 with gadolinium  show a 36- x 12-mm septated lytic area in the left mandible with homogenous enhancement with flow voids indicating high-flow  malformation. The patient was scheduled for transfemoral angiography and embolization under general anaesthesia. (d and e)  Angiography of the left external carotid shows two large tangles of vessels, one over the angle of the mandible and the other over  the condyle that interconnect with each other. Feeding arteries that supply the AVM are the lingual, facial and the first five branches  of the internal maxillary artery (inferior alveolar artery, pterygoid artery, messeteric artery, buccinator artery and posterior superior  alveolar artery). There is early venous drainage into the venous compartment of the mandible that drains into the external jugular  vein. (f and g) Angiogram after embolization of the AVM nidus with 3.9-cc liquid Onyx (Micro Therapeutics, Irvine, CA). There is an  onyx cast seen within the facial artery, the pedicles of the AVM and within the venous saccule of the mandible. Approximately 25%  of the AVM has been embolized. During the procedure, excessive intra-oral bleeding was controlled with extraction of the lower left  second and the third molars, packing the sockets with Avitene and Surgicel, suturing and pressure. Two months later, the lower left  first molar was also extracted due to tooth mobility, pain and bleeding from its gingival sulcus. (h) Panorex 2.5 years post-emboliza-  tion and extraction of three molars associated with the AVM shows the embolization material in the bony cavity. The malformation  became and remains quiescent (Shobinger stage |) after treatment.    © Embolization of internal carotid branches can cause  ischaemic stroke. General risks of angiography and  embolization are death, bleeding, coma, damage to  blood vessels and infection.    e First, determine if the lesion is an haemangioma or a  malformation.   e An intra-osseous vascular lesion is most frequently a  malformation, not an haemangioma.   e In the case of haemangioma, determine whether it is  proliferating or involuting.   e Sclerotherapy is effective for slow-flow vascular malfor-  mations, especially macrocystic LM and VM with large  venous lakes.   e AVMsare treated with embolization and resection when  possible, but recurrence rate is high. If dentoalveolar  segment is involved, embolization and then removal  of the teeth may result in long-term control with the  lesion remaining in Shobinger stage | (quiescence).   e Patients with slow-flow lesions adjacent to bone  can have skeletal deformity treated. With proper  preparation there is little chance of life-endangering  haemorrhage.    Boon LM, MacDonald DM and Mulliken JB. Complications  of systemic corticosteroid therapy for problem-  atic hemangioma. Plast Reconstr Surg. 1999; 104:  1617-1623.   Boyd JB, Mulliken JB, Kaban LB, Upton J 3rd and Murray  JE. Skeletal changes associated with vascular malfor-  mations. Plast Reconstr Surg. 1984; 74: 789.   Ezekowitz RA, Mulliken JB and Folkman J. Interferon  alfa 2a therapy for life-threatening hemangiomas of  infancy. N Engl JMed. 1992; 326: 1456-1463.    Kaban LB and Mulliken JB. Vascular anomalies of the max-  illofacial region. J Oral Maxillofac Surg. 1986; 44: 203.   Kaban LB and Mulliken JB. Vascular lesions of the max-  illofacial region. In Kaban LB and Troulis MJ (eds.),  Pediatric Oral and Maxillofac Surgery. Philadelphia,  PA: WB Saunders; 2004. pp. 259-284.   Kohout MP, Hansen M, Pribaz JJ and Mulliken JB.  Arteriovenous malformations of the head and neck:  Natural history and management. Plast Reconst Surg.  1998; 102: 643-654.   Mulliken JB, Fishman SJ and Burrows PE. Vascular anoma-  lies. Curr Probl Surg. 2000; 37: 520.   Mulliken JB and Glowacki J. Hemangiomas and vascu-  lar malformations in infants and children: A clas-  sification based on endothelial characteristics. Plast  Reconstr Surg. 1982; 69: 412.   Mulliken JB, Rogers GF and Marler JJ. Circular exci-  sion of hemangioma and purse-string closure: The  smallest possible scar. Plast Reconst Surg. 2002; 109:  1544-1554.   Padwa BL. Orthognathic surgery in the growing child.  In Kaban LB and Troulis MJ (eds.), Pediatric Oral  and Maxillofacial Surgery. Philadelphia, PA: WB  Saunders; 2004. 384-385.   Padwa BL, Hayward PG, Ferraro NF and Mulliken JB.  Cervicofacial lymphatic malformation: Clinical  course, surgical intervention, and pathogenesis of  skeletal hypertrophy. Plas Reconstr Surg. 1997; 95:  951-960.   Perrott DH, Schmidt B, Dowd CF and Kaban LB. Treatment  of a highflow arteriovenous malformation by direct  puncture and coil embolization. J Oral Maxillofac  Surg. 1994; 52: 1083-1086.   Qin Zhong P, Xin ZF and Ren L. Long term results of intra-  tumorous bleomycin A5 injection for head and neck  lympangioma. Oral Surg Oral Med Oral Pathol Oral  Radiol Endod. 1998; 86: 139-144.   Watson WL and McCarthy WD. Blood and lymphatic ves-  sel tumors: Report of 1056 cases. Surg Gynecol Obstet.  1940; 71: 569.    There has been rapid and widespread development of vas-  cular interventional radiological techniques and devices  over the past two decades and this chapter outlines their  role in maxillofacial surgery.   First, an understanding of the classification and the  role of imaging in the diagnosis of head and neck vascu-  lar malformations is essential. The various endovascular  techniques that are employed in the treatment of these  conditions will follow.   The importance of a multidisciplinary team approach  to the management of these conditions must be stressed.  In addition to oromaxillofacial surgeons and interven-  tional radiologists, the expertise of numerous special-  ists, drawn from dermatology, diagnostic radiology, ENT  ophthalmology, paediatrics, plastic and reconstructive  surgery, pathology and neurosurgery will be required to  deal optimally with these complex lesions. It goes without  saying that close involvement of the patient in all decision-  making is essential and psychotherapeutic support may be  necessary as curative treatment may not be possible.    The classification of vascular anomalies of the head and  neck, proposed by Mulliken and Glowacki in their paper    of 1982, is widely employed. They categorized vascular  anomalies according to endothelial cell characteristics  and, although many more types of vascular lesions are  recognized with the aid of modern immunohistochemical  techniques, it has stood the test of time and represents a  sound basis for the effective understanding and commu-  nication of these conditions (Table 50.1).   Haemangiomas are characterized histologically by high  endothelial cell turnover. They are true neoplasms that  usually present in infancy. They enlarge by cellular pro-  liferation and exhibit a clinical life cycle which typically  includes phases of proliferation, plateau and subsequent  involution. They may be further characterized by cell  markers (e.g. GLUT-1, merosin, Lewis Y) that are otherwise  found only in human placental tissue. Most other vascu-  lar anomalies are properly termed ‘malformations’, which  are characterized by normal endothelial cell turnover and  abnormal gross vascular anatomy. These are thought to be  present from birth and enlarge as the patient grows. From  the therapeutic point of view, it is convenient to separate  these into low-flow and high-flow malformations.   Other indications for endovascular interventional radi-  ology in the head and neck include the pre-operative  embolization of various hypervascular tumours including  paragangliomas, juvenile angiofibromas, extracranial menin-  giomas and endolymphatic sac tumours. Uncontrolled, spon-  taneous epistaxis and oral or nasopharyngeal haemorrhage    secondary to malignant tumour, radiotherapy or trauma  may require urgent embolization which can be life-saving.  Traumatic or congenital arteriovenous fistula (AVF) of the  head and neck are now usually dealt with by endovascular  techniques.    Useful information may be obtained from ultrasound and  computed tomography (CT) but magnetic resonance imag-  ing (MRI) is the examination of choice. MRI accurately  defines the extent and depth of vascular anomalies of the  head and neck. It also provides information on whether the  lesion appears discrete or invasive which is of fundamental  importance in surgical planning. Contrast administration  is helpful in defining the full extent of haemangiomas and  solid, hypervascular components of vascular anomalies  and tumours. Signal void within a lesion raises the pos-  sibility of high flow due to arteriovenous (AV) shunting  which may be further elucidated by MR angiography.   Rapidly involuting congenital haemangioma  Non-involuting congenital haemangioma  Kaposiform haemangioendothelioma  Tufted angioma    Source: Adapted from Mulliken JB and Glowacki J, Plast Reconstr Surg,  1982; 69: 412-422, revised by the International Society for the  Study of Vascular Anomalies, 1996.    Calcification in a phlebolith, a characteristic of venous  malformations and gas may also exhibit signal void on  MRI, mimicking high flow. Phleboliths and gas are readily  identified on CT and will often be visible on plain x-ray.   Doppler ultrasound, particularly colour flow, will  often reveal areas of high flow not appreciated on clinical  examination, but the full characterization of the angioar-  chitecture of high-flow lesions, however, can only reliably  be made with selective and super-selective catheter, digital  subtraction angiography (DSA).   In addition to general neuroradiological catheter skills,  training in the various microcatheter techniques and the  handling of embolic agents, is required. A thorough under-  standing of vascular anatomy of the head and neck is essen-  tial. There are numerous predictable anastomoses between  branches of the external carotid artery (ECA) system and  the intracranial circulation in addition to critical supply to  the cranial nerves from certain ECA branches. A detailed  account of these is beyond the scope of this text and the  interested reader is referred to texts listed in the bibliography.    High-quality, bi-plane angiography with fluoroscopy and  road map facility is essential for the avoidance of inad-  vertent penetration of embolic material through dan-  gerous anastomoses, particularly when one is working  in the region of the skull base. The success of modern  interventional techniques depends in no small measure  to the advances that have occurred in microcatheter and  guide wire technology. Procedures are carried out using  a co-axial technique. Typically an external carotid branch  is selectively catheterized with a 5F or 6F guide catheter.  A 2F microcatheter is passed through the guide catheter  and navigated super-selectively into the desired vessel.   Thromboembolism is the main risk of these procedures.  Haemostatic valves permit continuous flushing of cath-  eters with heparinized saline throughout the procedure  in addition to systemic heparinization employing point of  care assay to monitor clotting (ACT).   The list of embolic materials employed is extensive and  growing (Table 50.2). It includes agents for temporary  and permanent occlusion, liquid or particulate agents and    Large vessel Medium vessel Small vessel  Coils: Gelatin: Particles:  Pushable Gelfoam sponge/particles PVA 50-150 pm  Embospheres®  Embozene®  Detachable - Particles: Liquids:    coils, which may be pushable (non-retrievable) or detach-  able (retrievable) by a variety of mechanisms. These are  usually made of platinum and may be bare or covered  with Dacron fibres to increase thrombogenicity. A variety  of sclerosant agents for the treatment of veno-lymphatic  malformations are available. These are discussed in more  detail in Chapter 49.    Neuroendovascular therapy may be curative in its own  right, e.g. coiling of cerebral aneurysms, embolization  of AV fistula, dural AVF/brain arteriovenous malforma-  tion (AVM) etc., but, in the head and neck, it is usually  employed to reduce operative blood loss in hypervascular  lesions. In some instances, conditional on the appropriate  choice of embolic agent, embolization may lead to perma-  nent devascularization of the lesion leading to necrosis,  shrinkage and cure, but usually the reduction in vascular-  ity is temporary. Embolization and surgery therefore need  to be scheduled with this constraint in mind. The aim of  embolization depends on the type of lesion (Table 50.3).   Although polyvinyl alcohol (PVA) is non-resorbable and  is, therefore, considered a permanent agent, in practice it  acts as temporary embolic agent because recanalization  occurs within the thrombus generated by the particles.  Gelfoam is an example of a truly resorbable, temporary  agent. Cyanoacrylate glue is widely used as an embolic agent  in Europe but less often in North America due to licens-  ing issues. It is a highly effective, permanent embolic agent  which, because it is a liquid, is capable of distal penetration.  It polymerizes rapidly once it comes into contact with ionic  solutions including blood. This process can be delayed by  mixing it with lipiodol which also renders it radio-opaque.  Because it is capable of penetrating small branches the risk  of cranial nerve damage and inadvertent intracranial embo-  lization is much greater than with particulate embolization.   Ethylene vinyl alcohol copolymer dissolved in dimethyl  sulfoxide (DMSO) (Onyx®) is a recently introduced liq-  uid embolic agent which has been found to be extremely  useful in the treatment of AVMs of the brain and dural  AVF. It is showing promise in the management peripheral  AVMs including the head and neck.   Effective treatment of an AVF requires point occlu-  sion of the fistula and proximal draining vein. This is not    always as straight forward as it may seem due to prob-  lems of access and difficulties accurately identifying the  exact site of the fistula. Detachable balloon occlusion of  AV fistula was the earliest type of neuroendovascular pro-  cedure and it remains an effective method of treatment.  Coil occlusion, however, is generally preferred because it  affords a greater degree of control at the fistula site, and  the risk of migration and distal embolization is reduced.   Thus, although there is commonality of the techniques  and the materials employed, the aim of embolization is not  the same in every case and an understanding of the natural  history of the lesion, before and after treatment, is essen-  tial. For example, whilst proximal occlusion of feeding  arteries is desirable in epistaxis, it is contraindicated in the  treatment of AVMs, as this would lead to angiogenesis and  vascular recruitment around the periphery of the lesion  making subsequent, curative treatment more difficult.   In the head and neck, particularly in the facial vessels,  vascular tortuosity and lack of external support often  makes peripheral microcatheter vascular access difficult  if not impossible. Conversely, a superficial location lends  itself to direct puncture and this is, therefore, a technique  that is frequently employed, not only of necessity for angi-  ographically occult, low-flow malformations but also for  peripheral high-flow AVMs.   There are some situations where free flow around a  microcatheter during embolization is essential, e.g. par-  ticulate embolization of a glomus jugulare from the  ascending pharyngeal artery and others where a wedged  microcatheter position is desirable, e.g. onyx emboliza-  tion of an AVM to achieve good nidal penetration. In the  former, a wedged position risks forcing particles through  anastomoses to the vertebral circulation with a conse-  quent risk of stroke or occlusion of the supply to the vasa  nervosum of the lower cranial nerves.    The target for AVM embolization is the ‘nidus’ - the  abnormal vessels which represent the level of the shunt.  After occlusion of the nidus it is desirable to occlude the  proximal draining vein. The lesion may be a discrete or  diffuse collection of anomalous vessels comprising a plexi-  form network resulting in AV shunting or may include  larger AV fistula responsible for the majority of the shunt.    Abbreviations: AVF, arteriovenous fistula; AVM, arteriovenous malformation; NCBA, N-butyl cyanoacrylate; PVA, polyvinyl alcohol.    In either case high flow, secondary to the AV shunt is a  hallmark feature. Over time, this leads to arterial and  venous dilatation, tortuosity and occasionally aneurysm  formation.   The exception to targeted nidal embolization of an  AVM is the occasional requirement for pre-operative  devascularization of large feeding arteries to high-flow  AVMs immediately prior to surgery. In such cases proxi-  mal embolization is acceptable. Pre-operative occlusion of  surgically inaccessible arterial feeders reduces blood loss  and improves visualization of the limits of the lesion mak-  ing curative excision more likely and, provided surgery is  carried out soon after embolization (24-48 hours), periph-  eral recruitment of feeders should not be a problem.   As with all vascular lesions of the head and neck close  consultation between the surgeon and the interventional  radiologist is essential to plan the appropriate treatment  strategy. Understanding the goal of treatment is crucial.  The location of the AVM, angioarchitecture of the nidus  and the feasibility of vascular access, defined by angiogra-  phy merely determine the most effective method of achiev-  ing that end. The appropriate choice of embolic agent, the  method of access and the target follow from that.    Haemangiomas usually occur in infancy and rarely  require active treatment due to the tendency for spontane-  ous involution. Indications for treatment include threat to  vision, airway obstruction, haemorrhage or skin necrosis  associated and infection. High output cardiac failure and  consumptive coagulopathy (Kasabach—Merritt syndrome)  may occur with large visceral haemangiomas dictating the  need for intervention. Embolization may be required prior  to surgery. The technique employed is similar to that for  the embolization of a hypervascular tumour.    In this group of conditions, we can include paragan-  glioma (glomus, chemodectoma), meningioma, juvenile  angiofibroma, endolymphatic sac tumour and hypervas-  cular metastases (typically, thyroid and renal). Detailed  selective and super-selective angiography is performed to  define the feeding arteries and define any dangerous anas-  tomoses. The largest contributing branch is usually embo-  lized first. With the microcatheter tip in the appropriate  vessel, in a condition of free flow around the catheter, a  suspension of PVA particles (150-300 ym) in contrast  medium is injected under fluoroscopic control until near  stasis is achieved. The catheter is then flushed with saline.  In some instances, fibred pushable coils will be placed in  the pedicle to ensure haemostasis. The procedure is then  repeated in each of the feeding arteries until the tumour  is devascularized or the risks of further embolization are  judged to outweigh the potential benefit.    By virtue of their uniformity (size and shape) together  with the smoothness of their surface, biocompatible  microspheres (Embosphere®, Embozene®) are less throm-  bogenic than PVA. This results in better penetration of  tumour microvasculature compared to the mixture of  thrombus and embolic agent that more irregular particles  such as PVA induce. Experience suggests that emboliza-  tion with these newer embolic agents translates to more  effective tumour devascularization compared to PVA.   Some tumours, particularly paragangliomas, may have  AV shunts within the tumour circulation. These carry the  risk of pulmonary embolization of small particles. If sus-  pected on angiography, larger particles may be employed at  the outset to occlude this component. Once this has been  achieved switching to smaller particles will achieve a more  effective devascularization of the intra-tumoural vessels.    AVF of the head and neck may arise from the branches of  the ECA or the vertebral arteries (VA). The latter usually  shunt into the adjacent vertebral venous plexus and may  be congenital or arise secondary to trauma which can be  penetrating or non-penetrating. AV fistula ofthe ECA may  occur secondary to trauma, infection, malignant invasion  or radiotherapy. They are a feature of hereditary haemor-  rhagic telangiectasia (Osler-Weber-Rendu syndrome).   Vertebro-vertebral fistula can usually be occluded by  the endovascular route employing detachable balloons or  coils. If the shunt is so large that point occlusion of the  fistula is not feasible then ‘trapping’ the fistula may be  necessary. This involves occlusion of the vertebral artery  above and below the fistula. Occlusion from above usually  requires retrograde navigation of the vertebral artery from  the contra-lateral side via the vertebro-basilar junction.   AVF of the ECA may present with a pulsatile mass or  haemorrhage. Occlusion with coils or a liquid embolic  agent may be necessary and is usually curative.    Spontaneous epistaxis can usually be controlled by ante-  rior and, if necessary, posterior nasal packing. Nasal  endoscopy is frequently employed to ligate the sphenopal-  atine artery and its branches. If, despite these measures,  it cannot be controlled, embolization with PVA particles  or biocompatible microspheres is usually highly effec-  tive. Super-selective catheterization of the sphenopalatine  artery is performed and, under conditions of free flow,  150-300 um particles suspended in iodinated contrast  medium are injected on the side of the epistaxis. Bilateral  embolization may be required to control the haemorrhage  but carries an increased risk of tissue necrosis.   The technique is similar to the embolization of hypervas-  cular tumours but the principle in this case is to reduce the  arterial head of pressure to the nasal mucosa rather than    occlude the microvasculature of the nasal mucosa. This  technique may also be employed in oro-pharyngeal haem-  orrhage uncontrolled by other methods. The distressing  and life-threatening condition of nasal mucosa rather than  occlude the microvasculature of the nasal mucosa. This  technique may also be employed in oro-pharyngeal haem-  orrhage uncontrolled by other methods. The distressing  and life threatening condition of ‘carotid blow-out’ requires  more drastic therapy. This is usually due to malignant inva-  sion of the common or internal carotid artery in the set-  ting of an open wound, leading to massive haemorrhage.  Carotid occlusion (trapping) may be life-saving but carries  a significant risk of stroke even if the collateral circulation  of the circle of Willis appears intact. Stenting of the carotid  artery has been successfully employed in some instances  avoiding the need to occlude the artery.    These will often be dealt with by sclerosant therapy but  this may not be suitable for very large malformations. They  are angiographically occult which means they cannot be    accessed from the arterial route. Venous outflow is exceed-  ingly slow and a retrograde venous approach is usually not  possible either. Direct puncture and contrast venography  to define the malformation and confirm an intravascular  position may allow injection cyanoacrylate glue as a pre-  lude to excision (Figures 50.1 through 50.5).   e Signal void on MRI - consider high-flow vascular lesion,  calcification or gas.   e CT and contrast-enhanced computed tomography  (CECT) will differentiate these conditions.   e Pre-operative embolization can significantly reduce  blood loss in hypervascular lesions.   e Embolization is the curative treatment of choice for AV  fistula and certain AVMs.    Figure 50.1 Appearance of vascular lesions of the head and neck on magnetic resonance imaging (MRI). (a) Axial contrast  enhanced T1-weighted (T1W) MRI reveals a solid enhancing component and a region of flow void in a presumed haemangioma of  the masseter. (b) Lateral digital subtraction angiography (DSA) shows corresponding tumour blush and enlarged facial artery. In con-  trast, the submental AVM in panels (c) and (d) illustrate a lesion exhibiting exclusively, flow void on coronal T1W MRI corresponding  to the arteriovenous malformation (AVM) nidus revealed on lateral DSA.    Juvenile angiofibroma. (a) Axial computed tomography (CT) reveals characteristic enlargement of pterygomaxil-  lary fissure. (b) and (c) Coronal magnetic resonance imaging (MRI) before and after contrast delineate a brightly enhancing mass  in posterior nasal space. (d) and (e) Frontal selective and super-selective DSA show typical tumour blush. (f) and (g) Pre-operative,  super-selective embolization of tumour with PVA and coils. (Courtesy of Dr Adam Ditchfield, Wessex Neurological Centre.)    Figure 50.3 Large sub-mental, venous malformation. (a) Axial CT reveals characteristic phleboliths and venous lakes (arrows).  (b) Direct, percutaneous venography confirms slowly emptying venous lakes. (c) and (d) Pre-operative embolization with  cyanoacrylate/lipiodol.    Figu re 50.4 Traumatic arteriovenous fistula of the left superficial temporal artery resulting from a stab wound 20 years  previously. The patient presented with pain and a sudden increase in size suggestive of haemorrhage. CT angiography (a) reveals an  aneurysm at the site of the fistula with a small patent lumen within a largely thrombosed aneurysm or varix. Angiography confirmed  virtual occlusion of the fistula and a residual aneurysm which filled and emptied slowly (b and c). This was occluded with coils (d) to  avoid spontaneous recanalisation of the aneurysm and or fistula. (Continued)    (Continued) Traumatic arteriovenous fistula of the left superficial temporal artery resulting from a stab wound 20 years  previously. The patient presented with pain and a sudden increase in size suggestive of haemorrhage. CT angiography (a) reveals an  aneurysm at the site of the fistula with a small patent lumen within a largely thrombosed aneurysm or varix. Angiography confirmed  virtual occlusion of the fistula and a residual aneurysm which filled and emptied slowly (b and c). This was occluded with coils (d) to  avoid spontaneous recanalisation of the aneurysm and or fistula.    Large mental AVM presenting with recurrent skin necrosis and haemorrhage treated by staged embolisation with  Onyx prior to successful surgical excision and skin grafting. Preoperative elective angiography of the right and left facial arteries,  AP and lateral (a—d) and following embolization (e and f). (Continued)    (Continued) Large mental AVM presenting with recurrent skin necrosis and haemorrhage treated by staged  embolisation with Onyx prior to successful surgical excision and skin grafting. Preoperative elective angiography of the right and  left facial arteries, AP and lateral (a—d) and following embolization (e and f).    Berenstein A and Lasjaunias P. Surgical Neuro-Angiography,  Vol 1-5. Berlin: Springer-Verlag; 1987-1992.   Connors JJ and Wojak JC. Interventional Neuroradiology:  Strategies and Practical Techniques. Philadelphia, PA:  WB Saunders; 1999.   Morris P. Interventional and Endovascular Therapy of  the Nervous System. A Practical Guide. New York:  Springer; 2002.    Mulliken JB, Glowacki J. Hemangiomas and vascular mal-  formations in infants and children: A classification  based on endothelial characteristics. Plast Reconstr  Surg. 1982; 69: 412-422.   Neuroimaging Clinics of North America. Head and Neck  Imaging. Philadelphia, PA: WB Saunders; 1996.  Osborn AG. Diagnostic Cerebral Angiography. PA:   Traumatized children  Abdominal trauma  Laryngotracheal disruption  Maxillofacial assessment and initial management  Lacerations of soft tissue  Maxillofacial fractures  Suggested readings    The facial soft tissues and underlying facial bony skeleton  are, at once, the most important and most vulnerable por-  tion of the human body. Here the personality is perceived  and the senses reside but it is also here that accident and  assault most frequently occur.   Some compensation for this is found in the ready access  of the area for examination, and the obvious familiarity  of the structures. The facial skeleton is also largely sub-  cutaneous and readily amenable to direct and indirect  repair.   The initial temptation to allow spectacular and disfigur-  ing facial injuries to override measured surgical practice  must be resisted.   The proactive and comprehensive systems taught on all  advanced trauma life support (ATLS) and trauma skills  courses are followed with prompt, appropriate and struc-  tured assessment and action with constant reappraisal of  the patient’s condition.    The care of the trauma patient arriving in an accident and  emergency department (A&E) unit can be broken down  into four elements:    1.A primary survey is carried out, in which the  so-called ABCs are assessed and if necessary dealt with  immediately.   « A (airway): The oronasal airway is assessed, foreign  bodies cleared, blood and inspissated secretions  aspirated: a check is made that a potentially unsta-  ble cervical spine fracture is not displaced.   e B (breathing): This is checked to ensure that the  apparently clear airway is functioning. At this  stage, assisted respiration and ventilation with nec-  essary intubation or tracheal access surgery may be  required.   e C (circulation): The presence of an adequate blood  circulation is assessed and any significant haemor-  rhage is controlled, usually by pressure.   2. The second element is resuscitation of the patient  and includes the constant reassessment of problems  identified in the primary survey, with continuation  of care. Treatment of shock is commenced, including  the placement of vascular lines, urinary catheters and  nasogastric tubes if appropriate, and electrocardio-  gram (ECG) monitoring. In the case of multi-system  trauma, emergency screening radiography is carried  out to include lateral cervical spine, chest and pelvic  x-rays.    3. The third element of the trauma patient’s care is a con-  solidation exercise where a thorough total examination  of the patient is carried out as a ‘secondary survey’.   4.In the fourth element, definitive care will be decided  by specialist teams, and it may be necessary to trans-  fer the patient for this (for example to a maxillofacial or  neurosurgical unit). The primary surgery is usually car-  ried out by the frontline team in the A&E department,  whilst maxillofacial surgeons will require to undertake  a secondary survey prior to the definitive management  of maxillofacial injuries.    After the initial care of the trauma and before the patient  is passed to specialist maxillofacial assessment and initial  management, it is worth considering a number of topics in  more detail.    It should be assumed that any significant maxillofacial  injury may be associated with a cervical spine injury.  Care, therefore, must be taken when the head and  neck are manipulated during maintenance of the air-  way, examination and radiology. A lateral view of the  cervical spine showing all cervical vertebrae must be  examined and if there is a high index of suspicion, then,  cervical anterioposterior and open mouth odontoid  views should also be taken. Confirmation of a cervical  spine injury may require simple tomography or com-  puted tomography (CT) scanning. Where there is doubt  the opinion of a neurosurgeon should be sought, and  the use of a semi-rigid cervical collar considered in the  interim.    Although these fractures are not invariably involved with  brain injury, they provide a significant index of suspicion  with regard to present or future neurological deficit or the  presence of developing haematomas.   Skull vault fractures may be linear when they will often  require no direct treatment, or depressed, when they may  require elevation. Basal fractures are often diagnosed by  a leakage of cerebrospinal fluid (CSF), a classic bruis-  ing in the mastoid area (Battle’s sign) or blood seques-  tered behind the tympanic membrane. Skull fractures  which expose the brain or dura require early surgery.  Patients with head injuries require continuous assess-  ment and reassessment of their neurological status and  this monitoring may be done by the use of a combination  of the Glasgow Coma Scale (GCS), pupillary assessment  and extremity weakness. Abnormal and particularly  deteriorating results of these assessments should raise  suspicion of neurological damage or of a developing  space-occupying lesion.    This system of assessment works on the basis of numbers  being allocated to a spectrum of grades of neurological  responses, including eye opening, best motor response  and best verbal response. The scores for the three groups  are summated as the GCS. When these assessments are  repeated, a trend towards improvement or deterioration  can clearly be seen and appropriate action should be taken.    @ Eye opening is graded 1-4 as follows:  1 = no eye opening  2 = opening to pain  3 = opening to speech  4 = spontaneous opening  © The best motor response is graded on limb movements  from | to 6:  1 = no movement  2 = extensor response only  3 = abnormal flexion  4 = withdrawal from painful stimuli  5 = movement towards painful stimuli  6 = movement of limb on command  ® Capability of verbal response is graded from 1 to 5:  1 = no verbal response  2 = inarticulate sound  3 = recognizable words inappropriately uttered  4 = confused conversation  5 = fully orientated    Patients with GCS <8 are in a coma and have a severe head  injury. Those with a GCS of 9-12 are considered to have  a moderate head injury and a GCS of 13-15 indicates a  minor head injury.    Pupil size is measured regularly. A unilaterally enlarged  pupil may indicate a contralateral space-occupying lesion.  It is helpful to know from relatives or friends if the patient  had a disparate pupil size prior to the trauma. Slow light  reactions may indicate brain injury.    Equal movement of limbs on both sides is looked for whilst  a lateralizing weakness suggests contralateral brain injury.   The use of GCS, pupillary assessment and extremity  weakness assessment together provides a sensitive and  easily understood neurological monitoring system.    The proximity of swelling, bruising, lacerations and facial  fractures around the orbits and the type of trauma suffered    will give some indication as to the likelihood of eye injury.  If there is any doubt, an ophthalmologist must be asked to  see the patient and guidance sought as to whether explora-  tion of the orbit surgically might be required.   The eyelids, conjunctiva, cornea and globe should be  grossly examined for damage, and particularly for lacera-  tions. Visual fields in both eyes should be grossly mea-  sured, with the patient wearing glasses where appropriate,  either counting fingers at a distance or reading newspaper  print. The pupils are assessed for normal shape and light  response. The eye should be examined with an ophthal-  moscope for internal derangement. Flaccidity of the globe  on palpitation may indicate a laceration.    There will be some obvious differences in assessing the  pregnant woman. Where x-rays are essential they should  be taken and an obstetrician requested to see the patient as  soon as possible.    It is often difficult to examine a traumatized and dis-  tressed child accurately and a history may be impossible  to obtain. In view of the child’s small size and incom-  pletely calcified skeleton, there is often a higher chance of  organ damage, whilst paradoxically the skeleton is more  often spared than in adults. A thorough examination  and the advice of a paediatrician is, therefore, essential;  in most hospitals, a paediatric team will wish to become  closely involved with the child’s management. It should  be remembered that in view of a child’s relatively large  surface area in proportion to body volume, loss of heat  may occur more rapidly than with an adult, and the  smaller blood volume can result in a child becoming  shocked with what appears to be a relatively small blood  loss in adult terms. It should be remembered that a dis-  tressed and terrified child can be severely traumatized  psychologically, as well as physically, and sympathetic  management should reflect this concern.    It can be easy for occult abdominal damage to remain so  until the patient descends into extremis or death, and it is  therefore important that the abdomen is examined thor-  oughly and then reassessed. A history of trauma to, or  pain from, the abdomen should be noted and the abdo-  men inspected for wounds and contusions. A careful aus-  cultation should be carried out to assess the presence of  bowel sounds which may be absent as in an ileus owing  to peritoneal irritation by blood or bowel contents, or  extra-abdominal injury to the spine. Gentle palpation will    elicit pain, and involuntary muscle guarding is a sign of  underlying peritoneal irritation. A routine rectal exami-  nation may show blood from a bowel perforation or more  local damage.    Fractures of the larynx are uncommon and are indicated  by emphysema, hoarseness and local crepitus. Loud tra-  cheal breath sounds may indicate partial obstruction of  the airway that may be followed by a complete cessation of  sounds when total obstruction occurs. Use of endoscopy  to assess tracheal damage is often invaluable.   Obstruction in the trachea and upper airway can  be overcome with a number of surgical interventions  depending on the severity of the obstruction and its level.  A needle cricothyroidotomy with jet insufflation of oxy-  gen (Figure 51.1) can be a useful emergency measure and  allows for formal tracheostomy to be carried out in a less  hurried fashion.   Apart from respiratory obstruction, tracheostomy may  be indicated in patients where there are flail segments or  lung contusion or in severe head injury cases. This proce-  dure, which can be carried out under either local or gen-  eral anaesthesia, should be in the armamentarium of all  surgeons. The technique is fundamentally a simple one.  However, for most surgeons who do not perform it regu-  larly, the procedure can be more testing than textbooks  suggest. A conscious patient is likely to be distressed and  the neck can after trauma, be engorged with oedema fluid  and blood. Bearing this in mind ifa methodical approach is  taken, the procedure is usually accomplished successfully.    Maxillofacial injuries often excite considerable anxiety  amongst clinical and nursing members of the trauma  team, due to the grotesque swelling and bruising with    which they are associated. The majority of road trauma  and interpersonal violence cases are associated with max-  illofacial head injuries to a greater or lesser extent and it is  important therefore that these injuries are treated practi-  cally and without mystique.   The very real risk to both the nasal and oral airway in  severe injuries gives additional concern, and the tempta-  tion to employ the aphorism that ‘the injury invariably  looks worse than it is’, should be resisted. Although this  is often the case, a careful check using the fundamental  ‘ABC’ system can prove life-saving.   Fractures of the facial bones are often difficult for other  clinicians to understand, owing to the close juxtaposition  of intricate bony complexes and the need to comprehend  these in three dimensions. In addition, the difficulty of  obtaining good quality diagnostic radiographs, particu-  larly late at night, of a swollen patient in pain, and often  without a specialist radiographer, can make diagnosis yet  more fraught.   We have discussed the importance of first identifying  collateral injuries before concentrating on the maxillo-  facial region. However, once potentially life-threatening  injuries have been identified and controlled, maxillofa-  cial injuries must be accurately assessed. These may be  broadly divided into lacerations of the soft tissues of the  scalp, face and neck, and fractures of the facial skeleton. It  should be remembered that there is often a direct relation-  ship between an overlying laceration and an underlying  fracture.    These wounds cause a discontinuity in the soft tissue at  any level, from superficial skin abrasions to deep cuts,  and may open up a number of tissue planes. They may be  clean, contused or puncture wounds, or any combination  of these three.   Initially, any significant haemorrhage should be con-  trolled with pressure. The presence of foreign bodies or  the involvement of important underlying structures and  any loss of tissue can then be assessed. The possibility of  infection must not be overlooked, and although clean non-  contused wounds may not require antibiotics, old or dirty  wounds or those occurring in a medically compromised  patient, such as a diabetic, should be ‘covered’ by antibiotic  prophylaxis.   Contused, deep or puncture wounds, especially those  occurring out-of-doors, or as part of a multiplicity of  injuries, require an assessment of the patient’s tetanus  immunization status. The use of tetanus immune globu-  lin (TIG) rarely causes adverse reactions and may be con-  sidered for individual patients. If the patient has received  two or more injections of toxoid in the past, TIG is only  indicated if the wound is tetanus-prone or over 24 hours  old. The use of equine tetanus antitoxin is potentially  hazardous.    Uncomplicated lacerations in cooperative adults and older  children are usually treated well and promptly under local  analgesia. The use of general anaesthesia may be neces-  sary for complex lacerations, particularly where there is  skin loss, or simple lacerations in young un-cooperative  children.   The wound should first be carefully examined to  enable the removal of foreign bodies (soft-tissue radio-  graphs may help to locate radio-opaque material). Tissue  with poor viability may require clean excision, but a  most conservative approach must be taken in the facial  region, where every effort should be made to conserve  soft tissue.   Dirt should be thoroughly removed from wounds to  prevent skin tattooing and a sterile nail brush should be  used with dilute Savlon solution to thoroughly remove  any such debris, followed by copious irrigation with sterile  normal saline.   Haemostasis should be obtained by electrocoagulation  for small-vessel bleeds and ties used for bleeds from larger  vessels.   The cleansed wound is first loosely assembled, in order  that an assessment of any tissue loss can be made. If the  wound can be brought together with only moderate ten-  sion after wide undermining of the adjacent tissue if nec-  essary, then primary closure should be carried out. If an  aesthetic and functional primary closure is not possible,  consideration of grafting procedures or flap development  should be considered, and this is likely to be scheduled  as a further elective procedure. This may involve the use  of split or full-thickness skin grafts, local rotation flaps,  distant pedicled flaps or free flaps with microvascular  anastomosis. In these instances, temporary closure of a  wound will reduce the possibility of infection or haem-  orrhage whilst arrangements for definitive treatment  are made.   When dealing with lacerations in the facial region, it is  essential to assess the integrity of the facial nerve particu-  larly where damage to the parotid gland has occurred. The  nerve ends may either be repaired immediately or tagged  (with a suture) for future repair, including grafting, where  nerve division has occurred.   Lacerations in the cheek may also damage the parotid  duct requiring repair over a fine catheter.   Injuries to the eyelids must be associated with careful  examination to rule out damage to the globe and lacrimal  duct injuries.    The facial skeleton is arbitrarily divide into the upper third  or frontal bone, middle third or bony skeleton, from the  frontal bone down to the upper alveolus, and the lower  third or mandible.    Upper third fractures are usually linear cracks or bony  depressions over the frontal sinuses. Middle third frac-  tures result in detachment of this portion of the facial  skeleton to a greater or lesser extent from the rest through  the areas of anatomical weakness identified by Le Fort  during his cadaver studies, and which are illustrated in  Figure 51.2.   Severe displacement of the middle third of the facial  skeleton can result in the detached portion being thrust  backwards down the inclined slope of the base of the skull,  causing the classic ‘dished-in’ facies. There is also a danger  that this posterior movement of the mid-facial skeleton  might close off the nasopharyngeal airway. This should  be assessed promptly in the primary survey of the trauma  patient, and can be rectified either by attempting to draw  the posteriorly impacted bony complex forward by finger  pressure around the hard palate and tuberosities, or, by  prompt tracheostomy.   Fractures of the middle third of the facial skeleton  should be considered as a combination of the major  lamella displacements described by Le Fort, and of dam-  age to the specialized bony complexes which we recog-  nize as the dentoalveolar, mid-maxillary, malar, nasal  and orbital complexes. Fractures at more than one Le Fort  level or at different levels on separate sides are common.  Specialized complexes may be damaged in isolation or in  any combination.   Mandibular fractures are notated by site, as condylar,  ramus, angle, body or parasymphyseal fractures. The  combination of parasymphyseal and angle fracture occurs  most commonly, and it is wise always to look for more  than one mandibular fracture.    Figure 51.2 Le Fort low (I), middle (I) and high (Ill) fracture  lines. The mandible exhibits right angle and left parasymphy-  seal fracture lines.    Fractures of the maxilla and mandible occur in  numerous combinations, often with comminution and,  whilst rarely compound in the maxilla, are invariably so in  the mandible, along the roots of the teeth into the mouth.    A clinical assessment for fractures of the facial skeleton is  usually best carried out systematically from above down-  wards, starting with a careful examination and palpation  of the cranium, gently probing through any lacerations  where present for underlying bony damage.   Next, the orbital rims are examined with the nasal skel-  eton, malar bodies and zygomatic arches. Tenderness and  step deformities or swellings will usually betray underly-  ing fractures.   When the facial skeleton from the front has been  viewed, a further examination should be made by the phy-  sician standing behind the seated patient: looking down  on the facial skeleton from above can be revealing. Nasal  deviation or depression and flattening over the malar  prominences can be seen, as can ‘thumb print’ depres-  sions over the zygomatic arch. It is always wise to question  the patient with regard to previous nasal fractures that can  otherwise be deceptive.   The dentition and alveolus must be carefully checked  for fractured or missing teeth and radiographs of lacerated  soft tissue or chest and abdominal films used to reveal the  presence of avulsed teeth or dental prostheses.   The mandible is carefully examined by palpation, feel-  ing for step defects; intra-orally, the occlusion is examined  for discontinuity. The patient will be able to perceive any  small disruption in the occlusion accurately. The presence  of lacerations or ecchymosis in the buccal or lingual sulcae  often indicates underlying mandibular fractures.    The appearance of bilateral orbital ecchymosis and  oedema of the soft tissues of the face, with disruption of  the nasal skeleton, and the presence of blood in the nos-  trils is quite characteristic of this type of pan-mid-face  fracture (Figure 51.3). The maxilla is often mobile and a  CSF rhinorrhoea or otorrhoea should be looked for. If the  ‘examining’ hand grasps the upper alveolus and gently but  firmly moves it, whilst the ‘watching’ hand palpates at Le  Fort I, II and III levels in turn, some idea of the extent of  the mid-face injuries can be ascertained.    These fractures (Figure 51.4) are characterized clinically  by a flattening over the malar prominence or zygomatic  arch that can be obscured by oedema, and a difficulty    Figure 51.3 Classic appearance of panfacial fractures (at  all Le Fort levels).    in moving the jaw when the coronoid process impinges  on a depressed zygomatic arch. Circumorbital and  subconjunctival ecchymosis may be present, with limi-  tation of eye movements where there has been muscle  trapping, often the inferior rectus in fractures of the  floor of the orbit. A step defect is usually palpable in the  inferior rim of the orbit and there is frequently numb-  ness over the distribution of the inferior orbital nerve  ipsilaterally.    There may be diplopia, often owing to oedema or  displacement of the orbital complex, but sometimes owing  to detachment of suspensory ligaments of the globe. The  globe should be examined by an ophthalmologist to rule  out internal derangement. Malar complex fractures and  those of the orbit are frequently associated with subcon-  junctival ecchymosis, which has no posterior margin  extending as it does from the depths of the orbit posteri-  orly. Punctate subconjunctival ecchymosis occurs when a  blow to the eye causes the extravasation of blood below the  conjunctiva related locally to the blow.    The paper-thin bones of the floor of the orbit also form  the roof of the antrum and are in continuity with the  zygomatic complex. Fractures to the fragile floor of  the orbit also occur in isolation, particularly when  there is direct blunt trauma to the globe itself which,  by displacement or distortion of the globe, ‘blows out’  the vulnerable bone of the orbital floor. On these occa-  sions, a herniation of peri-orbital fat and the inferior  rectus muscle may occur, often with a restriction of eye  movement, particularly on upward gaze (Figure 51.5),  and a lowering of pupillary height on the affected side.  Enophthalmos can present either early or late. The thin  medial wall of the orbit is also prone to being ‘blown in,  with a commensurate increase in orbital volume and a  danger of late enophthalmos.    Bilateral circumorbital ecchymosis is pathognomonic of  this type of fracture, along with a deviation of the nose  laterally where lateral force has been applied, or resulting    in the collapse of the nose where the trauma has occurred  anteriorly. Epistaxis occurs invariably. In nasoethmoidal  disjunction, the damage must be analysed carefully in  order to plan satisfactory reconstruction. In addition,  damage involving the cribriform plate may be signalled by  CSF leak, and can result in anosmia.    These fractures are normally easy to elicit, particularly in  the dentate patient. There is an inability to close the teeth  into normal occlusion, with commensurate discomfort  over the fracture site. Often and particularly when there  has been distraction at the fracture site, there can be  anaesthesia of the lower lip on the affected side, from infe-  rior alveolar neuropraxia. Where fractures of the body of  the mandible have occurred, this can often be identified by  bleeding from tears in the overlying mucosa. Step defects  in the occlusion and lower border of the mandible are usu-  ally easily identified.    This screen of radiographs should provide adequate views  for an initial diagnosis to be made:    As we have noted earlier, the possibility of cervical spine  injury must first be excluded by clinical examination and,  if appropriate, cervical spine views.   The submentovertical view provides a ‘skyline’ view  of the zygomatic arches (Figure 51.6) showing the arches  and any displacement. The occipitomental views show  the integrity of the orbital rim and floor, providing  further useful views of the zygomatic arches and will  clarify the outline of the antral walls and the presence of  fluid levels in the sinuses. The so-called ‘hanging-drop’  sign caused by soft-tissue herniating through the floor of  the orbit into the antrum below is best seen in this view  (Figure 51.7).   Fractures of the nasal bones and posterior maxilla can  be seen on the lateral skull view. If nasal bone fractures  are suspected, a ‘soft-tissue’ lateral will often show these  clearly. The orthopantomogram allows fractures of the  basal bones of the mandible, the teeth and alveolus to be  assessed (Figure 51.8). As this latter view is tomographic,  remember that there is always a danger of information  outside the “focal trough’ not being reproduced.    Figure 51.6 Submentovertical view clearly showing (a) the  pre-operative crumpled and (b) post-operative reduced left  zygomatic arch as ‘sky-line views’.    Figure 51.8 Orthopantomogram illustrating (a) right body  fracture in edentulous mandible, (b) right-angle fracture in  partially dentate patient, (c) reduction and fixation of fracture  in (b) using miniplate osteosynthesis.    The plain films here are important for the diagnosis and  localization of fractures of the facial skeleton. In order to  examine the three-dimensional (3D) relationships of the  complex facial fractures, CT scans are invaluable, espe-  cially with 3D re-formatting. In the case of a fracture of  the frontal bone over the frontal sinus, for example, a CT  scan will show the extent and severity of the injury to the  outer bony table and, in addition, define any involvement  of the inner table of the sinus wall (Figure 51.9).    Figure 51.9 Axial computed tomography (CT) scan  showing comminution of anterior wall frontal sinus with intact  posterior wall.    The increasing use of CT scanning with 3D re-format-  ting, especially with spiral machines, is providing unpar-  alleled imaging of complex fractures of the facial skeleton  with the facility for ‘virtual’ surgery and with the possibil-  ity of utilising the software to mill prostheses to replace  large portions of lost bone.   e Obtaining pre-trauma photographs builds empathy  with relatives and can act as a useful operating guide.   e Sudden deterioration of an otherwise stable patient  prompts reassessment of primary survey.   e Even severe lacerations are rarely associated with sig-  nificant tissue loss.   e Check for damage to the lacrimal and parotid ducts and  facial nerve branches before closing deep lacerations.    Ali T and Shepherd JP. The measurement of injury sever-  ity. Br J Oral Maxillofac Surg. 1994; 32: 13-18.   Key SJ, Thomas DW and Shepherd JP. The management of  soft tissue facial wounds. Br J Oral Maxillofac Surg.  1995; 33: 76-85.   Marks PV and Lavy CBD. A Practical Guide to Head  Injury. London: W.B. Saunders Co. Ltd; 1992.   Russell C and Matta B. Tracheostomy: A Multiprofessional  Handbook. London: Greenwich Medical Media Ltd;  2004.    Hippocrates was the first to emphasize the importance  of reduction and immobilization of the mandible frac-  ture, with the use of the interdental ‘bridal wire’. As time  passed, closed reduction and stabilization with maxillo-  mandibular fixation (MMF) was introduced by techniques  such as external bandages (i.e. the Barton bandage), inter-  nal splints (i.e. Gunning splints), external frame and pin  fixation and various forms of interdental wiring. These  techniques rely on secondary bone healing, but have lim-  ited application in modern practice, because of the delayed  return of function and higher rates of infection, malunion,  non-union and malocclusion. This led to the development  of open reduction and internal fixation techniques, which  provides anatomical reduction and stabilization, in turn  optimizing primary bone healing.   One of the earlier forms of internal fixation was the  use of transosseous wires, a semi-rigid form of fixation  which was an effective technique for its time, and is occa-  sionally still employed. In the 1960s and 1970s, this tech-  nique was replaced with the advent of plates and screws.  These early plating techniques were first adopted from  orthopaedic experience with the treatment of long bone  fractures. However, large compression plates which used  bicortical screws that were placed along the inferior border  of the mandible splayed the superior aspect of the fracture.  Compression plates apply force to areas of the mandible  which are already under biomechanical compression.  Eccentric dynamic compression plates were then devel-  oped to attempt to counteract these distraction forces, but  were too cumbersome and technique sensitive.   More recent advancements in plating techniques have  provided many different forms of plating technology to    the surgeon including non-locking plates, threaded lock-  ing plates, tapered locking plates, bicortical and monocor-  tical fixation and rigid and semi-rigid plates. In order to  achieve a level of excellence for each patient, today’s sur-  geon must not only understand each type of technique,  but also appreciate the advantages and disadvantages of  each, as well as their basic principles of management. The  goals of treatment should be as follows:    Understanding these goals is paramount and the sur-  geon must weigh the risks against the benefits of the pro-  posed management. The objective of this chapter is to  provide the clinician with an overview of the advance-  ments made in maxillofacial fixation and the types of  techniques available.    MME is a hallmark principle of maxillofacial trauma  which uses the patient’s occlusion to establish the proper  reduction and stabilization of facial fractures, thus provid-  ing a foundation to reconstruct facial form and function.  Various forms of MMF have been described in the litera-  ture, e.g. eyelet loops, skeletal suspension wires and Erich  arch bars. Arch bars are currently the workhorse for MMF,  they are applied using circumdental wires (Figure 52.1).    The patient is placed into his premorbid occlusion upon  the final tightening of the intra- and interarch wires. Arch  bars are valuable in re-establishing the intra-arch con-  tour when managing dentoalveolar fractures and they  also serve as a ‘tension band’ by resisting the forces along  the alveolar level of the mandible. They provide a versa-  tile means of directing vectors of forces with a V-W pat-  tern of crossbracing, to assist in fracture reduction and  re-establishment of the premorbid occlusion. While arch  bars provide an effective means of MMF, their use is not  without consequence.   Increased surgical time both in placement and removal,  risk of penetrating injury to the surgeon associated with  the use of stainless steel wires, trauma to the periodontal  soft tissue and compromised oral hygiene are all short-  comings of traditional arch bars. Also, arch bar placement  in the paediatric patient can be difficult, depending on the  patient’s age and stage of tooth eruption. The height of con-  tour position and contacts in the primary dentition may  prevent the application of circumdental wires. Second,  there is the potential for extrusion of the primary tooth  upon tightening the wire, especially in the root resorption  stage for exfoliation.    Recently, the introduction of self-drilling/tapping inter-  maxillary fixation screws (IMFs) has eliminated some  of the problems associated with arch bars (Figure 52.2).  Many clinicians elect to use them based on a decreased  risk of penetrating injury for the user, ease of placement  with shorter operating room time, decreased trauma to the  periodontium, convenience of maintaining oral hygiene,  and the ability to use them both intraoperatively and post-  operatively, such as with guiding elastics. The first genera-  tions of IMF screws were simply modified monocortical  self-tapping screws. Because they required a drilled hole  for placement, there were concerns about suboptimal    placement and root damage that occurred during place-  ment. The second generation self-drilling/self-tapping  screws improved tactile feedback, limiting the possibility  of root damage. Additionally, because power equipment is  not needed, the system can be used outside the operating  room (i.e. in the intensive care unit or emergency depart-  ment). The manufacturer recommends placing screws  above the root apices; however, the author has found that  subapical placement led to mucosal overgrowth compli-  cating their removal. Instead, the screws should be placed  in a bicortical fashion between the roots at the level of the  mucogingival junction. It is recommended, if possible, to  obtain a panorex film prior to placement of the screws in  order to evaluate the root morphology. When possible, at  least one screw should be placed proximal and distal to the  fracture. However, multiple screws can be placed to direct  the vectors of the interarch wires appropriately which in  turn aids in fracture reduction and stabilization. Since  their introduction, they have been met with both enthusi-  asm and criticism. Recent reports have illustrated several    inherent risks and limitations which include root injury,  screw loosening, screw shearing and aspiration. The self-  drilling feature offers a greater degree of tactile feedback  during placement, allowing the operator to change inser-  tion location before root damage occurs. In paediatric  patients, the IMF screws should be avoided or used with  caution to prevent injury to the tooth buds.    External mandibular fixation has played an important  role in the management of comminuted mandible frac-  tures, infected mandible fractures and maintaining con-  tinuity defects secondary to infected osteoradionecrosis  (Figure 52.3). However, through the advancements made  with rigid fixation, as well as microvascular reconstructive  surgery, this technique has waned in its use. In circumstances  which are relative contraindications to internal rigid fixa-  tion (i.e. infected hardware) where the surgeon is attempting  to optimize soft-tissue health, the external fixator functions  to maintain the mandibular continuity defect, as well as  eliminating any foreign body within the wound bed. Once  soft-tissue stabilization is achieved, the definitive repair can  take place and the external fixation removed.   First-generation external fixators utilized transcuta-  neous bicortical pins (placed along the inferior border)  which were then bridged by filling an endotracheal tube  with acrylic resin. Today’s second-generation systems  still use similar types of pins, but instead use alloy bars  or carbon fibre, with locking clamps to finalize the fixa-  tion. These fixators are less cumbersome with streamlined  instrumentation. One advantage is the ability to perform  minor adjustments to address malocclusions, by simply  loosening the clamps, placing the patient into MMF and  retightening the clamps.   @ Palpation of the inferior border proximal and distal to  the continuity defect.   @ A stab incision with a No. 15 blade where pins are to be  placed.    Rigid fixation utilizes bicortical screws and rigid plates  (2.0-2.4 mm) along the inferior or posterior border of  the mandible, with or without a second monocortical  plate (typically a miniplate) placed in the subapical region  or external oblique ridge. This plate is termed a ‘tension  band’ because of its use in an area of biomechanical ten-  sion. Rigid fixation should not require the use of post-  operative MMF. Depending upon the circumstance, rigid  fixation can be placed either through a transoral/buccal  (described in section ‘Miniplate (Semi-Rigid) Fixation’) or  transcervical approach, the author's approach is as follows:    ® Local anaesthesia and muscle relaxation is avoided dur-  ing this dissection to allow localization and protection  of the marginal mandibular branch of the facial nerve.   ® A curvilinear incision is based at least 2 cm inferior to  the inferior of the mandible within a skin crease.   © The marginal mandibular branch is superior to the infe-  rior border of the mandible once it passes to the anterior  facial vessels. However, when it is posterior to these ves-  sels the nerve is within 1 cm below the inferior border  19% of the time.   ® Incision is made through the skin and subcutaneous tis-  sue to the level of the platysma.   ® Dissection continues through the platysma to the level  of the superficial layer of the deep cervical fascia.   ® In addition, the external jugular vein and greater auric-  ular nerve are identified overlying the sternocleidomas-  toid muscle (SCM).   @ The superficial layer of the deep cervical fascia is  incised, the facial vein is identified and is then clamped,  divided and ligated. The distal aspect of the vein is left  on a long silk tie and is gently retracted superiorly with  this suture. This manoeuvre retracts the nerve (which is  superficial to the vein in the cervical fascia) superiorly  protecting it from injury.   © The facial artery is identified at the posterior/superior  aspect of the submandibular gland. It is then clamped,  divided and ligated.   © The fascial plane overlying the SCM is followed to the  angle and posterior border of the mandible.   © In the submental region, the fascial plane overlying the  anterior belly of the digastric is followed superiorly to its  attachment at the symphysis.    © The periosteum and masseteric sling is then incised and  a subperiosteal plane of dissection is then performed to  expose the mandible.    Almost all the screws manufactured today for use in  the mandible are self-tapping in design. A plating system  is defined by the diameter of the screws; depending on the  manufacturer, the diameters used for mandibular repair  will range from 2.0 to 3.0 mm. The non-locking plates/  screws are designed to act as separate units working in con-  junction with one another to establish a stabilized fracture.  When non-locking screws are tightened, the heads of the  screws exert pressure upon the plate which provides stabi-  lization across the fracture. This design is effective, but is  not without potential consequences. The pressure generated  by the screws is translated through the plate to the underly-  ing bone (Figure 52.4). This has the potential to cause bone  resorption beneath the plate. If this occurs prior to the time  required for primary bone healing, the hardware can then  fail, increasing the risk of non-union, malunion, malocclu-  sion and infection. In addition, poor technique with plate  adaptation and utilizing non-locking screws can increase  the potential for fracture displacement (Figure 52.5). This  occurs when the screw head comes into contact with the  plate during the tightening process. This action pulls the  fracture segments to the plate, resulting in displacement  of the segments and malalignment. There are specific  situations where this feature can be used to the surgeon’s  advantage, such as reducing the lingual splay of symphyseal  fractures caused by muscle pull. In these situations, the plate  can be intentionally overcontoured and the use of non-lock-  ing screws will help reduce the lingual cortex (Figure 52.6).    The introduction of locking plates/screws has addressed  some of the issues discussed earlier (Figure 52.7). The lock-  ing plate/screws have two sets of threads, bone threads and    plate threads, which are threads in the head of the screw.  This second set of threads unifies (locks) the screws to the  plate creating a single rigid functional unit. Some feel this  type of design is more stable and predictable to use. It cre-  ates a system which eliminates pressure being translated  through the plate and underlying bone, thereby decreas-  ing the likelihood of bone resorption and hardware fail-  ure. In addition, should any gaps exist between the plate  and bone due to imprecise bending, this system is theo-  retically more forgiving, with less likelihood of fracture  displacement, although studies indicate displacement is  still possible with locking plates.   There are two types of locking designs available, the  threaded and tapered systems. Each uses the same prin-  ciple of locking the screw to the plate; however, the actual  mechanics vary, giving each a relative advantage and dis-  advantage. In the threaded design, the plate itself also has  machined threads, so that these screws are placed perpen-  dicular to the plate. The second set of screw head threads  mesh with the plate threads creating a locking system.  When using locking technology in ablative surgery, the  manufacturers recommend limiting the number of times  the same screw is reinserted to three attempts. In addition,  although these screws should be placed perpendicular to  allow the threads to mesh appropriately. Some manufac-  turers state that the screws can be angled in limited access  cases, essentially allowing the screw/plate to cross-thread.   Most recently, tapered locking plates/screws have been  introduced, where the threads in the head of the screw are  tapered and, depending on the manufacturer, there is either  a single machined thread within the plate or no machined  threads at all. The threads in the head of these screws will  either cut its own thread pattern into the plate as the screw  is being seated, or upon the last turn of the screw a single  thread will engage the plate, providing a locking mecha-  nism. It is suggested that one of the advantages of the tapered  locking design is the freedom to place the screws at up to  a 10° angulation from the plane perpendicular to the plate.  This alleviates the risk of cross-threading and security of the  locking mechanism. This may be advantageous when access  is limited, although the author rarely finds this to be an issue.   A theoretical advantage of the tapered locking design is its  ability to compensate for thread/hole distortion. This poten-  tially occurs during the adaptation and bending process of    the plate. To help alleviate this problem with the threaded  design, some manufacturers have fabricated bending inserts  which are screwed into the plates during the contouring  process, and are later removed. In practical application, the  amount of distortion remains unknown, because the plates  are bent between the screw holes, not directly over them.  If, however, thread/hole distortion in the plate is considered  a clinical concern, the concept of a tapered screw design  might alleviate this issue. In order to prevent the possibility  of fracture displacement, the author recommends a modi-  fication of the manufacturer recommended sequence of  screw placement (Figures 52.8 and 52.9).    Although the theory behind the design of locking  plates/screws is plausible, presently there is lack of clinical  data to support their superiority to its non-locking coun-  terpart when used in mandible fracture repair. However,  the use of locking technology for mandibular continuity  defects has been shown to be of benefit when compared to  its non-locking counterpart.    Semi-rigid fixation is the employment of miniplates and  monocortical screws for the treatment of fractures and  dentofacial deformities of the mandible. The term ‘semi-  rigid’ is reserved for the load-bearing areas of the man-  dible; however, these miniplates are considered rigid  forms of fixation when used for upper and midface trauma  because of the non-load-bearing features of these regions.  Semi-rigid fixation has been described as an effective form  of treatment of mandible fractures when placed along the  lines of osteosynthesis. The lines of osteosynthesis are    biomechanical points of compression, tension or torsion  (depending on the region of the mandible). This technique  has undergone modifications since its introduction and it  utilizes a transoral and/or transbuccal approach (Figures  52.10 and 52.11) and can involve a single malleable plate  or three-dimensional (‘box’) plate, with 2.0-mm diameter  monocortical screws proximal and distal to the fracture.    @ Local anaesthesia and vasoconstrictor are injected  along the planned incision (if not contraindicated).   @ Incisions are based in the mandibular vestibule at least  5-7 mm inferior to the mucogingival junction to facili-  tate ease of closure and prevent dehiscence.   @ The dissection is performed through mucosa, submu-  cosa, mentalis or buccinator muscle (depending on the  location of the fracture) and periosteum.   e A subperiosteal plane of dissection is then performed to  the inferior border of the mandible.   @ The mental nerve is identified in the premolar region  and the nerve sheath is carefully skeletalized with a  scalpel or tenotomy scissors. This is to allow for mobi-  lization of the nerve and to prevent possible avulsion  from the foramen by retractors.   e@ The fractures are mobilized, and any soft tissue  entrapped within the fracture is removed, care is taken  not to injure the inferior alveolar nerve.   © Bone-reducing forceps can be utilized in the transoral  approach to assist in fracture reduction within the para-  symphyseal region. They are difficult to use in the angle  region due to limited access.    ® The approach is essentially the same as the transoral  approach.   @ In the posterior mandibular regions, a transbuccal  approach with the transbuccal trocar system is used  to facilitate placing the screws as perpendicular to the  plate as possible.   e A stab incision is made on the cheek overlying were the  anticipated hardware is to be placed.   © Blunt dissection through the masseter and periosteum  is performed with a haemostat.   © The trocar system is then placed in a non-traumatic  fashion and the cheek retractor is assembled to the tro-  car handle.    In its classic form, the ‘Champy technique’ uses a single  plate in the subapical region or along the external oblique  ridge when fractures are posterior to the mental foramen.    When treating parasymphyseal fractures (anterior to the  mental foramen), two miniplates are used in order to resist  the forces of torsion seen in this region. The first plate is  placed in the subapical region and the second plate 5 mm  inferior to the first. Miniplate fixation is not recommended  in cases that lack adequate buttressing of bone or situa-  tions were patient compliance is doubtful.   When miniplates are used in the upper and middle  facial thirds, the size of the plate/screws used varies from  1.0 to 2.0 mm. This is typically dependent on the region  being fixated, as well as the manufacturer of the plating    system. The types of screws used for miniplates are either  self-tapping (which require pre-drilling) or self-drilling.  Again, the circumstances (i.e. bone quality, pattern of  fracture) will determine the type of screws used with the  miniplate.    Another form of rigid fixation is the use of positioning or  lag screws (Figures 52.12 and 52.13). This form of fixation    is typically used in orthognathic surgery of the mandible,  bone grafting procedures and specific patterns of mandi-  ble fractures. The lag screw engages the inner cortex of the  bone alone, so the head can apply compressive forces along  its axial length. Positioning screws engage both cortices  and do not apply the same compressive forces seen with  lag screws; they fixate the bone in a more neutral position.  When utilizing the position screw, the segments of bone  are approximated (i.e. sagittal split osteotomy, bone graft),  the bone is pre-drilled with the appropriate size bit prior  to screw placement. Proponents of positioning screws for  sagittal split ramus osteotomies feel there is less potential  for compression of the inferior alveolar nerve and less    torquing of the condyle from the fossa (more likely occur-  ring with flared rami). When fixating these osteotomies,  three screws can be placed along the external oblique  ridge; or a triangulation technique can be employed with  two screws along the external oblique ridge and one at  the inferior border. Due to the nature of the positioning  screws, one can experience a false sense of security because  the screw can appear tight even if it is stripped from one of  the cortices. For this reason, the surgeon must be aware of  the screw engaging both cortices upon insertion.   There are two different ways to apply lag screws: one  requires more bone preparation by the surgeon, the other  uses a premanufactured lag screw (which requires less  bone preparation). In order to be effective, the screws must  be placed perpendicular to the fracture line. The diameter  of lag screws can range from 2.3 to 3.5 mm and lengths  vary depending upon the application. In the first method,  both cortices are pre-drilled, but the proximal cortex is  drilled to a larger diameter than the screw. This assures    that only the distal cortex is being engaged so the screw  head can compress the inner and outer cortices together.  The second method relies on a manufactured lag screw  which has threads only on the distal half of the shank; the  proximal half is smooth. After the bone is pre-drilled, only  the distal half has threads which engage the inner cortex,  allowing the head of the screw to apply compressive forces  to both cortices.   Lag screws have been described for fracture fixation in  every region of the mandible. They are ideal for symphy-  seal fractures which have stable buttressing. Ideally, two  screws are placed parallel to each other and perpendicular  to the fracture line, in order to resist the forces of torsion  within this area. Countersinking the outer cortex is rec-  ommended to allow the screw head to sit flush with the  bone. Some manufacturers provide washers to be used  under the screw head to prevent the compressive forces  from submerging the screw head beyond the lateral cortex  into the medullary space. If this occurs, the technique is  rendered ineffective and retrieval of the screw is difficult.    Coletti D, Caccamese J, Norby J, Edwards S and von  Fraunhofer JA. Comparative analysis of the threaded  and tapered locking reconstruction plates. J Oral  Maxillofac Surg. 2007; 65: 2587-2593.   Coletti D, Salama A and Caccamese J. Application of  intermaxillary facial screws in maxillofacial trauma.  J Oral Maxillofac Surg. 2007; 65: 1746-1750.   Collins CP, Pirinjian-Leonard G, Tolas A and Alcalde R.  A prospective randomized clinical trial comparing  2.0-mm locking plates to 2.0-mm standard plates in  treatment of mandible fractures. J Oral Maxillofac  Surg. 2004; 62: 1392-1395.   Dingman RO and Grabb WC. Surgical anatomy of the  mandibular ramus of the facial nerve based on the    dissection of 100 facial halves. Plast Reconstr Surg.  1962; 29: 266-272.   Eckelt U and Hlawitschka M. Clinical and radiological  evaluation following surgical treatment of condylar  neck fractures with lag screws. J Craniomaxillofac  Surg. 1999; 27: 235-242.   Ellis E 3rd. Use of lag screws for fractures of the mandibu-  lar body. J Oral Maxillofac Surg. 1996; 54: 1314-1316.   Gordon KF, Reed JM and Anand VK. Results of intraoral  cortical bone screw fixation technique for mandibu-  lar fractures. Otolaryngol Head Neck Surg. 1995; 113:  248.   Gutwald R, Alpert B and Schmelzeisen R. Principle and  stability of locking plates. Keio J Med. 2003; 52: 21.   Haug RH, Street CC and Goltz M. Does plate adapta-  tion affect stability? A biomechanical comparison  of locking and nonlocking plates. J Oral Maxillofac  Surg. 2002; 60: 1319.   Jones DC. The intermaxillary screw: A dedicated bicorti-  cal bone screw for temporary intermaxillary fixa-  tion. Br J Oral Maxillofac Surg. 1999; 37: 115.   Kallela I, Hzuka T, Laine P and Lindqvist C. Lag-screw fix-  ation of mandibular parasymphyseal and angle frac-  tures. Oral Surg Oral Med Oral Pathol Oral Radiol  Endod. 1996; 82: 510-516.   Martin H. Surgery of Head and Neck Tumors. New York,  NY: Hoeber-Harper; 1957.   Onishi K and Maruyama Y. Simple intermaxillary fixation  for maxillomandibular osteosynthesis. J Craniofac  Surg. 1996; 7: 170-172.   Schneider AM, David LR, DeFranzo AJ, Marks MW,  Moinar JA and Argenta LC. Use of specialized bone  screws for intermaxillary fixation. Ann Plast Surg.  2000; 44: 154-157.   Soderholm AL, Lindqvist C, Skutnabb K and Rahn B.  Bridging of mandibular defects with two differ-  ent reconstruction systems: An experimental study.  J Oral Maxillofac Surg. 1991; 49: 1098-1105.   Principles of soft-tissue repair and wound healing  Injuries to facial structures requiring special treatment  Eyelid and nasolacrimal apparatus    The management of facial soft-tissue injuries is a criti-  cal component of trauma care. There is great variability  in complexity, with some superficial injuries requiring  little more than a dressing or simple re-approximation,  and other avulsive wounds requiring the transfer or local,  regional or distant tissue flaps.   A basic understanding of wound healing process is nec-  essary when repairing facial soft-tissue injuries. Wound  healing can be divided into three phases:    . Initial Lag Phase (up to day 5): No gain in wound  strength. Wound is dependent on epidermal cellular  adhesion and sutures to maintain closure.    Tensile strength of the soft tissue is only about 3%-7% of  normal by the end of the second week of healing after the  sutures are removed. This increases to about 20% by the  end of the third week and 50% by the end of the first month.  Wounds never regain more than 80% of the strength of  intact skin. Since wounds do not gain adequate strength  until about 5-6 days after repair, it is important to know  that the majority of the burden of approximating the tissue    during this period rests on the sutures used. Therefore,  the suture material and suturing technique used are very  important parts of treating facial soft-tissue injuries.  Suture material can be classified as absorbable or non-  absorbable, coated or uncoated, natural or synthetic and  multifilament (braided) or monofilament.    Lacerations: Usually have sharp edges. Washout with water  and debridement, primary closure is layers should be per-  formed. Lacerations can be broken down into several  categories:   2. Stellate Lacerations: caused by blunt, crushing trauma.  Usually have ragged edges which need to be cleaned  and the edges sharpened.   3. Flap-like Lacerations: these are avulsion injuries with-  out the loss of tissue.    Contusions: Refers to the bruise caused by edema and  haematoma in subcutaneous tissues resulting from blunt  compressive injuries. Usually they require no treatment  unless the haematoma becomes infected.    Abrasions: Caused by superficial damage to the skin no  deeper than epidermis via mechanisms such as scrapping.  Keeping the wound clean and moist is usually all that is  required for treatment. Usually the skin epithelializes in  7-10 days following the injury.   Avulsions: This type of soft-tissue injury involves  some level of tissue loss. Minimal tissue loss usually is of  little consequence as undermining the surround tissue  still allows for tension-free primary closure. Larger areas  of tissue loss may require skin graft, local tissue flaps or  free tissue transfer. Facial wounds should never be allowed  to heal via secondary granulation as these create very  unaesthetic results with scarring.   Facial wounds can be categorized as clean or  contaminated. Fresh clean wounds are usually in  no need of prophylactic antibiotics. The rate of  infection increases and is directly related to the length  of time that has elapsed since the initial injury. Skin  wounds are usually contaminated with Streptococcus and  Staphylococcus. Wounds that involve mucosal lining of  the oral cavity are contaminated by oral flora. Through-  and-through lacerations between oral cavity and facial/  neck skin are considered contaminated. The number of  bacteria present in the wound is more important than  the type of bacteria in causing infections. Simple lac-  erations and abrasions have low bacterial content and  very low chance of developing infection. On the other  hand, crushing injuries, presence of foreign bodies in  the wound, oro-cutaneous communication and animal  or human bites lead to increase number of bacteria and  much higher rates of infection. Additionally, it is very  important to evaluate the immune status of the host and  consider the comorbidities as well including poorly con-  trolled diabetes, history of steroid use, malnutrition and  so on. In these cases, antibiotic prophylaxis should be  considered.    The initial evaluation of the trauma patient is well des-  cribed by the American College of Surgeons Committee  on Trauma. Once the airway is established, breathing con-  firmed and haemorrhage controlled and adequate circula-  tory volumes established, a secondary assessment of the  maxillofacial region is performed.   Haemorrhage from the facial soft tissues is readily con-  trolled with direct pressure and occasionally ligation of  bleeding vessels. Epistaxis associated with concomitant  midface fractures can be life threatening and should be  managed with formal nasal packing or balloon occlusion  devices (see Chapter 16).   After the patient is initially stabilized and haemostasis  achieved, the facial wounds should be inspected closely.  The wounds should be pulse irrigated with saline or bal-  anced salt solutions. It is not the type of irrigation solu-  tion used that effects wound infection, but the mechanical  action of high pressure irrigation that is important for    successful outcomes. The use of undiluted hydrogen  peroxide as an irrigant should be avoided as it inhibits  wound healing and may cause tissue necrosis. Scrubbing  of the wound with a brush may be undertaken if neces-  sary but should be done sparingly to spare further dam-  age to soft tissues. All devitalized soft tissue should be  debrided and excised, and sharp healthy wound margins  should be obtained to facilitate closure with minimal scar-  ring. Devitalized tissue increases the local inflammatory  response and subsequent scarring.   During final examination, it is imperative to assess  cranial nerve function and to document injury to vital  structures, such as the eye and brain. Various nerve func-  tion grading systems have been described, most notably  the House-Brackmann score for facial nerve function.  A nerve stimulator may be helpful in assessing the integ-  rity of nerve branches. Consultation with subspecialists in  ophthalmology and/or neurosurgery should be obtained  as indicated.    Clean wounds may be closed primarily up to 48 hours  following the initial injury. A relatively short delay in the  definitive repair of soft-tissue injuries may be indicated  if the underlying facial bones have been fractured and  require surgical reduction. Temporary repair of the lacera-  tions will minimize the risk of wound infection and pre-  pare the wound bed for skeletal surgery on a semi-elective  basis.   Primary wound closure should almost always be  attempted if feasible. Wounds should be closed in lay-  ers if possible to place minimum tension on the super-  ficial skin closure and aid in the eversion of skin edges  to minimize scar widening. Tension across a wound  decreases blood flow which leads to necrosis of wound  edges and increased connective tissue growth in the  proliferation phase and to widening of scars in the  remodelling phase. Skin flaps should be appropriately  undermined so wound edges can be everted which will  minimize scar depression. Achieving good haemostasis  is critical, as haematoma formation is a major cause of  infection and wound break down. If adequate haemo-  stasis cannot be achieved, then drain placement should  be considered.   Delayed primary wound closure is usually indicated in  patients that have extensive high-energy tissue loss and/or  devitalized tissue, such as those caused by high-velocity  gunshot wounds. These wounds generally require serial  washouts and debridement before primary closure can  be attempted. Delayed repair of contaminated injuries  and bite wounds to the face is not recommended, as early  primary closure results in less scarring. In the case of sig-  nificant tissue avulsion, local flaps, regional flaps or free  tissue transfer may be needed to adequately restore tissue  to previous form and function.    The following general guidelines summarize the man-  agement of soft-tissue injuries:   4. When suturing, perform layered closure and ensure that  skin margins are relaxed without tension and everted.   5. Use fine sutures such at 5-0 or 6-0 sizes should be used  for skin and removed early usually between 4 and  6 days. 3-0 or 4-0 absorbable sutures can be used for  deep sutures.   6. Properly align key landmarks, such as eyebrows and  vermilion border of the lips for optimal aesthetic results.    Injuries of the lip can cause aesthetic and/or functional  problems. Accurate re-approximation the vermilion bor-  der of the lip, defined as the transition point between the  mucosal tissue and skin of the lip, is critical to achiev-  ing an aesthetically acceptable result. An irregular ver-  milion border or mismatch of more than 1 mm becomes  clinically noticeable. Deeper wounds to the lip should  be closed in layers to re-approximate the orbicularis oris  muscle as this muscle is important for oral function and  lip competence.   Avulsive injuries to the lip can still be repaired primar-  ily with minimal to no functional or aesthetic defects if  no more than about 25% of the upper or lower lip is lost.  For more extensive avulsive tissue loss, local flaps such  as the Abbe-Estlander flap can be used to rotate tissue  into the avulsed area. The Abbe flap is well suited for  both upper and lower lip reconstructions and is generally  indicated for repair of vertical defects of both vermilion  and cutaneous lip tissue that do not involve the commis-  sure. Injuries that involve the oral commissure can be  reconstructed with a Karapandzic flap which is designed  to re-establish the circumoral sphincter by rotating and  advancing the remaining innervated orbicularis oris  muscle. The Webster—-Bernard flap is used to reconstruct  the lower lip by advancing cheek tissue and the remain-  ing lip tissue medially. This technique is well suited for  subtotal defects of the lower lip where the commissure is  preserved (see Chapter 38).    Initial evaluation of injuries to the ear should include  examination of external and internal structures such as  the tympanic membrane and a gross hearing exam to rule    out sensorineural hearing loss. The pinna or auricle of  the ear is the portion of the external ear most commonly  involved in trauma. They consist of a thin central area of  relatively avascular cartilage which receives most of its  blood supply from the thin overlying layer of skin. This  avascular cartilage providing the semirigid configuration  of the auricle is a primary concern in the treatment and  post-operative management of an ear injury. Meticulous  approximation of both skin and cartilage is necessary to  assure favourable wound healing and prevent chondritis  or tissue necrosis. The cartilage should be covered by skin  and a bolster dressing is generally recommended to mini-  mize the risk of haematoma formation which can cause  ear deformities such as ‘cauliflower ear’. Leech therapy has  also been proposed for haematoma management of the  external ear with variable success rates.   Simple ear lacerations are usually easily treated under  local anaesthesia. The general principles of wound repair  are the same for the ear as they are elsewhere on the face.  5-0 or 6-0 monofilament sutures are recommended. In  simple lacerations, there is usually no need for sutures in  the cartilage of the auricle.   In partial ear avulsion, the type of reconstruction  depends on the size of the defect and the region of the  helix affected. In general, acquired defects of the superior  auricle no larger than 2 cm can be repaired primarily by  advancing the helix in both directions by making releasing  incisions. Middle auricle defects 2 cm or smaller can again  be closed primarily with the help of Burrow triangles to  allow approximation of tissue without tension. Larger  avulsive segments may require microvascular anastomo-  sis, although it is very rare to find good vessels for anas-  tomosis particularly in the avulsed segment. Depending  on the amount of cartilage lost, a variety of techniques  involving local skin flaps, contralateral conchal cartilage  graft and rib cartilage graft can be used.   The treatment of avulsive ear injuries depends on the  amount of tissue loss. For total avulsions the severed  ear should be evaluated for the possibility of microsurgical  reattachment. Other options included debriding the ear  of all soft tissue and burying it in a post-auricular pocket  to provide blood supply. This allows the ear to revascu-  larize and re-epithelialize which then can be uncovered.  Prosthetic rehabilitation of the external ear can also be  considered in cases of significant tissue loss.    The eyelids function to protect the globe from injury,  maintain moisture and aide in channelling tears through  the canalicular system. The anatomic layers of the eyelid  include the skin, alveolar tissue, orbicularis oculi muscle,  tarsus, septum orbitale, tarsal (meibomian) glands and  conjunctiva. The grey line is defined by the junction of  skin and mucosal membrane of the eyelid. Tarsal plate is  important for eyelid support. The muscular layer overly-  ing the tarsus is anchored to the lateral and medial canthal    ligaments. The orbital septum is attached to the perios-  teum circumferentially in support of the retro-orbital  contents.   A thorough examination of the globe and lacrimal  drainage system is needed whenever eyelid injuries are  present. Injuries to the globe should be identified and  appropriate treatment and referral to ophthalmologist  performed. A thorough visual examination including  visual acuity is very important.   Lacerations to the eyelid can be broken down into those  that involve the lid margin and those that do not. Simple  lacerations that do not involve the lid margin can be  repaired primarily with small sutures, ideally 6-0 in size.  Deep sutures are not recommended in the lower eyelid  since inadvertent suturing of the orbital septum can lead  to ectropion. If the attachment of the levator muscle to  the superior portion of the tarsus is involved, care should  be taken to repair this to prevent ptosis. In injuries where  the lid margin is involved, accurate re-approximation  of this structure is most important. The most important  structures of the lid margin that must be realigned are the  meibomian glands orifices, lash line and grey line.   Avulsive injuries to this region can be treated with  full-thickness skin grafts from the post-auricular region  which offers the best colour match. The eyelid avul-  sions can usually be closed primarily if less than 25% of  the length of eyelid is lost. If more is lost then options  such as a lid switch flap can be used. This is a two-stage  procedure which transfers a full-thickness portion of  the unaffected eyelid, together with the lashes, into the  defect via a rotation. At the second stage, the pedicle  is divided. Small injuries to the conjunctiva usually  require no treatment. If the canalicular drainage system  is involved, placement of silicone tubes through the sev-  ered tear ducts will preserve the drainage and prevent  epiphora. One intact canaliculus is often sufficient to  provide adequate drainage.    The nasal bone and cartilage are covered by muscle, sub-  cutaneous tissue and skin with the internal lining of  mucous membrane and glandular tissue. Proper examina-  tion of the nose requires use of nasal speculum with good  lighting and suction. Epistaxis should be controlled and  nasal bone fractures, septal haematoma and gross devia-  tion of nasal septum have to be ruled out before repair  of soft-tissue injuries. Nasal septal haematomas if pres-  ent will need to be evacuated to prevent possible septal  necrosis and nasal collapse/saddling. Closed reduction of  a displaced nasal septum may be attempted in the clinic.  Anterior traumatic nasal bleeding from the Kiesselbach’s  area is more common than posterior bleeding; they usu-  ally stop spontaneously, if not temporary nasal packing  may be required. Use of vasoconstrictor sprays such as  Afrin may be helpful as well for controlling small bleeds  (see Chapter 16).    Soft-tissue repair of the nose is based on which subunit  has been injured or deformed. A good understanding of  nasal anatomy is crucial.   © Tip: Central aspect of the nose bordered by the other  subunits and formed by the lateral genu of the lower lat-  eral cartilages   © Columella: Middle and medial crura of the lower lateral  cartilages extending from its junction with the upper lip  philtrum superiorly to the nasal tip   © Alae: Consists of the lateral crus of the lower lateral  cartilage and the soft tissue extending to the nasolabial  crease   © Sidewalls: Extend from medial canthus to lateral edge  of the nasal dorsum and lateral aspect merges with  cheek skin; inferior aspect merges with the nasal ala  and nasal tip   © Soft triangles: Soft-tissue depression inferior to the alar  cartilage extending from apex of nasal aperture with no  cartilage support    The deeper anatomy of the nasal complex is a combi-  nation of bony and cartilaginous support, starting from  the bony radix of the nose and extending inferiorly and  posteriorly into the lower lateral cartilages and the septal  cartilage, respectively.   Tears in the internal mucosal lining of the nose should  be repaired if possible with thin absorbable sutures.  Exposed septal cartilage does not pose any difficulty as  long as the mucosa is intact on the other side of the septum.  Full-thickness lacerations of the nose should be repaired  in a layered fashion, re-approximating the mucosa, car-  tilage and skin. Avulsive wounds of the nose with skin  missing may be repaired with full-thickness skin grafts  ideally from the post-auricular location. With larger more  involved defects, local flaps such as nasolabial flap or para-  median forehead flap may be utilized.    The anatomic layers are well described by the convenient  acronym “SCALP” Skin, Subcutaneous Connective tissue,  galea Aponeurosis, Loose areolar tissue and Pericranium.   The first superficial three layers are united as one and  difficult to separate. These three layers can easily slide  over the loose areolar connective tissue layer which is a  great dissection plane for the surgeon. Epicranial muscles,  where present, lie between the galea and the loose areo-  lar tissue. The pericranium is very vascular and deep full-  thickness injuries to scalp can be a major source of blood  loss. After good washout and achievement of haemostasis,  layered closure of the scalp wound should be achieved. In    large contaminated avulsive injuries, use of drains should  be considered. In avulsive scalp wounds, tissue survival is  usually dependent on the amount of residual pericranial  coverage of the skull. In cases where soft tissue is missing,  local rotation/advancement flaps, skin graft or even vascu-  larized tissue transfer can be considered.    About 15% of animal bite wounds involve the facial struc-  tures. The majority inflicted by dogs involve children.  They are considered complex injuries contaminated with  a unique polymicrobial inoculum. These types of injuries  usually fall into one of the following three categories:    1. Puncture wounds  2. Lacerations  3. Avulsions, with or without actual tissue defect    It is not uncommon to have a combination of the above  along with some degree of crush injuries. Dog bites tend to  be focused around the lips, cheek and nose. Human bites  on the other hand tend to be focused mainly around the  ears and lower lip.   Very similar principles are followed for repair of facial  bite wounds as other injuries to the facial region. After  thorough irrigation and debridement and achieving good  haemostasis, single- or multi-layered closure is achieved  if there are no obvious signs of infection. Local, distant  free flaps or skin grafts can be used if there is significant  tissue loss.   Fortunately, facial bite wounds generally display low  infection rates due to the rich blood supply of the area.  Puncture wounds can have higher infection rates since  they involve deep inoculation of pathogens. Crush inju-  ries can cause infections with lower bacterial counts in  the wound due to resultant tissue ischaemia. Ear and nose  human bite injuries have the highest infection rates due to  the inevitable cartilage exposure.   Antibiotic prophylaxis is an important part of manage-  ment of animal bites. Prophylaxis again Pasteurella spp.  from dog and cat bites, and Viridans streptococci, espe-  cially Streptococcus anginosus and also Staphylococci and    oral anaerobes from human bites is necessary. A close  follow-up of these patients is needed.    Facial injuries are very variable in nature and can involve  many vital structures. Recognition of injuries to these vital  structures of the face is extremely important. Accurate  diagnosis and management of acute soft-tissue inju-  ries will help to ensure optimal functional and aesthetic  results. Care should be taken with proper and meticulous  initial management to minimize complications. It is very  important to pay close attention not only to restoring  function but also achieving good cosmetic results.    We thank Suhail K. Mithani and Eduardo D. Rodriguez  for allowing us to use “TOP TIPS’ from second edition.    Initial evaluation of the extent of facial soft-tissue injury  includes thorough cleansing and removal of wound con-  taminants (e.g. dirt, glass).    e Lacerations can be repaired with up to 24 hours delay  with excellent results.   e A low threshold should be maintained for taking a  patient to the operating room for evaluation and repair  of soft-tissue injuries.   e Radiographic evaluation should be performed to rule  out fracture or presence of foreign bodies.   e All patients with periorbital injuries should be evalu-  ated for ocular injuries.   e Avulsed or amputated tissue can often be restored suc-  cessfully to the native.   e Re-approximation of the vermilion border should be  performed prior to injection of vasoconstrictive local  anaesthetic agent for repair of lip lacerations.    Dentoalveolar injuries are unique injuries. They can range  from minor dental fractures to multiple avulsed teeth.  Often, it is not clear if an injured patient should be taken  to an emergency department or a dental/oral and maxillo-  facial surgery office. Many emergency room personnel are  not familiar with treatment of dentoalveolar injuries or  are not equipped to adequately treat them. Private offices  may be well prepared to treat dentoalveolar injuries, but  unable to treat other injuries. Oral injuries may have con-  comitant injuries as well, including soft-tissue lacerations  or more significant neck, extremity or intracranial inju-  ries. Dentoalveolar trauma is more common in younger  patients; bony fractures are more common in older  patients. This chapter focuses on dentoalveolar injuries.    When assessing a patient with an oral injury, the mecha-  nism of injury is important. This may be a fall, assault, motor  vehicle crash, sports injury etc. It is important to know how  and when the injury occurred. This information is especially  important if a tooth has been avulsed: how long the tooth  has been out of the mouth and how it has been stored. In  addition to the history of the injury, a brief medical history  should be obtained. This would include medical history/  co-morbidities, medications, past surgical history and aller-  gies. The patient should be assessed for other injuries before  focusing exclusively on the orofacial injuries. Orthopaedic  injuries, neck pain, loss of consciousness etc. necessitate  a visit to an emergency department. A systematic exam of  the face/dentition helps to accurately and efficiently evaluate    each patient. For example, initially, extra-oral injuries are  documented. One method might be to evaluate the upper  facial third, the middle facial third and the lower facial third.  The upper facial third includes the forehead, eyes, orbits,  eyelids etc. The middle facial third encompasses the nose,  ears, zygomatic arches etc. The lower facial third includes  the mandible, dentition and oral cavity. Sensory and/or  motor deficits should not be overlooked. Once extra-oral  anomalies are documented, the examiner can look intra-  orally. Again, this includes both the hard and soft tissues.  The occlusion should be examined for mandibular step-ofts  or mal-occlusion indicating possible mandibular fracture.  Evaluation of the floor of the mouth is important to look for  ecchymosis or haematoma. If teeth are avulsed, it is help-  ful to account for the missing teeth to ensure they have not  been aspirated or displaced into the adjacent soft tissues. If  avulsed teeth are viable, they can be positioned back into the  alveolus. The details of treatment will be outlined later in  this chapter. There are a myriad of other dentoalveolar inju-  ries that occur. A thorough systematic post-traumatic evalu-  ation helps to avoid inadvertent unrecognized injury.   Imaging of the injured area may help to further assess  the injury. Imaging modalities may be limited, depend-  ing on the location of the exam and the availability of  resources. If adequate imaging is unavailable, timely  follow-up is important. Dental radiographs evaluate the  teeth for injury. These images show injuries that may not  be noticeable by clinical exam. A root fracture is a prime  example of this. A panoramic radiograph may assess for  mandibular injuries, if they are suspected. Dentoalveolar  fractures are sometimes difficult to see on conventional  peri-apical radiographs and panoramic radiographs.  A computed tomography (CT) scan may be warranted if  more extensive injuries are suspected (Figure 54.1).    Figure 54.1 A paediatric patient in the mixed dentition  sustained severely intruded teeth after falling while playing  basketball (3D CT reformat).    When seeing patients with dental trauma, after an initial  history and initial exam, the wounds should be cleaned.  Cleansing may start with saline or chlorhexidine mouth  rinse. Gentle debridement with gauze or a soft tooth brush  removes debris and may identify additional injuries. Soft-  tissue injuries should be addressed, if needed.    After the permanent incisors begin to erupt, the adult den-  tition is at risk for injury. The maxillary incisors are the  most prominent teeth in the anterior dentition and have a  high likelihood for damage. Ectopically erupting teeth or  patients with a significant mal-occlusion may have even  more prominent incisors. Dental injuries to the teeth have  been well classified by Dr Ellis. To briefly review, an Ellis  Class I fracture is an injury to the enamel of the tooth only.  An Ellis Class H fracture involves the enamel and dentin.  Ellis Class HII dental fractures involve the enamel, dentin  and pulpal tissues. Involvement of other dental specialists  is often necessary for these injuries (general dentists, pae-  diatric dentists, endodontists, prosthodontists etc.). This  chapter focuses on luxations of the teeth, avulsion and  dentoalveolar fractures.   The dentition is acutely traumatized, possibly resulting  in tooth mobility. The tooth will likely have some blood  near the gingival margin due to injury to the supporting  structures. If the tooth is not mobile, no clinical treat-  ment is warranted. If the tooth (or teeth) is mobile, a non-  rigid splint may be placed for approximately 2 weeks. The  patient should be advised to follow a soft diet and main-  tain good oral hygiene. Short-term and long-term follow-  up is warranted after subluxation to evaluate for pulpal  necrosis.    Intrusion occurs when the tooth is traumatized, pushing  it into the alveolar process. This commonly happens with  trauma directly to the incisal edge of the maxillary inci-  sors. The treatment varies depending on the development  of the tooth root and if the apex of the root is closed or  open (Figure 54.1).   If the root apex is open then the tooth can be allowed to  spontaneously erupt. If it fails to erupt spontaneously then  orthodontic treatment for extrusion should be considered.  As per the International Association of Dental Traumatology  (IADT) recommendations, if the tooth is intruded more  than 7 mm, the tooth should be re-positioned and stabilized  with a flexible splint (Figures 54.2 and 54.3).   If the tooth has a closed apex, the treatment recommenda-  tions differ. If the tooth is slightly intruded (<3 mm), the tooth  can be allowed to spontaneously erupt. The tooth should be  monitored and if it does not begin to erupt then an orth-  odontic referral is warranted for consideration of forced orth-  odontic eruption. A tooth with a closed apex that is intruded  more than 3 mm may be a candidate for orthodontic or sur-  gical treatment. Again, if the tooth is intruded greater than  7 mm, surgical re-positioning is indicated with placement  of a composite and wire splint (Figures 54.4 and 54.5).   For all of these injuries, follow-up is imperative for con-  tinued re-evaluation of the tooth vitality and timing of    Figure 54.2 The patient from Figure 54.1 with the teeth  re-positioned and stabilized with a flexible splint (frontal view).    Figure 54.3 The patient from Figure 54.1 with the teeth re-  positioned and stabilized with a flexible splint (occlusal view).    Figure 54.4 Anadult patient with both intruded teeth and  soft-tissue injuries after a mountain biking crash.    Figure 54.5 The patient from Figure 54.4 with the teeth  re-positioned and stabilized with a composite and wire splint.   Extrusion of the permanent dentition occurs when the  tooth is extruded from the alveolar socket. The incisal  edge will be ‘uneven’ with the adjacent teeth. This tooth  displacement may be a significant occlusal interference.  Treatment of extruded teeth includes re-positioning of the  tooth in the socket and securing it with a composite and  wire splint. Given the nature of the injury, once the splint  is in place, the patient’s occlusion should be evaluated to  avoid occlusal trauma to the affected tooth. The splint  should be considered for removal after 2 weeks. Again,  short- and long-term follow-up is imperative.    Dental avulsion is defined by a tooth that is avulsed from  the alveolus in its entirety. The goal is to find and identify  the missing tooth or teeth. Each situation is unique and  should be treated on a case-by-case basis. Severe dental  caries or periodontal disease may be a contraindication for  replacing an avulsed tooth. Patients with severe medical  co-morbidities or immunosuppression may not be candi-  dates for replantation of an avulsed tooth. Debris should  gently be removed from the tooth without scrubbing it.    Scrubbing the tooth, especially the root may remove viable  periodontal ligament (PDL) cells. If the patient is con-  scious and the site is amenable, the tooth should be placed  back in the socket. Alternatively, the tooth can be placed in  cold milk, Hank’s balanced salt solution (a physiologic salt  solution), saline or in the patient’s vestibule (avoid water).  The site needs to be in adequate condition for the tooth  to be placed in the socket. If the alveolus is crushed, the  tooth may not be able to be replanted. Once the tooth has  been replanted, a flexible composite/wire splint should be  placed. Depending on the specific situation, tetanus cover-  age should be verified with the patient.   Several different scenarios exist for the avulsed per-  manent tooth. The tooth can have a closed or open apex.  The overall prognosis of the tooth is based on the viability  of the PDL cells. The PDL cells viability depends on the time  out of the socket and the type of storage medium (if any).   If the injured patient presents with the tooth already in  the socket, the tooth should be examined for proper posi-  tioning, both clinically and radiographically (if possible).  Once this is confirmed, a non-rigid composite and wire  splint should be placed.   If the patient presents with an avulsed tooth with a  closed apex in physiologic media, the tooth should gently  be cleansed of debris. This cleansing should be done with  care to avoid disrupting the PDL cells as much as possible.  Once the patient is anaesthetized with local anaesthesia,  the tooth should be positioned in the alveolus and secured  with a flexible splint.   Patients presenting with an avulsed tooth with a closed  apex that has been stored dry or in non-physiologic media  have an increased challenge. The PDL cells are unlikely  to be viable. Again, the tooth should be gently debrided,  and the root bathed in 2% sodium fluoride for 20 minutes  (minimum of 5 minutes), if available. In this scenario,  the tooth has a poor long-term prognosis and is likely to  ankylose. The long-term prognosis of the tooth should be  discussed with the patient (and parents) at that time. An  ankylosed tooth may help to preserve space and alveolar  bone in anticipation of future dental implant placement.  The tooth should still be positioned in the alveolus and  stabilized with a flexible splint for 4 weeks.   If the avulsed tooth has an open apex, the treatment is  similar. The tooth should be gently cleansed, then placed  back in the socket. Topical antibiotics may improve the  chance of revascularization. If available, the avulsed tooth  is placed in a doxycycline solution (1-mg/20-mL sterile  saline for 5 minutes). A flexible splint should be placed for  about 2 weeks. Ongoing pulpal evaluation is important for  evaluation of revascularization or pulpal necrosis and the  need for endodontic treatment.   Similar to other dentoalveolar injuries, once the tooth is  splinted ensure that the injured tooth is not in traumatic  occlusion. The patient should be instructed to maintain  a soft diet. Oral hygiene instructions are reviewed with  the patient; chlorhexidine mouth rinse may be prescribed.  When a tooth is avulsed and repositioned, the patient should  be sent home with systemic antibiotics that are appropriate  for the patient’s age and weight (Figures 54.6 through 54.8).    A paediatric patient with four avulsed perma-  nent incisors after a bike crash over his handle bars, axial CT.    A panoramic radiograph of the patient in  Figure 54.6, with the teeth repositioned. He is now in the pro-  cess of endodontic treatment.    Root fractures occur with direct trauma to the crown. The  fractures can occur in the cervical third of the root, the  middle third of the root or the apical portion of the tooth.  Root fractures in the cervical one-third of the root are dif-  ficult to treat. The tooth has a guarded to poor long-term  prognosis. The crown of the tooth can be splinted to the  adjacent teeth, although this is for an extended period of  time: 4 weeks or more. Teeth with root fractures in the  middle third or the apical third have an improved long-  term prognosis, but still require long-term monitoring.  These teeth can be splinted with a non-rigid splint, with  re-assessment at 4 weeks after the injury.    A dentoalveolar fracture is a fracture of the alveolar  bone. This injury may be in an isolated area or include  several teeth. The fracture may or may not be visible  on conventional dental radiographs. If a CT scan was  obtained, the dentoalveolar fracture is generally visible;  however, sometimes the bony injuries are subtle. The  treatment recommendations vary depending on the  source. The IADT recommends flexible splinting for  4 weeks. Peterson’s text endorses rigid splinting for  4 weeks. Rigid stabilization of the fracture may involve  the use of an Erich arch bar with interdental wiring.  The teeth should be evaluated for occlusal trauma after  splinting. Patients should be instructed to maintain a  soft diet. Oral hygiene instructions should be reviewed.  Chlorhexidine oral rinse may facilitate improved hygiene  patients with dentoalveolar fractures. The splint should  be considered for removal in 4 weeks. Systemic antibiot-  ics should be considered, given the injury communica-  tion with the oral flora.    Appropriate follow-up should be arranged for patients sus-  taining any sort of dentoalveolar injury. These follow-ups  can range from clinical observation of the injury to root  canals, orthodontic treatment, prosthetic rehabilitation  etc. Appropriate instructions after a dentoalveolar injury  may help the prognosis of the teeth: good oral hygiene,  diligent follow-up and a soft diet. Good communication  and a coordinated effort by all members of the dental team  are imperative to achieve the best result possible.    Similar injuries can occur in the primary dentition,  some with differing treatment plans. The treatment  plans are based on several factors. Aside from medical  co-morbidities, treating a dentoalveolar injury may be  based on the root resorption of the primary tooth and  the potential injury of the developing permanent denti-  tion. Traumatized primary teeth that are repositioned or  remain in situ should be monitored until exfoliation for  signs of pulpal necrosis.    Intrusion of the primary teeth is when the teeth are  pushed into the alveolus. Intrusion of the primary teeth  can affect the developing dentition, depending on patient  age. If the crown of the intruded tooth is slightly pushed  lingually, the root is pushed to the buccal, likely avoiding  the tooth bud. In this case, the tooth can be left to spon-  taneously erupt. Conversely, if the crown of the intruded  tooth is pushed to the buccal, the tooth root is potentially  damaging the developing tooth. This tooth is indicated for  extraction. The consequence of this injury is an enamel  defect of the developing tooth.   Extrusion of a primary tooth happens when the tooth is  extruded from the alveolus. This can be subtle in which  case the tooth can gently be adjusted back into place. If  the tooth is extruded more than several millimetres, the  tooth should be extracted to avoid damage to the develop-  ing permanent tooth.    Unlike permanent teeth, primary teeth that are avulsed  should not be replanted and splinted.   Many factors are taken into account when treating den-  toalveolar fractures in the primary dentition. If the affected  teeth are near exfoliation or if repositioning may injure the  developing teeth, extraction should be considered. If the  segment can be effectively reduced, splinting of the seg-  ment may be an ideal treatment. Splinting requires a patient  who can cooperate for the procedure and adequate isola-  tion, if composite is going to be used. Treatment decisions  are multifactorial when treating dentoalveolar fractures of  patients in the primary dentition (Figures 54.9 and 54.10).    Figure 54.9 An axial CT of a dentoalveolar fracture of the  left maxilla in a paediatric patient. Notice the roots of the pri-  mary teeth and developing permanent teeth.    Figure 54.10 A 4-year-old female who was playing and  was struck in the mouth with her friend’s head. She sustained a  dentoalveolar fracture of the anterior mandible.    Dentoalveolar injuries come in all shapes and sizes. These  can be as subtle as a tooth that has sustained a concussive  injury without mobility or visible injury to significant den-  toalveolar fractures requiring stabilization and possible  tooth loss and reconstruction. No matter what the mecha-  nism of injury, all patients should be thoroughly and sys-  tematically examined to ensure injuries are not overlooked.  A recurring theme for all patients with dentoalveolar  trauma is the need for appropriate and timely follow-up. For  some patients, this follow-up would be a quick follow-up  exam. For others, the follow-up can be extensive involving  endodontic, orthodontic, surgical and prosthodontic input.  Educating parents, coaches, emergency personnel etc. may  help improve the prognosis of injured/avulsed teeth.  Quick dentoalveolar trauma resources:    @ The Dental Trauma Guide: www.dentaltraumaguide.  org, created by the International Association of Dental  Traumatology.   ® Guideline on Management of Acute Dental Trauma:  www.aapd.org/media/Policies_Guidelines/G_trauma.  pdf, Created and kept current by the American  Association of Pediatric Dentistry.    e The success of the treatment is directly proportional to  the delay.   e Always check the soft tissues, particularly the lower lip  for retained tooth fragments when teeth have been  fractured.   e Great care must be taken when cleaning any avulsed  tooth. The PDL cells on the root are very sensitive. Never  scrub the root and avoid handling if possible.   ¢ Root canal therapy should be undertaken at the first  sign of root resorption.    Courts FJ, Mueller WA and Tabeling HJ. Milk as an  interim storage medium for avulsed teeth. Pediatric  Dentistry. 1983; 5(3): 183-186.   The Dental Trauma Guide. Your Interactive Tool to  Evidence Based Trauma Treatment. International  Association of Dental Traumatology, published in  2010, updated in 2014.   Gassner R, Tuli T, Hach] O, Moreira R and Ulmer H.  Craniomaxillofacial trauma in children: A review  of 3,385 cases with 6,060 injuries in 10 years. J Oral  Maxillofac Surg. 2004; 62: 399-407.   Gassner R, Tuli T, Hachl O, Rudisch A, and Ulmer H.  Cranio-maxillofacial trauma: A 10 year review of    9,543 cases with 21, 067 injuries. J Craniomaxillofac  Surg. 2003; 31(1): 51-61.   Leathers RD and Gowans RE. Management of alveolar  and dental fractures. In Miloro M (ed.) Peterson’s  Principles of Oral and Maxillofacial Surgery, Part 4,  Chapter 21. Hamilton, Ontario: BC Decker; 2004. pp.  384-400.   Turkistani J and Hanno A. Recent trends in the manage-  ment of dentoalveolar traumatic injuries to primary  and young permanent teeth. Dental Traumatol. 2011;  27(1): 46-54.    The mandible is important in airway maintenance,  speech, mastication and deglutition. Fractures and inju-  ries to the associated muscles can, therefore, result in con-  siderable dysfunction and pain. Remember that in some  instances — multiple fractures, or associated bleeding, soft-  tissue swelling, alcohol intoxication and brain injury and  in patients in the supine position (see advanced trauma life  support [ATLS™)]) - the airway may be placed at risk and  needs careful and repeated evaluation.   Morphologically, the mandible is a U-shaped ‘long  bone’ and can be divided anatomically into  © Symphysis  © Parasymphysis  © Body  ® Angle  @ Ramus and condyle    @ The many muscle insertions (which can either support  or displace fractures)    @ The teeth (which together with the periodontal ligament  can act as a source of infection)   ©@ The inferior alveolar (inferior dental) nerve (which  together with the mental nerve, can be injured at the  time of fracture, or during their repair) (Figure 55.1)    The muscles of mastication and the suprahyoid muscles  are the principle movers of the mandible. Considerable  forces can be generated; hence certain fractures can  significantly displace and remain painfully mobile.  Conversely, the thick, fleshy masseter and medial ptery-  goid muscles attach to much of the ramus and therefore  splint fractures here. Ramus fractures (as distinct from  the condyle) rarely need operative repair. The genioglos-  sus (which forms the bulk of the tongue) and geniohyoid  are attached to the midline genial tubercles - mobile frac-  tures in this region may lead to loss of tongue support and  airway compromise.   The canine teeth have long roots and the mandibular  third molar teeth are often partially erupted. Together  with the mental foramen, these factors can weaken  bone locally and account for the frequency of fractures  in these regions. In young patients, the periosteum may    resist fracture displacement at the time of impact and in  minimally displaced fractures may facilitate non-opera-  tive management. However, once it is torn (by injury or  surgical exposure), fracture displacement can more read-  ily occur.    ‘If you leave the patient facing towards heaven, it won't be  long before they get there’ (paraphrased, original source  unknown). This aphorism, dating back to early times of  major conflict, refers to the possibility of airway obstruc-  tion developing in patients placed supine following facial  injuries.    Assessment of mandibular (and other) injuries com-  monly occurs in one of two scenarios:    1. High velocity injuries, where coexisting torso injuries  exist and ATLS™ principles apply. Of direct relevance,  here is immobilization of the entire patient and its  potential affect on the airway.    In both scenarios, assessment always starts with the  airway whilst simultaneously protecting the cervical  spine until injury can be excluded. Although an appro-  priate verbal response is encouraging, direct inspec-  tion of the oropharynx must be undertaken. Oral  bleeding and foreign bodies can be missed, which in  the supine patient poses an obvious threat to the air-  way. In awake, supine patient’s, blood may be swal-  lowed initially, but if it continues it places the patient at  risk of vomiting later (possibly at a time when they are  under less supervision). In some mandibular fractures  swallowing may be painful and ineffective. Correctly  fitting rigid collars restrict mouth opening and make  airway assessment difficult, but in all cases should be  loosened to enable thorough examination. During this  time, manual in-line immobilization of the neck must  be correctly performed. Sizing of collars and careful  application are also important. Correctly fitting col-  lars can support some mandibular fractures, whereas  poorly fitting ones can compromise the airway and  exacerbate ongoing swelling.   In obtunded patients, the jaw thrust and chin lift are  commonly performed to maintain the airway, but may  be difficult with comminuted fractures. Those patients at  high risk of vomiting may require intubation to protect  the airway. However, not all patients vomit and the dif-  ficulty, therefore, lies in deciding who should have their  airway secured as a precaution. This decision is even  more critical if inter-hospital transfer or imaging (nota-  bly CT) outside the relative safety of the resuscitation  room is necessary.   The hallmark of a mandible fracture is a change in  the occlusion. However, a normal occlusion does not  rule out a mandible fracture. Most fractures occur fol-  lowing blunt injury to the face, commonly following  interpersonal violence in many countries. Sports inju-  ries, falls and road traffic accidents are other frequent  causes. Clinically the following signs may be elicited to  varying degrees:   © With medial displacement of the condyle, injury to the  trigeminal nerve can result in ipsilateral facial numb-  ness (rare).   © The facial nerve may be damaged by a direct blow  over the ramus, resulting in ipsilateral facial weakness  (rare).    Imaging studies are not required in every patient to rule  out a fracture of the mandible. This would be the case in an  alert and orientated patient in which a thorough clinical  examination has confidently excluded any signs of frac-  ture. However, when a fracture(s) is/are suspected, imag-  ing will be required.   Deciding on the most appropriate imaging to evaluate  the fracture/fractures depends on whether the patient  presents with a suspected isolated injury or has suffered  multiple trauma. If only an isolated fracture is suspected,  the first choice would be to take two plain films of the  fracture at right angles to the other. With the mandible,  this is achieved by taking an orthopantomogram (OPT)  and a posteroanterior (PA) view. However, plain radiog-  raphy is not without its limitations:    1. Panoramic views in this region require a good technique  and a co-operative patient who can stand, a requirement  that may not be possible if the patient is intoxicated or  has multiple injuries. In this case, an oblique view may  be a better alternative.   2. Fractures of the condylar head are often especially dif-  ficult to see on any plain film view.   3. The symphysis is difficult to evaluate because of the  overlap from the cervical spine. A lower occlusal view is  useful for evaluating fractures in this region in particu-  lar the anterior lingual plate.    Computed tomography (CT) imaging may be indicated in  the following circumstances:    1. High-energy injuries or in patients unable to undergo  routine radiography (due to the presence of torso, cervi-  cal spine or brain injuries)   2. Complex fractures (e.g. comminuted fractures, cranio-  facial fractures or high condylar fractures that may be  suitable for surgical repair)    Initial helical CT scan has been shown to identify 100%  of mandibular fractures, whereas plain film panoramic  imaging shows only 86% of these fractures. Recently, the  use of cone-beam computed tomography (CBCT) has  been reported as an accurate and reliable alternative to  conventional CT, providing good quality images with less  radiation.   The use of three-dimensional reconstructed CT scans  (constructed from high-resolution thin sections of a CT    scan) is particularly useful in evaluating the relationships  of fracture segments preoperatively in panfacial injury  management.    Pain relief may be achieved by infiltration of local anaes-  thesia around the fracture, or if possible by an inferior  dental nerve block. If the neck is ‘clear’, a soft collar can  be used to support the mandible. ‘Bridal wires’ are the  maxillofacial equivalent of a backslab in limb fractures  (Figure 55.2). This is a tightened loop, or ‘figure of eight’  wire, encircling the teeth either side of the fracture. This,  and/or intermaxillary fixation (IMF), should be consid-  ered when delays in repair (ie. surgery the next day) are  anticipated. Any loose dento-alveolar fractures should  also be splinted.    Ideally, all fractures should be repaired as soon as pos-  sible, but this rarely happens. For all open fractures (e.g.  overlying laceration, or involvement of the periodon-  tium), it has been assumed that the longer the delay the  more likely infection will occur. However, more recent  studies have shown that a delay beyond 24 hours does  not increase the risk of complications. By and large,  in the absence of airway problems, active bleeding  and excessively mobile (and painful) fragments, most  patients’ surgery can be safely deferred until the next  day. General anaesthesia can be risky and is best avoided  late at night.   © Soft diet until a firm callus forms (usually around 4-6  weeks)    Figure 55.2 Bridal wires. (a) Pass wire as a figure-of-eight  around one or preferably two teeth, either side of the frac-  ture (must be firm). (b) Reduce fracture and tighten wire ends.  Ensure wire is below maximum bulbosity of the teeth (in the  cervical margin). (c) Wire tightened.    When closed treatment is inappropriate or has  failed. Closed treatment does not reduce fractures  anatomically — it is wrong to assume that just because  the teeth meet, the bone fragments are in the correct  position. IMF does work, but is required for at least 4  weeks and has its own set of problems - and it is not  without risk. Alternatively, open reduction and inter-  nal fixation (ORIF) may be undertaken. Both ORIF and  IMF have advantages and disadvantages which should  be carefully weighed and if possible discussed with the  patient.   With ‘ORIP’, surgical exposure of the fracture site and  (hopefully) anatomical reduction is carried out. There are  two schools of thought:    1. Mandibular fractures need rigid fixation. Dynamic  compression or rigid osteosynthesis offers this.  However this requires an external approach (scar and  risk to mandibular branch of facial nerve), (Figure 55.3)  whilst bicortical screw fixation poses risks to dental  roots and inferior alveolar nerve. A second procedure to  remove the metalwork, later. The mandibular curvature  makes this technically demanding and there are con-  cerns about stress shielding. Nevertheless, this is reli-  able treatment and patients return to normal function  quickly.   2. Mandibular fractures do not need rigid fixation.  Studies have shown that ‘micro movement’ following  ‘semi rigid’ fixation encourages callus formation and  healing. Instead of large rigid plates, smaller ones are  placed along well-defined ‘zones of tension’ arising at  the fracture site (Figure 55.4), effectively converting  them into ‘zones of compression’. In selected cases, this  can be done under local anaesthesia. For this fixation  to work the periosteum needs to be mostly intact with  good abutment of the fracture ends. Non compression,  ‘miniplates’ can be placed transorally (or via an overly-  ing laceration) and secured with monocortical screws,  thereby avoiding some of the problems associated with  the larger compression plates. Fine tuning of the bite is  possible with elastic IMF and routine removal of the  plates is not necessary. However, plates can occasionally  get infected and patients still require a soft diet for the  same period of time.    This method of fixation should be regarded as ‘open’,  even if the fracture is not accessed for inspection. It is  used less frequently, but is a useful alternative to IMF  (Figure 55.5):   2. To maintain space and fragment orientation in man-  dibular continuity defects (e.g. gunshot injuries).    Figu re 55.3 External approach to lower mandibular border. (a) Place skin incision in suitable crease (remember nerve anatomy).  (b) Following incision, carefully deepen wound through platysma. (c) Watch out for the mandibular branch of VII (bipolar is showing  nerve, not frying it!). (d) The facial vessels may need division and ligation. (e) Incise and lift periosteum to expose fracture. (f) Fracture  repaired (this is not compression plating).    4. In infected/contaminated fractures, at risk of spreading  infection and/or osteomyelitis.   External fixation involves inserting rigid pins into the  bone fragments via the skin, which are then joined by  a system of joints and connecting rods. Fixation can be  applied rapidly. Reduction is ‘blind’ although the frac-  tures can be adjusted post-operatively. Pin insertion may  damage the inferior dental nerve or teeth, patient activity  is restricted and the pin sites may become infected with  scarring. The frames are disliked by patients, and they can  injure themselves.    These may be partly splinted by the medial pterygoid and  masseter muscles, but are often displaced and mobile.  Fractures have been classified as vertically and horizon-  tally favourable, or unfavourable, depending on the orien-  tation of the fracture and tendency for it to displace by the  pull of these muscles (Figure 55.6). This can occur when  the periosteum has been ruptured or stripped from the  bone allowing displacement to occur.    Access can be made through a variety of incisions, sited  along or lateral to the external oblique ridge. As a general  principle, surgical wounds should not lay over any met-  alwork. Either an incision ‘down-to-bone’ or a two-layer  approach may be used. The fracture is then manipulated,  whilst re-establishing the occlusion (either by IMF or, if  experienced ‘hand-held’) until it appears anatomically  reduced. With simple fractures, a single-twisted (pro-  peller) miniplate placed along the external oblique ridge  (tension line) is usually sufficient in most cases. More  recently, however, there has been interest in the place-  ment of one or two plates, along the buccal surface of the  reduced fracture. This approach requires drilling and  screw placement via a transbuccal approach, whereby a  trochar is passed through the cheek. Each approach has  advantages and disadvantages and the final choice is a  matter of surgical preference. Certainly in comminuted  and very unstable fractures more than one plate may be  necessary. In such cases, a limited external approach to  enable lower mandibular border fixation may be required.    With symphyseal (midline) fractures the mylohyoid  and geniohyoid muscles may help stabilize the fracture.  However obliquely orientated fractures will tend to over-  lap. With bilateral parasymphyseal fractures the fragments  can displace posteroinferiorly - so called ‘bucket-handle’  fractures. There are a number of approaches to the ante-  rior mandible:    . Gingival sulcus incision. Although relatively simple, if  poorly closed can result in gingival recession.   . Single layer incision at the junction of the attached and  non-attached mucosa. This is also relatively simple, but  requires a careful and watertight closure to reduce the  likelihood of infection or dehiscence.    . A two-layer incision placed in the sulcus. This is the  authors’ preferred approach. Very often the branches  of the mental nerve can be seen through the mucosa  and protected. A two-layer closure is also usually  secure.    Figu re 55.5 Expose fracture intra-orally to precisely define its site and extent. Then (a) stab incision for pin placement, (b) pass  pointed trochar down to bone, (c) replace inner pointed trochar with drill guide and drill bicortical hole, (d) remove drill guide and  place pin (depth gauge may be used), (e) repeat so that there are two pins either side of fracture, (f) completed arrangement.    4. Via any overlying lacerations. Even small ones should  be considered - it is surprising how much access you  can get once the deeper tissues have been mobilized.    With ‘anterior’ fractures (usually taken to mean those  between the mental foramina), two miniplates are usually  required to resist torsional forces following muscle pull.  Place the lower miniplate along the thick lower border if    possible. Care is required with drilling the upper mini-  plate (dental roots). In theory, holes can be drilled over the  roots (monocortical screws), although in practice, many  surgeons place the holes 5 mm or more below the apices,  to avoid damage. This principle is often extended to the  premolar region, and the number of plates used depends  very much on the fracture configurations.    Protocols may vary between different units. The use of  pre-operative antibiotics has proven effective in reducing  post-operative complications following repair of man-  dibular fractures. A fracture involving the periodontium  of an erupted tooth should be considered an open frac-  ture, requiring the administration of systemic antibiotics  at least until the fracture has been reduced and immo-  bilized. Penicillin (or a cephalosporin) and metronida-  zole is one option, but many exist. There has been much  debate regarding the duration of antibiotics in the post-  operative period. Studies, however, have shown no benefit  for prolonged antibiotics (beyond post-operative day 1)  in reducing the incidence of infections in uncomplicated  mandibular fractures.   Tetanus prophylaxis should be considered especially  in unclean wounds. Steroids (dexamethasone/methyl-  prednisolone) are sometimes given in the perioperative  phase to reduce facial swelling. Studies have shown that  in healthy patients with clinically uninfected fractures  there is no significantly increased risk of impaired wound  healing associated with the prescription of perioperative  steroids. The main factors associated with delayed or poor  healing is being over 25 years of age and smoking.    Teeth in the line of a fractured mandible is a com-  mon problem. Canines and third molars in particular    create points of weakness making fractures at these  sites relatively common. Vital, functional or unerupted  teeth can be left in situ as long as there is no associated  pathology with the tooth. The concern is with retained  non-vital or periodontally involved teeth which may  encourage infection in the fracture resulting in non-  union or abscess formation. The indications for tooth  removal are as follows:   2. The tooth is fractured. Devitalized roots act as a nidus  for infection.   5. The presence of associated pathology such as cysts or  pericoronitis.    If the tooth is elevated, precise reduction and immobiliza-  tion of the fracture can be difficult particularly if bone has  been removed in the process. For this reason, if the tooth  has to be removed, it is sometimes easier to plate the frac-  ture first, then remove the plate before elevating the tooth.    Children have ‘bendy’ bones compared with adults. A  fracture anywhere in the body implies relatively more  force than in an adult (especially ribs). Mandibular frac-  tures are unusual as the facial skeleton is less prominent.  Any minor occlusal changes are usually compensated for  with growth and repair is less common. Resorbable plates  are often used.    The severely atrophic edentulous mandible often has a  poor outcome especially when the height of the man-  dible is 10 mm or less. These are characterized by poor  blood supply and slow healing, especially in patients  with poor general health and osteoporotic bones. IMF is  not possible (no teeth) and any periosteal stripping jeop-  ardizes the blood supply. A direct relationship between  the height of the bone in the fractured area and the  incidence of complications has been reported. A non-  union or fibrous union is more likely to occur when the  height of the mandible is less than 10 mm. The treat-  ment options for the fractured edentulous mandible are  as follows:    1. Soft diet and regular review to allow a fibrous union.  This is an appropriate option in frail patients and those  with minimally displaced closed fractures. This option  avoids the need for surgery. If necessary, the patient’s  dentures can be relined to improve the fit.    (respiratory diseases, etc.) as a general anaesthetic is  required to wire the splints and longer periods of IMF  maybe required.   3. External fixation. Used in cases where there are major  concerns about healing (e.g. infected wounds), or highly  comminuted fractures.   4. Internal fixation using miniplates. Usually effective in  simple fractures providing the height of the mandible is  above 20 mm.   5. Internal fixation using heavier reconstruction plates.  Appropriate for comminuted fractures particularly if  the height of the mandible is less than 20 mm.    However, the 2007 Cochrane database review failed to  show a better outcome regarding the management of eden-  tulous fractures with any single approach over the other  alternatives. Treatment must, therefore, be considered on  a case by case basis with very close follow-up.    ® Genioplasty dressing to prevent chin ptosis following  extensive anterior exposure (optional).   ® Antibiotics - no benefit in continuing antibiotics  beyond day 1 post-op in non-complicated fractures.    ® Oral hygiene is very important. Tooth brushing and  chlorhexidine mouth rinses are the main element.  © Regular follow-up for 6 weeks.   ¢ Comminution implies high energy and the risk of sig-  nificant airway swelling.   e Vomiting is best managed by tilting the trolley head  down, rather than attempting to log roll the patient.   e Mental parasthesia is both an important diagnostic  sign and an important medico-legal observation prior  to treatment.   e Missing teeth must be accounted for. Both a chest x-ray  and soft-tissue view of the neck may be required.   e A sublingual haematoma is pathognomonic of a man-  dibular fracture and may also compromise the airway.   e Unerupted wisdom teeth can rotate in their sockets and  displace angle fractures enough to affect the occlusion.   e If removing an associated tooth, plate the fracture first,  take the plate off and remove the tooth. This can help  in unstable fractures.    Condylar fractures are an important subgroup of man-  dibular fractures both in presentation and management.  Fractures may present in isolation or in conjunction with  other mandibular fractures, or as a component of a pan-  facial injury. The age of the patient is also an important  factor in the management of this subgroup of fractures.  Various issues have challenged the management of con-  dylar fractures, which include a variety of classifications,  concern in relation to surgical access and the limitations  of technology. The contemporary management of condy-  lar fractures exemplifies the advances in technology and  surgical access that the last decade has seen in oral and  maxillofacial surgery.    The literature has various figures for the incidence of con-  dylar fractures from 30% to 50% of all mandibular frac-  tures; the commonest cause of presentation in the United  Kingdom is a result of interpersonal violence, with at least    559  559  559  560  560  561  563  563  564  564  564  564  564    50% of patients having an associated mandibular fracture.  Over 80% of fractures are unilateral, with the highest inci-  dence in the age range of 20-39 with at least a 2:1 sex ratio  (male:female).   Classification of condylar injuries has been difficult.  This is in part due to the types of classification in use.  These may relate to anatomical position, ie. condylar  neck or may relate to displacement of the condylar frag-  ment. Previously classifications have included Speissl and  Schroll, MacLennan and Lindahl. In 2005 as part of the  Strasbourg Osteosynthesis Research Group (SORG) study,  Loukota et al.’ published a sub-classification of condylar  fractures which is both pragmatic and clinically useful  as it aids visualization and consideration of treatment  options when combined with degree of overlap (in mm)  and angle of displacement.    1. Diacapitular (through the head of the condyle) frac-  ture; the fracture starts in the articular surface and may  extend outside the capsule.    Figure 56.1 Classification of condylar fractures. (Modified from Loukota, R.A. et al. Br J Oral Maxillofac Surg., 43, 72-73, 2005.)    2. Fracture of the condylar neck. The fracture line starts  above line A, and in more than half the fracture dis-  tance runs above line A. High condylar fracture.   3. Fracture of the condylar base. The fracture line runs  behind the mandibular foramen and in more than half  the distance below line A. Low condylar fracture.   4. Line A. A perpendicular line through the sigmoid notch  tangential to the ascending ramus (Figure 56.1).    A good history and clinical examination will be required  as for all trauma patients. Condylar fractures may well  be discovered in the ‘secondary survey’, as in Advanced  Trauma Life Support (ATLS) protocols.   Clinical signs include pain, limited mouth opening,  deviation on opening, lateral or anterior open bites, chin  or external auditory meatus lacerations.   The mechanism of injury, associated injuries and the  clinical findings will direct the imaging required.   Imaging in two planes is the normal investigation,  usually an orthopantomogram (OPT) and posterioante-  rior (PA) mandible. With the advent of spiral computed  tomography (CT) scanning, some surgeons may have a  CT as an initial investigation. A CT may well be helpful  with bilateral fractures, gross medial displacement and  impacted fractures where a contralateral open bite is pres-  ent due to the ‘crushing’ of the condylar head. Cone beam  computed tomography (CBCT) is a new addition to the  available imaging options and may be useful in both diag-  nosis and follow-up.    The commonest clinical scenario is the management of  the unilateral condylar fracture, with or without another  mandibular fracture. Debate over this has been intense  over the last decade with two consensus conferences and    Pain-free mouth opening >40 mm  Pain-free lateral excursions >6 mm  Stable and pain-free occlusion  Normal facial and jaw symmetry    Condylar neck fractures in children <15 years  Very high condylar neck fractures without dislocation  Intra-capsular fractures    a recent prospective randomized multi-centre study. In  1993, only 9% of the surgeons questioned would consider  open reduction internal fixation (ORIF). Whilst opinion  is still divided, more evidence supports open reduction in  defined clinical circumstances.   Patient specific variables also impact on treatment  decisions: age, ability to cooperate; other facial fractures  and comorbidity all influence the management decision  (Table 56.1).   Surgical variables include experience, fracture location  (and imaging) and available instruments, e.g. endoscopy.    This is a blanket term, which implies no ‘open’ interven-  tion (Table 56.2). In common practice, it would involve  the placement of arch bars, splints, IMF screws or rapid  IMF™. All of these allow the placement of elastic inter-  maxillary traction/inter-maxillary fixation (IMF).   The precise post-operative course can vary from 2 weeks  to 3 months using guiding elastics, with most surgeons  using elastics for 2-4 weeks. It is now well accepted that  there is no place for rigid IMF.    Closed management was the previous treatment of  choice for both displaced and non-displaced fractures.  Many surgeons had concerns about damage to the facial  nerve with open reduction and it was not clear that surgi-  cally reduced fractures gave better results. Complications  of closed management can include painful or limited  opening, deviation on opening, malocclusion and loss of  posterior facial height. Outcome studies performed by  Ellis confirm malocclusion, occlusal canting and loss of  posterior facial height in patients treated with closed man-  agement compared to open reduction. The facial asymme-  try was notable at 6 weeks.    Open reduction is not a new concept having been pro-  posed in certain defined circumstances by Zide and Kent  in 1983.* The impact of technology as stated in Table 56.3  and the increased understanding of both the biomechani-  cal and functional advantages of plating supported by  good randomized studies have encouraged surgeons to  revaluate open reduction, and for others to explore endo-  scopically assisted reduction.   The principles of open management are similar for all  fractures and include accurate reduction, stable internal  fixation, preservation of blood supply and early active  mobilization.   With open reduction of condylar fractures, the main  specific concerns are facial nerve weakness/paralysis and  scarring.   Much work has been carried out on evaluating open  reduction (Table 56.4) and various surgical approaches  have been described including submandibular, retroman-  dibular with trans-parotid access, pre-auricular, coronal  and rhytidectomy. If midfacial access is required then a    coronal approach may well be helpful; however, for the  majority of cases a retromandibular incision parallel to the  posterior border of the mandible with trans-parotid dis-  section will allow safe exposure of the fracture. However,  no trial evidence exists comparing the various access  approaches, these can be broadly considered as either deep  to or transversing the course of the facial nerve.   Materials used for fixation include, transosseous wires,  K wire, screws and plates. The commonest method of fixa-  tion is 2.0 mm titanium semi-rigid plates. Asprino et al.’s?  biomechanical evaluation included one or two 2 mm plates  with 4, 6 or 8 mm screws. The most favourable mechanical  behaviour was with two-plate fixation, although increas-  ing screw length improved stability if only one thicker  plate was used. Current evidence supports the use of two  plates or specifically designed three-dimensional plates  with 8 or 6 mm screws.   A 70% success rate has been reported by Davis et al.‘  with free grafting alone or in conjunction with a ramus  osteotomy in cases when adequate reduction and fixation  could not be obtained.    Informed consent must be obtained including discussion  of likely complications including scarring and facial nerve  damage, though longer term studies by Downie et al.5 pro-  vide good evidence that permanent damage is rare.   Under endotracheal general anaesthesia the patient is  prepped and draped, allowing access to the oral cavity for  downward distraction of the ipsilateral angle to aid reduc-  tion. An intravenous dose of antibiotic is given at induc-  tion. Ideally, two assistants are required for retraction and  mandibular manipulation. A small plug is placed in the  external auditory meatus. The retromandibular incision is  marked 1 cm distal to the posterior border of the ramus,  approximately 2 cm in length (Figure 56.2).    Wide dissection in the superficial layer above the  parotid fascia is carried out to facilitate retraction. The  parotid fascia is divided sharply and with blunt dissection  under direct vision the facial nerve branches if encoun-  tered are retracted out of the operative field. Once the  masseter muscle is exposed, the surgeon uses a finger to  palpate the underlying fracture and a vertical incision is  made down to bone. Sub-periosteal stripping exposes the  fracture though the condylar fracture can be ‘trapped’ in  the muscle and then requires careful dissection.   With retraction in a superior/inferior direction and use  of a thin-bladed retractor behind the posterior border, the  mandible can be displaced downwards and backwards  with occlusal pressure, which increases the space and  aids fracture reduction. Once fracture reduction has been  achieved, adequate fixation is required. Some surgeons use  intra-operative IMF, others will handhold the occlusion  whilst it is fixed.   Options for plate fixation include one 2-mm dynamic  compression plate (DCP) plate or two 2-mm plates placed  as far apart as possible. Newer shaped plates may offer  some ease of application. It is important to insert at least  two screws (6-8 mm) in the distal aspect of the proximal  fracture. Placing the superior screw without the mandible  in occlusion then re-reducing the fracture and placing the  second screw, prior to fixation of the distal fragment, can  facilitate this. A fracture gap can open at this point anda  two holes-spaced plate with the space over the fracture  is useful to close this gap by placing the superior screw  and then securing manual reduction of occlusion with  inferior traction on the distal screw holes of both plates  to close the fracture gap prior to placing the final three  screws (Figure 56.3).   The wound is closed in layers with attention to clos-  ing the masseter muscle and the parotid fascia/superficial  musculoaponeurotic system (SMAS) prior to skin closure  with non-resorbable sutures.   In 2009, using this technique 50 patients were reported  by Downie et al.4 No patients had permanent facial    weakness, seven patients had transient facial weakness  most commonly the buccal branch with a mean recov-  ery of 4 months, two sialoceles which settled with time, a  wound infection and a plate failure, which did not impact  on the clinical result (Figures 56.4 through 56.6).    Although open reduction became more accepted, groups  of surgeons have looked at using newer technology and  applying this within maxillofacial surgery. Endoscopically  assisted reduction is a good example, as it reduces the risk to  the facial nerve and minimizes scarring. Work done on the  development of this technique confirms that there is a long    and steep learning curve and that laterally displaced frac-  tures are much easier than medially displaced fractures; like  all endoscopic procedures, surgeons must be able to convert  to an open procedure to complete the surgery if needed.   With this, development plating companies have  designed and produced special instruments to facilitate  endoscopically assisted reduction; however, most institu-  tions have only the basic light sources, monitor banks and  camera attachments.   The endoscopic approach uses an intra-oral approach  or a submandibular approach along with a trans-buccal  access for some fixation.   Using the intra-oral approach, a ramus incision similar  to one for a mandibular osteotomy is made and the mas-  seter muscle stripped to create the optical cavity. A4 mm  30° endoscope with an adapted retractor provides direct  vision and this is aided by a Freer elevator with built in  suction. Under vision and with special instruments the  fracture is manipulated and reduced, this may require  extensive dissection at the posterior border or the sigmoid  notch. Occasionally downward traction may be needed,  this can be digital occlusal pressure or a wire at the angle.   The transoral approach can be used to place screws  using an adaptable plate holder or a 90° screwdriver can  be used though this can be difficult in a tight soft-tissue  envelope. Occasionally a second trans-buccal stab may be  needed to use a threaded fracture manipulator ‘the screw  on a stick’, which can be used to place the initial screw in  the proximal fragment.   In 2006, Muller et al.° reported results of 150 fractures,  where treatment times were down to 70 minutes, and 91%  obtaining primary plate fixation. Unfortunately, 9% were  aborted and required either open or closed management    and fewer than 2% developing plate fracture or transient  facial nerve weakness.   Modifications of this approach repeated in 2011 with  transoral access with a 90° screwdriver and drill have  given equivalent results but with mean treatment times of  50 minutes.   Further refinement of all these techniques will be  required as challenges exist with difficulty reducing medi-  ally displaced fractures, a limited surgical cavity compared  to other endoscopic procedures, the need for special train-  ing and instrumentation, and the reduction of morbidity  and treatment time (Figure 56.7).    Children with condylar fractures are a very different  group. Children exhibit a regenerative capacity that adults  do not and will regenerate condylar form and function  whilst adults compensate at an occlusal level with loss of  posterior facial height.   In 2005, Dodson’ reviewed paediatric condyle/ramus  fractures and reported good outcomes; however, increas-  ing age was associated with poorer outcomes. These  younger patients often require long-term follow-up as they  can in rare circumstances present in later years with devel-  opmental abnormalities including asymmetry, condylar  head resorption or ankylosis.    One of the clear indications for open reduction of condylar  fractures is an associated midfacial fracture. The correc-  tion of vertical height aids the correction of the midfacial  deformity and should be carried out when the mandibular  fractures are reduced, perhaps before definitive midface  correction.    When associated with a symphyseal fracture this can lead  to mandibular widening and great care must be taken  to ensure accurate reduction at the symphysis or a post-  operative malocclusion will be evident, in spite of anatom-  ical condylar fracture reductions.   If two fractures are present it is ideal to fix both; how-  ever, at least one needs to be fixed to regain facial height.    Good post-operative care with elastic traction for closed  management and jaw exercises and clear post-operative  instructions for open or endoscopic treated fractures are  needed.    e Treat the patient and the occlusion, not the radiograph.  Ensure you have adequate assistance.   e Give clear post-operative instructions.  Consider endoscopic approaches only when you have  mastered open surgery.    1. Loukota RA, Eckelt U, De Bont L and Rasse M.  Subclassification of fractures of the condylar process  of the mandible. Br J Oral Maxillofac Surg. 2005; 43:  72-73.   2. Zide MF and Kent JN. Indications for open reduc-  tion of mandibular condyle fractures. J Oral and  Maxillofac Surg. 1983; 41: 89-95.    3. Asprino L, Consani S and de Moraes M. A comparative  biomechanical evaluation of mandibular condyle frac-  ture plating techniques. J Oral Maxillofac Surg. 2006;  64: 452-456.   4. Davis BR, Powell JE and Morrison AD. Free grafting  of mandibular condyle fractures: Clinical outcomes  in 10 consecutive patients. Int J Oral Maxillofac Surg.  2005; 34: 871-876.   5. Downie JT, Devlin MF, Carton ATM and Hislop  WS. Prospective study of mobidity associated with  open reduction and internal fixation of the fractured  condyle by the transparotid approach. Br J Oral  Maxillofac Surg. 2009; 47: 370-373.   6. Muller RV, Czerwinski M, Lee C and Kellman RM.  Condylar fracture repair: Use of the endoscope to  advance traditional treatment philosophy. Facial  Plast Surg Clin N Am. 2006; 14: 1-9.   7. Dodson TB. Condyle and ramus - Condyle unit  fractures in growing patients: Management and out-  comes. Oral Maxillofacial Surg Clin N Am. 2005; 17:  447-453.    Adbel-Galik and Loukota RA. Fractures of the mandibu-  lar condyle: Evidence base and current concepts of  management. Br J Oral Maxillofac Surg. 2009; 48:  520-526.   Assael LA. Open versus closed reduction of adult man-  dibular condyle fractures: An alternative interpreta-  tion of the evidence. J Oral Maxillofac Surg. 2003; 61:  1333-1339.   Baker AW, McMahon J and Moos KF. Current consensus  on the management of fractures of the mandibular  condyle. Int J Oral Maxillofac Surg. 1998; 27: 258-266.   Brandt MT and Haug RH. Open versus closed reduction  of adult mandibular condyle fractures: A review  of the literature regarding the evolution of current  thoughts on management. J Oral Maxillofac Surg.  2003; 61: 1324-1332.   Ellis E, Simon P and Throckmorton GS. Occlusal results  after open or closed treatment of fractures of the  mandibular condylar process. J Oral Maxillofac Surg.  2004; 58: 260-264.   Kanno T, Sukegawa S, Fujioka M, Takabatake K and  Furuki Y. Transoral open reduction with rigid inter-  nal fixation for subcondylar fractures of the man-  dible using a small angulated screwdriver system: Is  endoscopic assistance necessary? J Oral Maxillofac  Surg. 2011; 69: e372-e384.    The essential basic history, examination and directed  special tests are the same as for any injured patient (see  Chapter 51). Particular care in clinical examination should  be sufficient to make most diagnoses of middle third frac-  tures (see the section ‘Classification’).    Plain radiography has a limited place in the diagnosis and  treatment planning, as illustrated (Figure 57.1). Computed  tomography (CT) scanning has enabled greatly improved  visualization of the nature of the midface injury, which  is usually much more complex than has previously been  realized (Figures 57.2 and 57.3). Having said that, all that  is revealed by a scan does not necessarily need internal  fixation. Dental models from impressions taken once the  patient is stabilized may be very helpful in diagnosing  and restoring the occlusion at operation. Other imaging  modalities may be necessary when indicated, e.g. contrast  arteriography.    Midface fractures are often classified as central midface  and lateral midface or zygomatico-orbital fractures.    © Low level, just above the tooth-bearing maxilla and  alveolar process: Le Fort I (Figure 57.4a through d).   © Midface, involving the inferior orbital margins and nasal  complex (pyramidal): Le Fort II (Figure 57.5a through d).   © High level, involving the arch of the zygoma, lateral,  floor and medial orbit and root of the nose/frontal sinus:  Le Fort II (Figure 57.6a through d).    Naso-orbital ethmoidal (NOE) injuries are central midface  fractures forming an integral part of the higher level injuries:  Le Fort II and II fractures. NOE fracture management may  be particularly complex and is dealt with in Chapter 59.    Examination identifies and differentiates between these  levels. This may be difficult and academic as ‘imperfect’  fracture lines often mean asymmetry, as well as impossible  subclassifications (for example, is there a unilateral Le Fort  IH or a Le Fort I associated with a same side zygomatico-  orbital complex fracture?).    Occipito mental (OM) view of injury (not show-  ing any obvious fracture).    Three dimensional computed tomography  (3D CT) showing Le Fort Il and | fractures.    Look in particular for bruising, lacerations and loss of  facial contour around the orbits and midface. This may be  difficult to see because of swelling (balloon facies) disguis-  ing the underlying facial contour. Gentle palpation may be  helpful around the orbits. Bilateral ‘panda eyes’ (indicating  fractures within the orbit or base of skull), nasal deformi-  ties and lengthening of the face (the maxilla is often driven  down and back) may also be seen.    An isolated fracture may cause minimal facial defor-  mity (Figures 57.7 and 57.8). Most higher level fractures    will have a Le Fort I component (see under the section  “Treatment’). There may be lengthening of the face associ-  ated with the maxilla being driven down and back. Oral  examination may reveal mobility of the whole maxillary  dentition: dentoalveolar fractures may lead to more local-  ized areas of mobility, split palate can give a traumatic  central diastema and palpation of the zygomatic buttress  may reveal irregularities from the fractures. An impacted,  immobile maxillary fracture may exhibit a dull note when  tapping the teeth (‘cracked cup sign’).    Isolated fractures are rare and these injuries are often  associated with other maxillary fractures and fractures  of the surrounding structures. The illustrated case  does not have a significant NOE component; however,  this should be assessed over time if there is significant  swelling, as any functional problem or deformity may  be disguised. Issues, such as medial canthal ligament  attachment (tested using the draw sign - palpation of  the tensed ligament), orbital involvement, e.g. a palpa-  ble step in the orbital rim or eye movement problems  giving double vision, frontal sinus fracture (usually  confirmed and assessed using imaging) and nasal dis-  ruption, should be addressed.    Le Fort III fractures present a similar picture with  even more chance of significant involvement of the    Figure 57.7 (a and b) Anteroposterior (AP) and lateral views showing no significant clinical naso-orbital ethmoidal injury or    surrounding structures. The main concern is of cranial  involvement and scanning is mandatory. The higher  level fractures both have the capability for increas-  ing the width of the facial skeleton, as well as antero-  posterior and height issues. This dimension is easily   The authors hope it is clear that the more complex  higher level injuries will need assessment and treatment of  the surrounding structures.    As well as the frontal sinus and base of skull already  mentioned, the assessment of the NOE complex, the orbit  and the zygomatic orbital complex need to be looked at in  detail.    High- or low-velocity impact will determine the likelihood  of significant other injuries and the possibility of bone loss  and the need for grafting.    Older patients often have very thin bone, particularly  when edentulous. This may have particular relevance  when determining what kind of fixation to use and  whether more simple ‘closed’ methods should be contem-  plated. Young patients may not have fully formed sinuses  and exhibit unusual patterns of injury. The child’s max-  illa will be full of developing teeth, again posing potential  problems for the use of internal fixation.    Gruss and Mackinnon made an important conceptual  advance in the mid-1980s describing the vertical sup-  portive pillars of the midface: anteromedially the paired  frontonasal maxillary pillars, laterally the zygomatico-  maxillary pillars and posteriorly the pterygoid processes.  In individuals with fully developed sinuses, these pil-  lars are relatively weak in the midface. Unfortunately,  for those repairing midface fractures, the most robust  of these supportive pillars, the pterygoid plates (in fact,  muscular processes) are inaccessible for direct operative  repair. Subsequently, horizontal facial buttresses have  been added: superiorly, the frontal bar of the upper facial    subunit, inferiorly, the maxillary alveolus and palatal pro-  cesses, with a contribution from the horizontal process  of the palatine bone. The middle horizontal buttress is  composed of the zygomatic arches, body of the zygomatic  bones and the infraorbital rim. These transversely orien-  tated supportive elements link the zygomaticomaxillary  processes and nasomaxillary processes.   There are many issues with regards to the facial  soft tissues and the effects of trauma, as well as wide  undermining to access fractures. A feature of severe  midface trauma is an appearance that suggests prema-  ture ageing when patients are reviewed later. This may  be related to the changes within the soft-tissue facial  drape as a consequence of severe contusion. However,  where wide access is employed, the entire superficial  muscular aponeurotic system (SMAS) retaining adhe-  sions and septa are detached. Soft-tissue resuspen-  sion must therefore be part of any successful operative  strategy.    The condition of the patient and their other injuries will  be considered first. The authors work in a unit that delays  treatment until brain swelling has had time to settle (usu-  ally 7-10 days). Only interventions that are absolutely  necessary (for example, laparotomy, limb fracture stabili-  zation and mandible fracture open reduction and internal  fixation [ORIF]) are carried out earlier.   Operative planning for the facial injuries is facilitated  with elective scans, involvement of other specialties (for  example, neurosurgery, ophthalmology, otorhinolaryn-  gology and maxillofacial technicians), use of dental casts  and even photographs of the patients face prior to the  trauma.   The management of the airway, if not already dealt  with by tracheostomy, is a major issue. There are other  methods of securing the airway, e.g. submental intu-  bation; however, these issues need specialist planning.  More simple fractures may be dealt with by nasal intu-  bation. An experienced anaesthetist is needed when sig-  nificant nasal disruption is present. In this type of case,  a change of tube to an oral intubation may be necessary  once the maxilla is fixed internally, in order to deal with  the nose.   Often midface fractures are present with multiple other  facial and skull injuries. The definitive intervention is  best planned meticulously, as several specialties may be  involved. Sequencing of the various parts of the reduction  and fixation are very important when dealing with mul-  tiple fracture levels (see a suggested sequence in Figures  57.9 through 57.15).   The upper facial half can be divided into an upper unit  (comprising the frontal bone and a maxillofacial unit). The  lower facial half is subdivided into an occlusal unit and a  lower basal unit.    Figure 57.9 A useful way of looking at panfacial fractures  is to divide them into two facial halves separated by a fracture  at the Le Fort | level.    Figure 57.10 We suggest establishing facial width at the  occlusal level first in order to deal with the sagittal element of  maxilla and mandible fractures.    Figure 57.11 This is a good point to fix the condyles in  order to finalize width issues and help with establishing pos-  terior height (do not forget that the condyle may be accessible  from the bicoronal flap approach).    Figure 57.13 The midface repair should begin at the area  of least displacement so as to give the best chance of getting  the correct AP projection and width in this region. The arch of  the zygoma is straight, not curved.    The gross manipulation of the facial skeleton using  the Rowe’s disimpaction forceps needs to be completed  before any fixation is applied. If the neurosurgeons are  involved with anterior fossa repair, the reduction may  be done under direct vision to minimize disruption.   When starting this part of the reduction, pressure at  the gonial angles will reduce the splay until the anterior  mandibular fracture begins to open. This is the moment  to stop any further pressure on the reduction and apply  the plates.    Figure 57.14 Finally the piriform fossa and zygomatic but-  tress plating is performed. The area of thin bone in between  the buttresses can be severely comminuted. Occasionally in  the high-velocity injuries the buttress areas are missing too.  Grafting may then be necessary.    The frontal sinus/base of skull repair/reconstruction  including any dural repair (possibly needing local pericra-  nial or galeofronteal flaps) will need to be finalized now.    Conservative treatment is recommended when the dental  occlusion is not disturbed and there is an acceptable facial  contour with no other functional problems. There is more  scope for this sort of treatment plan with an edentulous  maxilla.    ORIF is the treatment of choice for most displaced  fractures. The sequence illustrated is of a minimally  displaced Le Fort II fracture on the right with more dis-  placement on the left. Examination of the face shows  no obvious NOE injury with a reasonable nasal contour  and no disruption of the medial canthi. A step defect  was palpable at the left infraorbital margin and there  was no clinical evidence of orbital floor or wall prob-  lems. There is a Le Fort I component to the fracture that  gives a much more pronounced occlusal discrepancy  of anterior open bite. CT scanning helps to delineate  the injuries in great detail compared with plain radio-  graphs (Figures 57.1 through 57.3).    Figure 57.15 The last issue is to address any bone graft-  ing issues within the orbit or onlayed on the nose. Soft-tissue  aspects such as soft-tissue drape and suspension can be con-  sidered now. Any canthopexy issues can be finalized.    The incision is placed high up in the buccal sulcus and is  the most usual access to low-level maxillary fractures. The  dissection proceeds subperiosteally and care needs to be  taken to keep in the correct plane when pieces of bone are  displaced. In the area of the anterior maxilla, small pieces  of comminuted bone may be best left attached to the peri-  osteum so as to retain their viability.    These incisions would be as for access to the NOE complex  (Chapter 59), orbital complex (Chapter 58) and zygomatic  orbital complex (Chapter 60).    For high-level midface fractures, the bicoronal incision  is used to gain access to the lateral and medial orbit, as  well as the frontonasal region as for isolated injuries in the  NOE area (Chapter 59). This incision enables neurosurgi-  cal access to the skull at the same time, if required.    Direct reduction of the fractures relies on visualization  of the midface fractures using the access described. The  Rowe’s disimpaction forceps are placed under the dis-  sected nasal mucosa. The other prong of the forceps (which    is usually padded with a silicone tube) is placed against the  palatal mucosa (Figures 57.16 through 57.18).   The maxilla is typically mobile and displaced inferi-  orly and posteriorly. Occasionally, the maxilla is impacted  superiorly and posteriorly, when it can be quite solidly  impacted and difficult to mobilize. Anterior and inferior  movement may require considerable manipulation in  order to re-establish the correct anteroposterior and ver-  tical dimensions and the intercuspation of the occlusion.  This manipulation may restart or worsen the leakage of  cerebrospinal fluid. There is a balance needed in manipu-  lating the displaced maxilla so as to adequately reduce the  fracture while minimizing further injury to the cranial  base structures or orbital contents.   Sequencing midface fracture reduction when these  fractures are part of panfacial injuries may involve com-  plex three-dimensional (3D) issues for the restoration of  function and re-establishing facial contours. Typically,  the major mobilization of the maxilla is performed early  on in the operation as any fixation applied elsewhere  would be disrupted by this. There are real issues with    the correct orientation of the maxilla in high-velocity  injuries with bone loss and damage to neighbouring  structures. In major craniofacial injuries, dealt with in  collaboration with neurosurgeons, the mobilization of  the maxilla is often performed only when the anterior  cranial floor fractures are directly visualized follow-  ing craniotomy and suitable brain retraction, so as to  make sure further damage to the brain and dura does  not occur.    The majority of midface injuries are fixed internally using  low-profile titanium plates and screws (typically, 1.7 and  1.3 mm). They are usually placed in the areas of thickest  bone which is most easily accessible, at the piriform aper-  ture and the buttress of the zygoma in low-level fractures.  At higher levels, the orbital rims and glabellar region offer  the best bone for plate application.   The use of arch bars and temporary intermaxillary fixation  (IMF) may be very helpful in maintaining the correct reduc-  tion during application of the plates. The correct positioning  of the fractured maxilla is guided by the anatomic position  of the fractured bones, as well as the intercuspation of the  dentition. The dental occlusion may not be easily attained if  there is a pre-existing abnormal bite and/or missing teeth.  Impressions and study models taken pre-operatively with    fabrication of an occlusal splint help attain the correct dental  bite at operation and may be very helpful.   A source of error in positioning of the maxilla is dis-  traction of the mandibular condyles when achieving the  final position of the maxilla prior to plating. These issues  are exactly the same as the problems facing the surgeon in  correct positioning of the maxilla in midface osteotomy  surgery. The solution is to make sure the mandible is pas-  sive when applying IMF or hand holding the occlusion  prior to plating.    There are real advantages in having arch bars in position  for minor post-operative occlusal problems when treating  maxillary fractures. Elastic IMF may be sufficient to finalize  any small discrepancy. Jaw opening and lateral excursion  exercises are helpful in regaining functional movements.    Only contemplated in minimally displaced fractures in  order to optimize the occlusion. Issues to do with the res-  toration of correct facial height, anterioposterior displace-  ment or lateral facial splay cannot be addressed.    Again, there are limitations with this treatment; however,  the issues associated with facial height and anteroposterio  position may be addressed to an extent. We would use this  technique in the very rare situation of needing to stabilize  the maxilla when packing the nose for a maxillary fracture  complicated with a torrential midface haemorrhage.   The maxilla can be attached to an arch bar or cast splint  by a projecting bar. Alternatively, projecting bars can be  adapted from two bone pins placed directly into the pre-  maxilla through small stab incisions, on either side at the  alar base/nasal sill region, providing there is no comminu-  tion here. The projecting bars are connected to supraor-  bital pins or a halo frame.    e Fractures of the midface are easily missed by inexpe-  rienced clinicians (often they are hidden beneath soft-  tissue swelling). All components, including the orbital  and eye, nasal and eyelid attachment and dental  aspects are routinely underestimated.   e CT scanning is the imaging of choice. Scans often reveal  extensive fractures unappreciated by clinical examina-  tion. These may not need active treatment, but it is use-  ful to know of their presence.   e Work up for these injuries may involve other specialties.  Surgical intervention is often delayed until associated  head injury and facial swelling have resolved. This time  should be utilized to develop a comprehensive surgical  treatment plan.   e Having waited for the brain swelling to settle down, an  operation if needed should not be delayed, despite any  obtunded conscious level. Patients often make delayed  recovery of brain function. Secondary correction is  never as easy as primary anatomic repositioning of  the basic midface structure. The planned intervention  should be performed without further compromise to  the damaged brain.   e¢ The development of low profile (0.7 mm) and miniplate  (0.3 mm) fixation systems has revolutionized our ability  to reduce and fix these complex fractures.   e Despite apparent anatomic reduction at operation,  post-operative elastic IMF using elastics is often  required.    Gruss JS and Mackinnon SE. Complex maxillary frac-  tures; role of buttress reconstruction and immediate  bone grafts. Plast Reconstr Surg. 1986; 78: 9-22.   Manson PM, Clark N, Robertson B, Slezak S, Wheatly M,  Vander Kolk C et al. Subunit principles in midfa-  cial fractures: The importance of sagittal buttresses,  soft tissue reductions, and sequencing treatment of  segmental fractures. Plast Reconstr Surg. 1999; 103:  1287-1306.   McMahon JD, Koppel DA, Devlin M and Moos KF.  Maxillary and panfacial fractures. In: Ward Booth  P, Eppley BL, Schmelzeisen R (eds.), Maxillofacial  Trauma and Esthetic Facial Reconstruction. London:  Churchill Livingstone; 2003. pp. 237-261.   Moss CJ, Mendelson BC and Taylor GI. Surgical anatomy  of the ligamentous adhesions in the temple and  periorbital regions. Plast Reconstr Surg. 2000; 105:  1475-1490.    Orbital trauma is common, the orbit being involved to  some extent in approximately 40% of all blunt facial inju-  ries. Most of these occur in conjunction with an outer  orbital frame fracture including fractures of the zygomatic  complex, maxilla and naso-ethmoidal fractures. However,  there is a second group, in which a fracture of one or more  of the orbital walls occurs with the outer orbital frame  intact. Often described as ‘blow out fractures’, it is perhaps  more accurate to describe this second group as isolated  wall or floor fractures.   Complications of these injuries can be divided into  functional (blindness and diplopia) which take priority  in decision-making, and aesthetics including enophthal-  mos. Accurate assessment combined with meticulous  attention to detail during the planning and operative  procedure is essential to prevent or minimize poor  outcomes.    The orbit is comprised of an orbital frame or rim within  which the walls can be conveniently described as floor,  medial wall, roof and lateral wall (Figure 58.1). The orbital  frame is strong and forms part of the midfacial buttress-  ing system. However, the walls particularly the floor    and medial wall are extremely thin accounting for the  frequency of fractures in these areas. The lateral wall and  roof are stronger and as a result, fractures of these regions  are less common. It is important to note that the medial  walls lie parallel to each other, and the lateral wall lies  approximately 45% to the medial wall. The floor is con-  cave upwards in the anterior third but then becomes con-  vex upwards in the posterior two thirds (post-bulbar bulge  blending into the key area medially).   Although there are four walls at the orbital rim, further  back in the orbit the medial wall and floor blend together;  at this point, the orbit becomes a three-walled pyramidal  structure. This blending of the medial and lateral wall  forms an important postero-medial bulge which has also  been coined the ‘key area’. This is an important area to rep-  licate in orbital reconstruction to minimize post-operative  enophthalmos. The anterior and posterior ethmoidal  arteries pass through the medial wall and are important  surgical landmarks. Passing through the floor is the infe-  rior orbital fissure which contains no structure of surgical  importance.   At the orbital apex, the medially located optic canal  passes through dense bone of the sphenoid bone transmit-  ting the optic nerve together with the central artery of the  retina. More laterally, the superior orbital fissure trans-  mits branches of the ophthalmic division of the trigemi-  nal nerve together with the third, fourth and sixth cranial  nerves. The ‘superior orbital fissure syndrome’ comprises    total ophthalmoplegia, upper lid ptosis and anaesthesia in  the distribution of the ophthalmic division of the trigemi-  nal nerve, ‘orbital apex syndrome’ includes these signs in  conjunction with blindness. Within the orbit, the globe is  supported by Lockwood's suspensory ligament and moved  by the extraocular muscles, it is enclosed in periorbital fat  whose loss can contribute to enophthalmos. Anterior to  the globe, the upper and lower tarsal plates are attached  to the medial and lateral walls by the medial and lateral  palprebal ligaments. This tense fascial sheath constitutes a  ‘fifth wall’ of the orbital pyramid thereby forming a closed  box. It is important to recognize this, for if orbital pressure  increases following trauma, release of this fascial band by  way of a lateral canthotomy can be sight saving, an impor-  tant emergency surgical skill in the management of these  injuries.    Two theories have been proposed to explain the presence  of isolated orbital wall fractures. In the first, an occluding  force applied to the outer orbital rim leads to a transient  increase in intra-orbital pressure leading to a ‘blow out  fracture’. The second theory proposes a transient deforma-  tion of the rim which remains intact but the transmitted  force leads to a fracture within the orbit Figure 58.2 as    orbital injuries rarely lead to significant ocular injury, this  second theory is probably more likely.    Following a full systemic and maxillofacial examina-  tion, the orbital injury should be carefully assessed.  The mechanism of injury is important in particular to  differentiate between blunt and penetrating trauma.  Visual acuity must be assessed at an early stage and  enquiries made regarding the presence of double vision  and numbness around the orbit. Traumatic optic neu-  ropathy is uncommon and presents a challenging man-  agement problem; surgical exploration is difficult and  expertise may not be available locally, there is little  evidence to support the use of mega dose steroids in its  management.'   Examination should include the peri-orbital soft tissues  especially the lid, cornea and anterior chamber of the eye,  looking particularly for the presence of hyphema, corneal  injury and iris injury and importantly, the presence of  contact lenses which should be removed. The presence of a  subconjunctival haematoma without posterior limit indi-  cates a likely breach in the orbital periosteum.   Examination proceeds with palpation of the outer  orbital frame, following which eye movements are care-  fully assessed in the nine cardinal positions of gaze    carefully documenting the presence of diplopia in any of  these positions. Red colour desaturation is an important  sign which when combined with swinging light test may  indicate reduced optic nerve function, a relative afferent  pupillary defect (RAPD).   In the unconscious casualty, pupillary reactions take  on further importance and if the eye of the injured side  is closed, then optic nerve function can be assessed with a  bright light whilst monitoring the uninjured eye.    Plain radiographs are of limited value in isolated orbital  wall injuries but the hanging drop sign may be noticed,  and they are of value in assessing the outer orbital  frame. However, the imaging modality of choice for  orbital trauma is a fine cut spiral computed tomogra-  phy (CT) which should include all four walls with coro-  nal, sagittal and occasionally three-dimensional (3D)  reformatting.    Orbital trauma should ideally be managed jointly with  ophthalmic surgeons and an important component is pre-  operative orthoptic assessment. This will include clinical  measurement of visual acuity and ocular motility, together  with a cover test for near and distant vision. Any deviation  is measured for consideration of prisms.   The Hess chart is a dissociation test allowing objective  measuring and recording of ocular motility. The mobil-  ity of the injured eye being compared with the fellow  uninjured eye.    Restricted movement is observed in the injured eye and  overcompensation seen in the normal eye (Herrings Law)  (Figure 58.3).   It is essential to assess and confirm the visual acuity of  the contralateral, uninjured eye and to rule out pathology  in this eye.    Paediatric orbital fractures are less common, the walls  being much thicker as a consequence of the under devel-  opment of the associated paranasal sinuses. However,  when they occur, they often lead to a true trap door green  stick fracture often trapping peri-orbital tissue. These are  commonly missed injuries due to absence of other signs”  it is imperative to operate and release the entrapped tis-  sues as soon as possible, many emphasizing within 5  days.*    It cannot be overemphasized that ocular function is the  single most important consideration in the management  of these injuries. This takes on even greater importance  should poor or absent vision exist in the uninjured eye.  This would be a contraindication for surgical repair,  hence the need for its accurate assessment. It may be  entirely appropriate not to treat a minor degree of enoph-  thamos in a patient who has normal visual acuity and no  diplopia.   For non-isolated orbital injuries, it is essential that the  outer orbital frame is treated first, the orbital wall factures  are then repaired in exactly the same way as for an isolated  wall injury.    Figure 58.4 Forced duction test which should be per-  formed pre-operatively and on completion of repair to exclude  entrapment.    Treatment options for an isolated wall fractures are  either conservative treatment or operative repair. Small  isolated injuries with no evidence of enophthalmos or dip-  lopia can be safely observed and in many cases, no opera-  tive intervention will be required. However, larger defects  are likely to lead to a significant enophthalmos which can  be difficult to correct, accordingly most would favour early  operative repair. Other indications for operative interven-  tion would include significant diplopia or obvious entrap-  ment of peri-ocular tissues.    The patient is placed supine on the operating table  with a slight degree of head up tilt with modest hypo-  tension provided by the anaesthetist. Both eyes should  be exposed and protected and a forced duction test  performed to assess any restriction in ocular motility  (Figure 58.4). There should be due attention to corneal  protection, this may be provided either in the form of  a corneal shield ifa trans-conjunctival incision is utilized  or a temporary tarsorophy if a lower eyelid incision  is used.    The orbit can be exposed through a variety of incisions  depending on which walls are fractured and the amount  of exposure required. The floor can be approached by  either a lower eyelid incision or a trans-conjunctival inci-  sion with or without a lateral canthotomy. There are three  lower eyelid incisions (Figure 58.5): the subciliary (or  blepharoplasty) incision, the midtarsal incision and the    infra-orbital incision. With regards to complications, the  infra-orbital incision has a very low incidence of ectropion  but an increased incidence of poor scarring. The subcili-  ary or blepharoplasty incision has a very low incidence of  scarring but an increased incidence of ectropion although  this can be reduced by not suturing the wound and leav-  ing a cuff of orbicularis occuli attached to the lid margin.  The midtarsal incision combines the advantages of both  these procedures having very acceptable scarring together  with a low incidence of ectropion? and is the author's pre-  ferred lower lid incision. The incision is carried through  skin followed by careful sharp dissection through orbicu-  laris oculi to reach the tarsal plate. Meticulous haemosta-  sis with bipolar forceps is essential and further aided by  pre-operative infiltration with lidocaine and epinephrine.  Using careful retraction with a Desmare retractor, a clear  plane is revealed between orbicularis oculi and tarsal plate  which is followed by sharp dissection onto the anterior  face of the orbital rim (Figure 58.6).   The trans-conjunctival incision gives very generous  exposure of the orbit and is probably the approach of  choice for larger defects. It can be made pre or post-sep-  tally, the pre-septal approach is more complicated with  few advantages and the post-septal approach is generally  preferred. With the lower lid retracted anteriorly with a  Desmare retractor, a malleable retractor can be placed  directly behind the orbital rim, thus placing the tissues  under tension (Figure 58.7). The conjunctival incision is  then made, preferably made with a needle point diathermy  following which the retractors are repositioned inside the  wound allowing further dissection, again to the anterior  face of the orbital rim.   Whichever incision has been used the periosteum on  the anterior aspect of the orbital rim is now incised. It is  important to keep the dissection on the anterior surface    Figure 58.6 (a) Midtarsal skin incision. (b) Retraction of  wound edge revealing plane betweenxs orbicularis occuli and  the tarsal plate; (c) incision on anterior wall of orbital rim to  give access to orbital floor.    of the orbital rim since this minimizes herniation of  peri-orbital fat.   Greater exposure of the orbital floor can be gained by  combining the trans-conjunctival incision with a lat-  eral canthotomy. For this procedure, a small skin inci-  sion passes through the fornix between the upper and  lower eyelids following which the lower limb of the lateral    Figure 58.7 Trans-conjunctival incision. Retraction of  lower eyelid with Desmare retractor combined with tension  applied with blunt malleable retractor inside orbital rim to  place tissues under tension prior to division with needle point  diathermy.    Figure 58.8 Lateral canthotomy, following skin incision  the lower canthal band is identified and divided.    canthus can be divided (Figure 58.8). If this incision is uti-  lized it is generally more convenient to perform the lat-  eral skin incision and canthotomy prior to dividing the  conjunctiva.   Following incision of the inferior orbital rim perios-  teum, the periosteum is easily elevated over the rim and  dissection proceeds in a downwards direction before  passing posteriorly until the anterior margin of the floor  defect is identified, dissection should be careful and  precise to avoid enlarging the defect. At this point, it is  important to ‘out flank’ the defect and since the lateral  wall is less commonly fractured it seems more convenient  to follow this as the next step. The inferior orbital fissure  is then identified and can be safely coagulated between  bipolar forceps and then divided to give much improved  access (Figure 58.9).    The presence of a significant medial wall fracture (often  in combination with a floor fracture) requires a further  incision to gain proper access. The established approach to  the medial wall is via a coronal flap. The incision extends  from a pre-auricular incision passing coronally across the  scalp to be completed by a pre-auricular incision on the  contra-lateral side. The so called stealth variant zigzags  the incision across the scalp to allow disguising of the scar  by hair growth although in the author's experience a wavy  line incision is easier to raise and avoids hair loss at points  of the zigzags.   The incision is ideally made with a ceramic blade pass-  ing through skin and the aponeurosis with careful vas-  cular control provided with Raney clips. The flap can be  rapidly mobilized in the sub-galeal plane to a point just  above the fronto-zygomatic suture at which point the  periosteum is incised and the incision carried laterally  through the outer layer of the deep temporal fascia to  the root of the zygomatic arch. By this means, the facial  nerve is protected and temporal hollowing is minimized.  By continuing dissection in a sub-periosteal plane the  supraorbital notch is identified. If the supraorbital nerve  is lying in a foramen then the lower margin of this can  be osteotomized to allow the supra-orbital nerves to be  freed. The peri-orbital rim periosteum is dissected and  carried down the medial aspect. Flap mobility can be  improved by incising the periosteum on the under sur-  face of the flap in the midline. By proceeding posteri-  orly, generous exposure of the medial wall is obtained.  It is important to complete any lower eyelid incisions  before raising a coronal flap as it often leads to significant  oedema in the lower eye lids.   The coronal flap can have significant morbidity includ-  ing poor scarring, alopecia, temporal hollowing. Injury  to the temporal branch of the facial nerve and numbness  in the distribution of the supraorbital and supratrochlear  nerves can also occur. Its use is probably more appropriate  in pan facial injuries.    Less invasive approaches such as the trans-curuncular  incision which is essentially a medial extension of the  trans-conjunctival incision gives adequate exposure to the  medial wall without such morbidity.   Dissection posteriorly along the medial wall almost  certainly will require ligation or diathermy of the anterior  ethmoidal vessels.   The posterior limit of dissection should ideally be to the  posterior margin of the defect but in deep orbital trauma  there is clearly a limit to how far dissection can proceed  without endangering the optic nerve. It has been suggested  that sub-periosteal dissection should not proceed beyond  35 mm from the orbital rim but this guideline should not  be used in the presence of an orbital rim fracture. Other  guidelines are the level of the posterior ethmoidal artery.  More recently, stereotactic navigation has been suggested  but this is not widely available and a recent paper has reit-  erated the importance of proper anatomical knowledge in  such dissection.°   On completing the sub-periosteal dissection, exposure  of the defect can be improved by undertaking a marginal  orbitotomy.° For this procedure, the segment of inferior  orbital rim to be removed is marked and a low profile  microplate adapted and temporarily fixed to bridge the  proposed osteotomy (Figure 58.10). The plate is removed  and the orbitotomy completed. Removal of this segment  of infra-orbital rim certainly improves access but is not  always essential, furthermore, it is extremely difficult to  undertake in the presence of an orbital rim fracture.    Following complete exposure of the defect, the surgeon  is now in a position to plan the reconstruction. There are  essentially two choices either to use autologous bone or an  alloplastic material.   Historically, the use of alloplastic materials was  associated with complications including infection and  extrusion and as a result, autologous bone became the  preferred reconstructive material. Autologous bone can  be conveniently harvested from the calvarium if a coro-  nal flap has been raised. Other sites include the anterior  wall of the ipsilateral maxillary sinus if intact, iliac crest  or rib. However, there can be significant donor morbidity  from bone graft harvest and also unpredictable resorp-  tion’ these factors together with the poor accuracy of  orbital volume reconstruction have lead to new interest in  alloplastic materials.* There is now a wide range of such  materials which can be divided into resorbable and non-  resorbable groups.   Resorbable membranes such as polydioxanone (PDS)  sheet and poly-lactic/glycolic acid are thin and mal-  leable but are not suitable for large defects since they  lack sufficient structural rigidity and have unpredictable  resorption.’   Non-resorbable materials include titanium mesh and  polyethylene membranes (Medpore). Titanium mesh can  either be provided in simple plain sheet form which can    Figure 58.10 (a) Bridging plate adapted to orbital rim  over proposed osteotomy site; (b) osteotomy completed with  micro saw.    be cut to shape but most manufacturers are now providing  pre-formed adaptable sheets allowing a very accurate 3D  reconstruction (Figure 58.11) particularly if used in con-  junction with an computer-generated stereolithographic  model constructed using a ‘mirror image’ of the non-  injured side.   Polyethylene sheet is very malleable but does have some  degree of memory. It has the advantage of providing a  smooth surface against the orbital tissues which makes  removal (if necessary) slightly easier than titanium mesh.  Fixation is less easy than with titanium mesh and can be  achieved either with a titanium screw behind the orbital  rim or with a PDS suture. More recently, polyethylene  sheeting has been made over a titanium mesh framework  combining the advantages of both materials.   A recent innovation is the production of anatomically  preformed orbital plates. Available in small and large for-  mat with left and right sides they are also supplied with  anatomical concave malleable retractors helpfully with  calibration markers and these have revolutionized orbital    Figure 58.11 Preformed titanium mesh allowing accurate  repair of complex orbital fractures.    reconstruction. The plates have a segmented design allow-  ing adaptation of both the medial wall height and floor  length together with fixation screws to accurately locate  the plate onto the orbital rim. Recognizing the importance  of the posterior bulge, the plates have a ‘rigid zone’ in the  posterior orbit to allow a consistent form in this region  (Figure 58.12).   Following insertion of the implant, careful assessment  is made with regards to correction of enophthalmos and  the pupillary level and the forced duction test is repeated  (Figure 58.3b). Once the surgeon is happy with the recon-  struction, the implant is fixed into position ideally with  titanium screws.   In cases of massive destruction of the orbital walls,  custom-made implants can be made via a ‘virtual stereo-  lithographic model’ from CT data these can lead to accu-  rate restoration of orbital volume and form, essentially  using a mirror image of the non-injured side.   Following implant fixation, wound closure can be  made over a small vacuum drain and it is important to  close the periosteum to allow proper suspension of the  malar fat pad, the muscle layer is not closed and the skin  gently opposed with interrupted 6-0 nylon sutures. For  trans-conjunctival incisions, following closure of the  periosteum, there is debate as to whether the conjunctiva  should be closed with many preferring not to close the  conjunctiva to reduce the risk of entropion. If a coronal  flap is being utilized, it is important to carefully close the  aponeurosis ideally using running 2-0 braided resorb-  able suture on a round bodied needle. Following this, the  skin can be conveniently closed with skin staples but the  preauricular incision should be carefully closed in layers  with 6-0 nylon sutures to skin. Two large vacuum drains  should also be used and it is advisable to apply a pressure  dressing for the first 24 hours.   Post-operative care includes careful eye observations to  include visual acuity, pupil reactions, ocular movements  and most importantly increasing pain. The patient should  be nursed with his head elevated to reduce peri-orbital    swelling. He should be encouraged to mobilize his eyes as  much as possible, and avoid nose blowing.    This is the most important complication of orbital surgery,  the incidence being extremely low at approximately 1 in  1500. Visual impairment may follow either injury to the  optic nerve or ophthalmic artery during the surgical pro-  cedure or by retro bulbar haemorrhage in the immediate  post-operative period. Close observation in the post-oper-  ative period is mandatory and clear protocols need to be  established.    Diplopia may be initially worse following surgery due to  oedema or haematoma but is likely to improve over the  next few weeks. Long-term complications include enoph-  thalmos, poor scarring and soft-tissue distortion.    Enophthalmos is largely due to inaccurate restoration  of orbital volume often requiring secondary correction  (Figure 58.13).    Poor scarring is more common with infra-orbital inci-  sions and rare with trans-conjunctival and blepharoplasty  incisions. Malposition of the lateral canthus can occur and  many suggest suturing the canthus with a non-resorbable  suture to be hole drilled in the lateral rim of the orbit, oth-  ers have suggested dividing the lower rim of the canthus  through the tarsal plate which can be more accurately  sutured to the correct position.    A retrobulbar haematoma follows bleeding within the  orbit and can either be within the cone of extra-ocular  muscles or outside this cone. As bleeding continues,  pressure increases within the orbit leading ultimately to  pressure on the optic nerve head with the clinical signs  of ophthalmoplegia, reducing visual acuity and pain lead-  ing to a fixed dilated pupil. This can occur either follow-  ing the initial injury or following surgical correction.  First aid measures include the use of steroids, Mannitol  and Acetazolamide combined with a lateral canthotomy    Figure 58.13 Enophthalmos clinical sequelae and imaging: The titanium mesh implant is malpositioned, being too low on the  medial wall (note the natural upwards and medial slope of the uninjured right floor which has not been replicated) which has led to    to give temporary control prior to urgent formal surgical  exploration and drainage.   More recently, the concept of a retrobulbar haemor-  rhage has been challenged and a better term may be orbital  compartment syndrome” since in many cases the signs  and symptoms are secondary to oedema rather than true  haematoma. It has been suggested that tonometry may  provide some guidance on which cases require operative  intervention and which can be safely observed;" however,  many would still recommend formal exploration in the  presence of such signs.   e Maintain high index of suspicion of orbital injury in all  midthird trauma.   e Accurate recording of size and location of defect using  high-resolution axial scanning with coronal and sagit-  tal reformatting.   e Plan access incisions with regard to size and location  of defect, coexisting fractures and choice of repair  material.    1. Steinsapir KP. Traumatic optic neuropathy. Curr  Opin Ophthalmol. 1999; 10: 340.   2. Tse R, Allen L and Matic D. The white eyed medial  blow out fracture. Plast Reconstr Surg. 2007;119: 277.   3. Kwon JH, Moon JH, Kwon MS and Cho JH. The dif-  ferences of blowout fracture of the inferior orbital    wall between children and adults. Arch Otolaryngol  Head Neck Surg. 2005; 131: 723.    Comparison of transcutaneous incisions used for  exposure of the infraorbital rim and orbital floor:  A retrospective approach. Plast Reconst Surg. 1992;  90: 583.    reconstruction anatomical landmarks and the con-  cept of the deep orbit. Br J Oral Maxillofacial Surg.  2007; 45: 183.    . Kontio RK, Laine P, Salo A, Paukku P, Lindqvist C    and Suuronen R. Reconstruction of internal orbital  wall fracture with iliac crest free bone graft clini-  cal, computed tomography and magnetic resonance  imaging follow up study. Plast Reconstr Surg. 2006;  118: 1365.    reconstruction for pure blow out fractures: Cranial  bone grafts versus titanium mesh. J Oral Maxillofac  Surg. 2003; 61: 442.    Konttinen YT and Lindqvist C. Effectiveness of  operative treatment of internal orbital wall fracture-  swith polydioxanone implant. Int J Oral Maxillofac  Surg. 2001; 30: 278.    Previously, patients sustaining craniofacial trauma were  routinely treated separately by several disciplines inde-  pendently often resulting in poor outcomes. However, it is  now widely accepted that this group of patients are treated  optimally by a multidisciplinary team approach in a neu-  rosurgical centre with ready access to modern imaging  technology and neurosurgical high dependency facilities.  It has been this development, together with the realization  that the first time is the best time to treat these injuries,  that has led to the significant reduction in aesthetic and  functional morbidity associated with such injuries.    While accepting the simple classifications of simple linear  fractures of a given bone or fossa involved, a more useful  working classification of fractures involving the frontobas-  ilar region was suggested by Bernstein et al. who divided  the injuries into central, lateral and complex groups. The  central group includes fractures involving the central  anterior skull base and cribriform region adjacent to the    585  585  Blois)  587  588  588  588  589  593  594  594  597  601    frontal, ethmoidal and sphenoidal sinuses (Figure 59.1).  The lateral group include frontal bone fractures associ-  ated with the orbital roof, but lateral to the frontal sinus  (Figure 59.2) and finally the complex group involving all  areas often bilaterally (Figure 59.3).   This classification helps relate the fracture pattern to  involvement of adjacent structures and the possible func-  tional sequelae. Thus, central injuries are far more likely to  involve sinus-related problems, whereas lateral injuries are  more often associated with orbital and globe issues. Second,  the classification helps plan the craniotomy to gain suffi-  cient access to perform a safe surgical repair.    Due to the mode of injury, patients with craniofacial  injuries will often present with associated head injury. In  addition, 30% of such patients will have another major  life-threatening injury elsewhere in the body and up to  20% will have an associated cervical spine injury. It is  therefore imperative that the principles and management  of advanced trauma life support (ATLS) are applied to this  group of patients (Figure 59.4).    586 Craniofacial trauma, including management of frontal sinus and nasoethmoidal injuries    Craniofacial assessment should include a full neuro-  logical examination paying particular attention to cranial  nerve deficits. Ophthalmic assessment is mandatory and  specialist help should be sought from an early stage even  in the unconscious and intubated patient.   Any nasal or middle ear discharges should be tested for  beta-2 transferrin to detect the presence of cerebrospinal  fluid (CSF).    The technical aspects have already been dealt with the  relevant section on radiological assessment of facial  trauma, but suffice to say the role of high speed spiral  computed tomography (CT) scanners and improved com-  puter software has revolutionized the ability to produce  high quality images quickly with the least embarrass-  ment to the patient and permits accurate visualization  of the fracture patterns in all three planes with three-  dimensional reconstructions, aiding the surgeon to  develop an operative plan.    588 Craniofacial trauma, including management of frontal sinus and nasoethmoidal injuries    © Central injuries, involving significant displacement  of the anterior fossa floor and posterior wall of the  frontal sinus   ® Lateral injuries, involving the roof of the orbit leading  to contour deformity, globe displacement or ocular  motility disturbance   ® Surgical goals of a combined repair fall into two broad  groups. First, to prevent the late sequelae of infection,  cosmetic deformity and lastly functional deficits.   © The use of vascularized peri-cranial flaps to help seal off  the dura from the nasal cavity    Dural tears in communication with the nasal cavity and  paranasal sinuses are common and place the patient at  an increased risk of developing meningitis. There is no  doubt that risk of infection is significantly increased by  the presence of a CSF fistula. This may be reduced, but not  abolished, by the use of antibiotics but may be reduced sig-  nificantly by achieving a dural closure. The problem areas  are not those cases where CSF leaks persist, but those that  stop within a relatively short space of time and no formal  repair is undertaken. Repair should be undertaken if the  CSF leak has not stopped after 14 days.    The key to craniofacial repair is the accurate reassembly  of the frontal bandeau which helps define a platform for  facial height, width and projection, as well as allowing for  accurate restoration of the convexity of the orbital roof,  reducing the adverse effects on globe motility and mini-  mizing the risks of altered orbital volume.    Surgery is usually directed towards life-saving neurosur-  gical compromise in the first instance based on Glasgow    Coma Scale (GCS) and CT findings supplemented with  intra-cranial pressure monitoring where necessary.  Assuming that these aspects have been addressed a time  frame of 10-14 days has been shown not to adversely affect  the patient’s outcome.    The choice of intubation may be normal oral intubation,  but if injuries include pan-facial fractures requiring sta-  bilization of the occlusion, then other options include  nasal intubation, submental intubation with a possible  tube switch to an oral tube at the end of the procedure to  address the nasoethmoidal injuries. Tracheostomy may be  required, especially ifa prolonged period of post-operative  ventilation is required due to a resolving head injury or  thoracic injuries.    Usually, the patient would be placed supine in a head ring  ensuring enough support to prevent excess head mobility,  but allowing good access to the vertex and posterior scalp  facilitating the coronal surgical approach and possible  need to harvest calvarial grafts.    The abilty to restore normal form, function and aesthetics  can only come from the anatomical reduction of the facial  skeleton and it is a prerequisite of this that all fracture sites  should be exposed in a subperiosteal plane. Fortunately,  previous experience has shown that due to the abundant  blood supply in the head and neck region. Such a proce-  dure is safe and does not lead to devitalization of the bone  as long as it is firmly immobilized and the soft tissues are  accurately redraped.   Adequate exposure may be achieved by a coronal  approach which may be modified depending on the frac-  ture pattern to allow for various forms of peri-cranial graft  to be used or extended to allow access further down to the  midfacial and condylar regions.   Consideration of the placement of the incision must  take into account the hairline of the patient. The incision  is best placed along the vertex of the scalp in a wave form  so that the first curvature is directed posteriorly from the  tragus ensuring the incisions amplitude is around 3 cm.  It is important that the anterior aspect of the incision are  kept within the hair line.   Pre-operative whole head shaving is not necessary,  but parting of the hair with a comb helps positioning of  the incision and this can be further aided by performing    a 3-cm width shave with clippers and a hair razor. The  hair may be treated liberally with chlorhexidine gluco-  nate hand wash which acts as a hair gel and allows the  hair to be gathered into clumps and secured with elastic  bands.   The whole site canbe prepared withaqueousiodineafter  eye shields and simple eye ointment have been applied to  each eye. Alternatively, temporary tarsorrhaphies may  be performed with a 4/0 monofilament suture with an  atraumatic needle utilizing 1-cm sections of paediatric  silastic feeding tube to help prevent undue pressure on  the delicate skin of the eyelids while maintaining pro-  tection. It is important to pass the needle through the  grey line of the lids to ensure some of the tarsal plate  is engaged helping prevent tearing of the eyelid skin  (Figure 59.5).   Surgical drapes are secured to the posterior aspect of the  proposed incision line with staples and a urology pouch  secured in a similar fashion helps to collect the irrigation  fluid. The patient is positioned slightly head up taking care  to liase with the anaesthetist, as unexpected air emboli  may infrequently complicate any cranial procedure with  head up tilt on the table (Figure 59.6).    The incision may be outlined using a pen and ink,  preferably Bonney’s blue, and the margins of the wound  may be crosshatched with a scalpel. A green needle may  be used to tattoo marks using ink adjacent to the inci-  sion. The permanency of the marks may be improved by  placing one’s finger over the hub of the needle and pass-  ing the needle into the scalp tangentially twice ensuring  good passage of ink into the tissues. Increased haemo-  stasis may be achieved by injection of a 1 in 200,000  epinephrine (adrenaline) containing local anaesthetic  solution into the subgaleal space. Distension of this space  has the added benefit of defining the plane for subsequent  dissection.   The initial incision is performed with a No. 10 scalpel  blade to the level of the hair follicles in the mid part of  the outlined flap for a distance of 5 cm (Figure 59.7).  The incision is deepened using a needle-point diathermy  (Colorado micro needle”), set to minimize heat generation,  but sufficient to help easy dissection down and through  the galea to enter the subgaleal space. This procedure may  be aided with gentle traction upwards and outwards with  skin hooks inserted into the wound margins. This not only  gives good access, but helps haemostasis. Having located  the subgaleal layer, further dissection is achieved by plac-  ing McIndoe scissors with their tips up beneath the galea  and opening the points widely. This action creates a pocket  which may be elevated by the skin hooks and clear of the    590 Craniofacial trauma, including management of frontal sinus and nasoethmoidal injuries    underlying pericranium, so that extension of the incision  along the galea can be achieved with the cutting dia-  thermy without damaging the pericranium (Figure 59.8).  As dissection progresses and the scalp flaps become more  mobile, haemostasis is obtained with the use of bipolar  forceps to accurately minimize the damage to the adja-  cent hair follicles. Rather than the use of Raney clips, this  technique helps to cut down haemorrhage at the end of  the procedure during wound closure and leads to a less  hurried and accurate closure. Dissection progresses infe-  riorly into the pre-auricular region below the level of the  superior temporal line keeping close to the underling tem-  poral fascia. This latter point ensures that the dissection is  beneath the level of the temporoparietal fascia which is a  continuation of the galea beneath the level of the temporal  line, and is important as the temporal branch of the facial  nerve runs either on its deep surface or within it. Damage  to this branch of the facial nerve results in weakness of the  forehead and partial ptosis due to loss of innervation to the  frontalis, corrugator, procerus and occasionally a portion  of the orbicularis oculi.   Flap elevation proceeds easily in the subgaleal layer by  maintaining tension on the skin flap with skin hooks and  Langenbeck retractors. Sharp-pronged retractors should  be avoided as they lead to damage and bleeding from  branches of the superficial temporal vessels on the surface  of the coronal flap. Dissection proceeds using the sweeping  action of a No. 10 scalpel blade or use of a ceramic mono-  polar diathermy blade, the latter having the advantage of  reducing further blood loss. As the flap is freed, tension  laterally is dealt with by incising the superficial layer of  the superficial temporal fascia, paying regard to the tem-  poral branch of the facial nerve. As the flap is dissected  inferiorly and anteriorly, an incision is made in the super-  ficial temporal facia at an angulation of 45° from a point  2.5 cm above the superior aspect of the lateral orbital mar-  gin, to a point at the base of the zygomatic arch. This inci-  sion is best performed with a No. 15 scalpel blade midway  along this line approximately 3-4 cm above the body of  the zygoma. Having made the incision, the yellow colour  of the superficial temporal fat pad is seen separating the  superficial and deep layers of the temporal fascia. The inci-  sion is now extended superiorly to the temporal line and  inferiorly to the zygomatic arch with dissecting scissors  (Figure 59.9). The next stage to help reflect the flap further  inferiorly is to decide at what level the pericranium should  be incised. If an anteriorly based flap is required then the  pericranium may be incised posteriorly using cutting dia-  thermy just above the superior temporal line from a point  marked from the superior aspect of the incised superficial  temporal fascia. The extent of the posterior dissection of  the flap should be enough to allow sufficient length of  this flap to cover any base of skull defect without tension  (Figure 59.10). Alternatively, if the viability of an anteriorly  based flap is in question due to trauma, then two later-  ally based flaps may be raised with the blood supply com-  ing from the lateral aspect (Figure 59.11). In either case,  sharp subperiosteal dissection allows reflection of the flap    inferiorly to the superior and lateral orbital margins. At  this juncture, the surpraorbital neurovascular bundles  will be encountered. In a proportion of cases, simple sub-  periosteal dissection will allow the bundle to be displaced  inferiorly. If there is a true foramen, the bundle may be  freed by inserting the tip of a 5-mm fine osteotome into  the foramen and hit inferiorly along already marked out  triangular bone cuts. This usually delivers the inferior bor-  der of the foramen freeing the bundle (Figure 59.12).   Further subperiosteal dissection along the root of the  nose may now proceed and may be aided by a vertical  incision of the periostium on the undersurface of the flap,  being careful not to attenuate the thickness of the skin flap.  This permits dissection along the medial orbital rim to the  level of the medial canthal tendon. The tendon’s attach-  ments should not be stripped of either its outer or inner  insertions to the anterior and posterior lacrimal crests  as this may lead to widening of the soft tissues across the  nasal root and, in extreme cases, may induce telecanthus.   Laterally having now incised through the superficial  temporal fascia and joined this superiorly with the reflected  pericranium, the flap may be dissected more inferiorly  by stripping of the lateral body of the zygoma and incis-  ing through the periosteum of the superior aspect of the  zygomatic arch and posterior zygomatic body. Reflection  of the flap exposes the body and arch of the zygoma leav-  ing behind the superficial temporal fat pad intact. The  temporal branch of the facial nerve is retracted in the flap  beneath the reflected superficial temporal fascia.   Finally, depending on the access required, the skin flap  may be mobilized still further by extension in the pre-auric-  ular skin crease, thus permitting full exposure of the root of  the zygomatic arch. Full subperiosteal orbital dissection is  now possible mobilizing the attachment of the lateral can-  thal tendon and medially by identifying the anterior and  posterior ethmoidal vessels. The ethmoidal vessels emerge  at the level of the cribriform plate. The anterior and poste-  rior vessels being 24 and 36 mm from the anterior lacrimal  crest and the latter being 3-5 mm anterior to the optic fora-  men. Occasionally, very large facial lacerations may have    592 Craniofacial trauma, including management of frontal sinus and nasoethmoidal injuries    to be incorporated into the line of the incision so as not to  risk the vascularity of the flap. Lacerations by themselves,  however, offer poor access and may compromise treatment  by restricting the size of craniotomy that may be achieved,  and for this reason, unless exceptionally large, extension of  lacerations is to be avoided.   Having achieved retraction of the flap, the craniotomy  must now be planned and again the paramount concern is  adequate access to effect intra-cranial inspection and dural  repair if necessary. This will depend on the site of injury  and suggested craniotomies are shown for central, lateral  and complex injuries as described by Burnstein. Burr  holes should be placed to minimize subsequent aesthetic  problems and also in a position that will allow a good,  low frontal craniotomy to deal with the frontal sinus, but  also minimize the amount of brain retraction needed to  explore the sub-basal region for dural repair and inspec-  tion of fractures of the orbital roof and anterior fossa floor.  For this reason, burr holes may be placed laterally in the  region of the pterion after reflection of the temporalis  muscle in this region. Not only does this permit good low  access to the horizontal cut of the craniotomy, but may be  covered with temporalis at the end of the procedure reduc-  ing visible defects in the bone. The craniotomy is raised  using a combination of large burs with or without a cut  out clutch to perforate the skull without damaging the  dura. Depending on the size of the flap required, further  bur holes are required superiorly and possibly adjacent  to the midline to help mobilize the flap with a side cut-  ting and end guarded craniotome, to avoid damage to the  dura and if the midline has to be crossed, then the sagittal  sinus. Finally, the bone flap is raised using blunt dissection  from the underlying dura. Exposure should now permit  easy tension-free retraction of the frontal lobes and allow  inspection of the anterior and posterior walls of the frontal  sinus, orbital roof and cribriform regions (Figure 59.13).   If there are sub-basal dural lacerations, retraction may  already have been facilitated by loss of CSF; alternatively,  an osteotomy of the frontal bandeau may further aid access  (Figure 59.14). A planned dural incision allows basal dural  lacerations to be approached with minimal brain retrac-  tion, especially of the basal region, without damage to the  olfactory tracts (Figure 59.15).   The next stage is to repair the frontal bandeau to restore  frontal projection, width and height. This is closely linked  to reductions in the temporal and zygomatic arch regions.  Not only does reduction of these fractures form the basis  for the accurate reposition of the mid-facial structures, but  permits the size of defects of the orbital roof to be gauged  and whether or not primary bone grafting is required.   If bone grafting is required, this is best performed now as  use of any peri-cranial flap will preclude further bone work.   Bone grafts may be obtained by harvesting the inner  table of the craniotomy segment. The cortices may be split  initially using a fissure burr to define the plane between  them, and the split is completed using a reciprocating saw  and flexible osteotomes. The outer cortex may then be  replaced over the donor site and the inner cortex used for  grafting (Figure 59.16).    Outer cortical grafts may be obtained from the tem-  poroparietal region overlying the non-dominant hemi-  sphere. The size of the graft can be outlined with a fissure  burr, used side on to cut through the outer cortex and the  bone immediately outside the segment may be reduced in    height using an acrylic burr. A slim osteotome can then be  introduced into the diploic space and the graft harvested.  Bleeding is arrested with a resorbable haemostatic agents  which gives some bulk to the haematoma which can then  be redraped with the periosteum to help minimize the  subsequent depression (Figure 59.17).   The selection of osteosynthesis material requires main-  tenance of the reduced fractures and bone grafts in a stable  position. Usually, titanium plates with a low profile utiliz-  ing screws 1-1.3 mm in diameter are used. This is sufficient  as the bone is not load-bearing other than to withstand  the pulsation of the dura or in the case of the orbital roof  the weight of the frontal lobes. Bone grafts must take into  account the original anatomy of the defect and nowhere is  this more important than in restoring the upward curving    nature of the orbital roof, failure to realize this important  point may result in vertical hypoglobus and potentially  exophthalmos. Bone grafting within the orbital roof is  important to separate the pulsation of the brain from the  orbital contents which may result in very unsightly pulsa-  tion of the eye. Having restored the orbital roof, the ante-  rior fossa floor and if necessary cranialization of the frontal  sinus, then vascularized peri-cranial grafts may now be  introduced. If an anterior flap is raised, this may be fed in  beneath the frontal lobes and be secured with a few sutures  and supplemented with fibrin glue to try and obtain a  watertight seal and close off the nasopharynx from the  anterior fossa. If damage to the pericranium anteriorly has  necessitated a laterally based flap, then this may be intro-  duced from the region of the lateral craniotomy cut and  burr hole. Finally, the craniotomy segment may be repo-  sitioned taking care not to compress the peri-cranial graft  and trying to position any subsequent space in the bone  cuts to give the most cosmetically acceptable result.    A good closure will help achieve the correct soft tissue  suspension over the anatomical hard tissue repair, fail-  ure to do so will result in gravity allowing the exten-  sively mobilized tissue to move ‘south’. This may be  achieved in a number of ways. First, non-resorbable  sutures are used to accurately attach the lateral canthal  tendon and peri-orbita to fine drill holes positioned  around the orbital aperture. This is combined with sus-  pension sutures inserted into the periosteum overlying  the zygomatic body and sutured to the temporal edge  of the incised superior margin of the superficial tempo-  ral fascia. The temporalis must be replaced over the burr  hole in the temporal region and bone dust kept from the  original access may be used in any residual bone defects.  Finally, the inferior aspect of the incised superficial  temporal fascia is attached to the temporal fascia at a  slightly higher level, to help further support the soft tis-  sue drape of the face (Figure 59.18). A drain is placed  beneath the flap with the inferior aspect reaching into    594 Craniofacial trauma, including management of frontal sinus and nasoethmoidal injuries    the side having undergone the most extensive dissection  to avoid collection in this region. A system with variable  amounts of suction is ideal as leakage of CSF may require  use of drains on gravity suction only. If CSF leakage is  a real concern, then placement of a lumbar drain for a  period of 5-7 days is favoured by some to allow time for  the dural repair to establish itself. The scalp is closed  with 2/0 resorbable suture, care being taken to use only  the galea which allows for good soft tissue support and  apposition of the wound margin.   In the region beneath the temporal line, more superfi-  cial sutures may be required and closure may be helped  by removal of the staples placed initially to secure the  drapes thus releasing tension from the posterior skin flap.  Accurate positioning of the scalp is ensured by aligning the  tattoo marks inserted at the beginning of the procedure.  Skin closure is achieved very easily with staples ensuring  that the wound margins are everted. A well-fitting head  bandage is placed, making sure to cover the wound in  the first instance with a non-adherent dressing and then  absorbent swabs and finally cotton wool across the fore-  head and behind the ears before fitting a well-placed crepe  bandage under tension. The cotton wool and avoidance of  excessive tension in the dressing avoid pressure necrosis,  particularly overlying the drain and forehead regions. The  drain is secured only with tape to the head dressing allow-  ing its removal when required without the need to disturb  the head dressing thus helping to prevent further fluid  accumulation which may lead to increased risk of infec-  tion and fibrosis.    The patient will be managed post-operatively in the neu-  rosurgical high-dependency unit. The decision to extu-  bate at the end of the procedure will have been discussed  previously with the anaesthetist, but occasionally due  to intra-operative considerations, such as frontal lobe  manipulation, CSF leakage and positioning of a spinal  drain, blood loss and temperature control, a short period  of maintained intubation may be advisable before extuba-  tion. If a tracheostomy is present it is not a concern, but if  the patient has had other forms of intubation, discussions  over tube switching and acceptance of the tube post-sur-  gery and in the weaning process will need to be decided  upon. Antibiotics are usually continued for at least three  post-operative doses and depending on the anterior  fossa and dural repairs, as well as CSF leakage, it may be  extended for several days.    The treatment of the frontal sinus is controversial, not  least of all as prospective studies in this area are few and  most algorithms relate to the retrospective analysis of a  unit’s data over many years. There is a problem as studies    certainly have shown complications many years after the  original treatment, often presenting in other centres  where the original treatment details are not known. It is  safe to assume that one unit’s complications may well be  treated by another unit due to the time scales involved.  Nonetheless, there has been a consensus about what one  is hoping to achieve, namely a ‘safe sinus’ with the least  intervention necessary. The frontal sinus is of variable size  and is lined by respiratory epithelium that communicates  via the frontonasal duct with the middle meatus of the  nose. The duct is again in a variable structure, being well  defined in some instances, but in more than 60% of cases  achieves its drainage via communication with the eth-  moidal air cells (Figure 59.19).   Frontal sinus fractures occur in approximately 2%-15%  of facial fractures and are far more associated with cranio-  facial fractures involving the skull base, but may occur in  isolation involving either the anterior wall, posterior wall  or floor with associated duct injuries (Figure 59.20). While  there may be obvious cosmetic concerns with depression  of the anterior wall of the frontal sinus, it is the functional  problems including chronic sinusitis (up to 60%), menin-  gitis (6%) and also mucopyocele, osteomyelitis and cere-  bral abscess formation that dictate the need for treatment.   Undisplaced anterior wall fractures may require no treat-  ment; however, if displaced, access is achieved along the lines  described previously as for craniofacial fractures only dif-  fering in the amount of exposure that is necessary limiting  exposure to between the superficial temporal lines, reducing  the risk to the facial nerve. If the anterior wall is depressed,  then it may be elevated without removal of the bone by plac-  ing 2-mm screws into the main fragments and elevated  using forceps and subsequently immobilized with low  profile 1.3 mm or similar titanium systems (Figure 59.21).    Figure 59.19 Anatomy of the frontal sinus and nasofrontal  duct. The frontal sinus is a pyramidal, air-filled cavity lying  within the lamina of the frontal bone creating an anterior  and posterior wall to the sinus. Drainage of the frontal sinus is  variable. A true nasofrontal duct exists in only 15%.    If fractures are more depressed, then the fragments will  have to be temporarily removed and accurately laid out on  a moist swab in the same orientation, to assist in their accu-  rate reassembly and subsequent insertion. Any necrotic or  damaged lining may then be removed carefully leaving all  viable mucosa. The remaining mucosa will help seed sub-  sequent re-epithelialization of the repaired sinus. If defects  have occurred, then calvarial grafts may be harvested as pre-  viously described and immobilized. If, after elevation of the  bone fragments, they appear not to fit, it may be necessary to  trim the bone margins to allow an accurate placement with-  out overlap. This latter point results from the deformation of  the bone segments during the fracture process.   Fractures of the frontal sinus floor may result in damage  to the frontonasal duct which may subsequently lead to  obstruction with mucocele formation. Stenting of the  ducts has been shown to be associated with long-term ste-  nosis, the author prefers, therefore, to seal off the fronto-  nasal duct in such circumstances. The procedure involves  the temporary removal of the anterior sinus wall, but in  this instance all the mucosal lining is removed meticu-  lously and the surface of the bone ground down with an    acrylic burr to try and assure removal of all crypts of  mucosa. The mucosa of the nasofrontal duct is mobilized  and inverted through the infundibulum. Oxidized cellu-  lose is then placed across and the defect is then filled with  autogenous bone. The volume required may be large and,  in some instances, iliac crest grafts may have to be uti-  lized rather than morcellized calvarial grafts. Abdominal  fat is to be avoided due to the variable levels of resorption  and potential subsequent mucocele formation. The ante-  rior wall may then be replaced and immobilized as previ-  ously described (Figure 59.22).   Isolated fractures of the posterior wall if displaced by  more than 5 mm have been shown to be associated with  dural lacerations and such fractures associated with a CSF  leak should undergo cranialization. The technique utilizes  the same exposure as before, but in this case following the  low craniotomy, the posterior wall of the frontal sinus is  removed, allowing all the frontal mucosa to be removed.  The duct mucosa is inverted, as previously described, and  covered with oxidized cellulose and this time a disc of cor-  tical bone is placed over the duct orifice, and bone dust and  milled bone obtained from the posterior wall is packed    596 Craniofacial trauma, including management of frontal sinus and nasoethmoidal injuries    above it (Figure 59.23). A vascularized peri-cranial flap is  then placed across the infundibulum and bone grafts, so  as to be supported beneath the frontal lobes with its vascu-  larized surface against the bone graft. Any dural tears will  have been repaired by this time, but if the tears are sub-  basal then an intra-dural repair may be performed with  the periocranium being introduced through the dural inci-  sion to lie under the frontal lobe (Figure 59.23), before the  flap is secured with fibrin glue to achieve a watertight seal.  The risk of a CSF leak may be further reduced by suturing  the incised dural margin to the peri-cranial flap, but care  has to be taken not to damage the vascularity of the graft.  Closure is performed as described earlier in this section.    Displaced fractures of the  anterior wall should be  reduced and fixed in the  anatomical position to  restore normal forehead  contour    Figure 59.21 Reduction of anterior wall fracture of the  frontal sinus.    Recently, several authors have advocated the endoscopic  repair of frontal sinus fractures and, while this is in the  early stages, there is some promise in this minimally inva-  sive technique in specific situations. The reader is referred  to the relevant articles, which are cited in ‘Suggested  Readings’ section for a review of this technique.   This may be immediate in the form of meningitis, brain  abscess or subdural emphyema, often related to failure to  debride and gain adequate closure. Treatment involves  antibiotic treatment with broad spectrum cephalosporins  and metronidazole, together with possible reoperation  and removal of infected craniotomy segments to allow the  infection to settle and delay reconstruction to a later date.  Late infection may be associated with the presence of a  mucocele due to an obstructed frontal sinus or CSF fistula  that will need to be addressed. Mococele formation may  complicate 10% of unrelated cases and require removal of  the frontal sinus and formal cranialization to remove all  the respiratory epithelium (Figure 59.24).   Fistulas are relatively rare in closed injuries affecting only  2%, which rises to 9% in open or penetrating head inju-  ries. Suggested investigations involve fine cut coronal CT  or T2-weighted magnetic resonance imaging (MRI) with  contrast.   Cisternograms are more invasive and the use of  fluorescein intrathecally combined with nasal endoscopy  has been shown to be of benefit in defects which are  difficult to identify.    Nasoethmoidal fractures present several difficul-  ties related not only to restoring the aesthetics of this  region, but also the functional consequences related to  the close proximity to the skull base and frontal sinus,  the orbital contents, and walls and lacrimal apparatus.  The force applied is well withstood by the stout bone of  the orbital aperture, including the bone of the frontona-  sal buttress, but if anterior force overcomes this initial  resistance then the pneumatized ethmoidal air cells and  weak medial walls of the orbit offer little structural sup-  port and may become grossly disrupted in comparison  to the greater resistance given by the anterior skull base  and orbital apex, designed physiologically to help pro-  tect the brain and soft tissues of the orbital apex. The key  to dealing with fractures in this region is understand-  ing the relationship of the medial canthal tendon and  its attachment to the so-called central fragment of the    Figure 59.24 Aetiology of mucocele formation. The risk of  infection is linked to communication between the nasal cavity  and dural tears via the frontal sinus. The aetiology of a muco-  cele appears to be related to obstruction of the nasofrontal  duct in a diseased or injured frontal sinus.    nasomaxillary complex and lacrimal bones. The medial  canthal tendon attaches to the medial orbit by superficial  and deep limbs attached to the anterior and posterior  lacrimal crests, respectively. It is the medial extension of  the upper and lower tarsi meeting, where the preseptal    598 Craniofacial trauma, including management of frontal sinus and nasoethmoidal injuries    muscles divide into deep and superficial heads. This  point is marked by the puntae of the upper and lower  canaliculi within the lid margins. From this point, the  canaliculi extend behind the medial canthal tendon into  the lacrimal sac. The anterior horizontal segment of the  tendon is attached firmly to the anterior lacrimal crest  and is stronger than the posterior limb which is attached  to the posterior lacrimal crest and serves to hold the  eyelids against the globe in a posterior fashion. It is this  medial and posterior relationship that has to be recon-  figured in injuries involving the medial canthal tendon if  the palpebral shape is to remain unaltered and the tarsal  plates are to be supported in close apposition to the sur-  face of the globe, and avoid epipora.   Nasoethmoidal fractures come as a spectrum ranging  from simple dislocation to those which involve a pattern  involving the medial wall of the orbit, frontal sinus, skull  base, ethmoidal air cells, orbital rim and nasal bones. This  means, therefore, that depending on the severity, other  injuries associated with the frontonasal duct, lacrimal  apparatus and medial canthal tendon must be addressed  and the aims of treatment must not only address the  reduction of the fractures, but deal with these functional  and aesthetic issues. A classification of these injuries has  been described by Markowitz, depending on the relative  displacement of the medial canthal tendon, as types 1-3  (Figure 59.25).   © Reduction and stabilization of the frontal bandeau and  anterior fossa floor    Apart from simple undisplaced rim fractures, the  approach of choice is the coronal flap modified to reach  the nasal bridge by incising the periosteum over the nasal  bridge, as previously described, care being taken to iden-  tify the lacrimal apparatus and medial canthal tendon. In  addition, the approaches previously described within the  orbital fracture section may be used to achieve adequate  exposure.   Assuming the frontal bandeau is intact or has been  repaired, the frontal nasal angle must be restored by reduc-  tion of the fracture and fixation with low profile 1-1.3-mm  plates and screws and, if necessary, primary bone grafting    using split calvarium. It is important to ensure that the  angle obtained is correct as significant shortening and  posterior displacement can occur. This may mean slim  osteotomes and spreaders being introduced to mobilize  the fragments if impacted and especially if the fracture is  more of a monobloc-type fracture than the more commi-  nuted variety.   The lateral and inferior orbital wall may be approached  via the coronal flap or adjuvant subciliary incisions so as  to permit accurate alignment of the orbital margin taking  care to use separate plates from above and below for frac-  tures of the medial orbital rim, thus reducing excessive  stripping of the anterior medial canthal tendon ligament  which may lead to iatrogenic telecanthus and widening of  the soft tissues across the bridge of the nose.   The alignment of the midfacial buttresses in the peria-  lar and zygomatic regions via an intra-oral approach will  help further with orientating the position of the max-  illa and establish facial height, width and projection and  aid accurate alignment of the nasoethmoidal complex  (Figure 59.26).   Having stabilized the outer orbital and facial frames  and frontonasal angle, the medial orbital wall defects  may be repaired with adaptive conical-shaped titanium  plates which can be placed from the subciliary approach    and visualized from above beneath the coronal flap. It is  easy for different surgical planes to be developed via both  approaches and to aid plate insertion, a polydioxanone  sheet passed from below into the medial orbital region  can easily be seen from above defining the subperiosteal  layer, acting as a soft tissue retractor. The plates may be  secured along the orbital rim, but if plates have already  been placed, then two or three screws placed into the infe-  rior lateral aspect of the orbit in the sounder bone found  here will suffice.   The medial canthal ligament in type 1 injuries will have  already been stabilized by reduction of the fractures.   In type 2 and 3 injuries, however, there is usually the  need to identify the ligament with the aid of a canthopexy  wire. Specialized wires are available (Synthes, Welwyn  Garden City, UK). A stainless steel needle is passed exter-  nally through the medial caruncular region emerging  interiorly through the inner surface of the down-turned  coronal flap through the identified medial canthal ten-  don. This latter point may be identified by grasping the  area behind the lacrimal apparatus with toothed forceps  and sequentially observing the effects on the medial can-  thal tendon. It must be remembered that the angulation of  the medial canthal region and the adaption of the eyelids  depend on good support of the eyelids by a medial canthal    600 Craniofacial trauma, including management of frontal sinus and nasoethmoidal injuries    tendon that is inserted superiorly and posteriorly. The best  way to ensure this is to use a curved plate from the frontal  region which may act as a point of support for the canthal  insertion. In such cases, the tendon wire is passed through  the lower hole of a suitable low profile plate. A passage for  the needle is then made by drilling across the ethmoidal  region behind the lacrimal apparatus to the contralateral  side aiming slightly posteriorly. The use of a green needle  will facilitate the passage of the wire’s needle across the tract  created. The curved plate may be so positioned and secured  on the frontal bone to give support for the tendon insertion  helping to restore the medial canthal angle, supporting the  tarsal plates and addressing any telecanthus by tightening  the wire to a superiorly placed screw (Figure 59.27).    Figure 59.27 Alignment of medial canthal tendon using  tendon wire and medial orbital plate.    The lacrimal sac and duct must be closely inspected  for damage. Many late obstructions of the system result  from inadequate reduction of the fractures and blockages  in the intra-bony part of the lacrimal system. Accurate  fixation of the fractures will help this point. However,  lacerations of the medial aspect of the lower eyelid carry  significant risk of damage to the inferior canaliculus. If  there is clear laceration in this region then identification  of the severed ends may be cannulated with ophthalmic  silastic stents, but it must be remembered that epiphora  will not result if one of the canaliculi are present and  functioning and if this is not easily achieved then such  procedures are best left as injudicious attempts at passing  catheters may cause damage to the remaining canalicu-  lus. It may be that further dacryocystorhinostomy may  be necessary even in those cases where the duct has been  repaired, as stenosis may occur even in stents left in place  for 6 months.    Aesthetic blunting and vertical discrepancies of the medial  canthal tendon are best dealt with through a combination  of osteotomy and reattachment of the tendon if necessary;  this latter point depends on the angle of the medial can-  thus. In general terms, trying to shorten the tendon with-  out addressing the widening of the bone will not correct  the defect.   Epiphora should be investigated by an ophthalmic  surgeon, usually with a dacryocystogram and either  the duct repaired or, more likely, a dacryocystorhinos-  tomy. Cerebral sinus thrombosis (CST), fistulas, infec-  tion and mucocoele formation associated with frontal  duct injuries and anterior fossa floor injuries are dealt  with as described above. A final complication involves  orbital volume changes to the associated medial wall  defects.    e Treat these injuries as part of a multidisciplinary team in  specialized centres.   e Avoidance of facial nerve injury by division of superfi-  cial temporalis fascia.  Mobilization of supraorbital bundle with osteotomes.  Preservation of peri-cranial flaps.   e Use of orbital plate to help give support for insertion of  medial canthal tendon.    Becelli R, Renzi G, Mannino G, Cerulli G and Iannetti G.  Posttraumatic obstruction oflacrimal pathways: A retro-  spective analysis of 58 consecutive naso-orbitoethmoid  fractures. J Craniofac Surg. 2004; 15: 29-33.   Bell RB, Dierks EJ, Brar P, Potter JK and Potter BE. A pro-  tocol for the management of frontal sinus fractures  emphasizing sinus preservation. J Oral Maxillofac  Surg. 2007; 65: 825-839.   Burstein F, Cohen S, Hudgins R and Boydston W. Frontal  basilar trauma: Classification and treatment. Plast  Reconstr Surg. 1997; 99: 1314-1321, discussion 1322.   Donald PJ. Management of frontal sinus fractures.  J Trauma. 2007; 62(Suppl): S91.   Ellis E 3rd. Sequencing treatment for naso-orbito-ethmoid  fractures. J Oral Maxillofac Surg. 1993; 51: 543-558.   Markowitz BL, Manson PN, Sargent L, Vander Kolk CA,  Yaremchuk M, Glassman D et al. Management of  the medial canthal tendon in nasoethmoid orbital    fractures: The importance of the central fragment  in classification and treatment. Plast Reconstr Surg.  1991; 87: 843-853.   Raveh J, Laedrach K, Vuillemin T and Zingg M. Management  of combined frontonaso-orbital/skull base fractures  and telecanthus in 355 cases. Arch Otolaryngol Head  Neck Surg. 1992; 118: 605-614.   Shumrick KA. Endoscopic management of frontal sinus  fractures. Otolaryngol Clin North Am. 2007; 40:  329-336.   Strong EB, Pahlavan N and Saito D. Frontal sinus fractures:  A 28-year retrospective review. Otolaryngol Head  Neck Surg. 2006; 135: 774-779.   Tiwari P, Higuera S, Thornton J and Hollier LH. The man-  agement of frontal sinus fractures. J Oral Maxillofac  Surg. 2005; 63: 1354-1360.    Terminology can be confusing. ‘Zygoma’, ‘malar’, ‘cheek’,  ‘zygomaticomaxillary’,, ‘zygomaticomaxillary orbital’,  ‘tripod’ and ‘tetrapod’ are all terms used to describe  essentially the same injury - a fracture of the zygomati-  comaxillary orbital complex (Figure 60.1). Apart from iso-  lated zygomatic arch fractures, nearly all other fractures  involve part of the orbital floor and lateral orbital wall.  Therefore, assessments of the orbit (and eye) are an inte-  gral part of management.    The cheek is predominantly formed by the zygomatic bone.  This fuses with the frontal bone at the frontozygomatic  (FZ) suture under the eyebrow, with the maxilla medi-  ally and with the temporal bone posteriorly and within  the orbit. The body of the zygoma provides the aesthetic  prominence of the cheek and together with the supraor-  bital ridge affords some protection to the eye. Superiorly,  the body of the zygoma forms approximately the lateral  two-thirds of the infraorbital rim, which is important for  lower eyelid support. Consequently, any displacement  in this area can affect eyelid function. Vertical displace-  ment of the entire zygoma can lower the lateral canthus  and lateral attachment of the globe with it (Whitnall’s  tubercle). This can result in diplopia, hypoglobus and an  anti-mongoloid slant to the eye (Figure 60.2).    The facial skeleton is not a solid structure, but contains  several ‘cavities’, notably the sinuses, orbits and nasal cav-  ity. Around these, the bones condense to form a series of  vertical struts known as ‘buttresses’. The zygoma forms  part of the lateral buttress. Horizontal buttresses also exist,  but are much thinner. Consequently, the facial skeleton is  very good at resisting vertically directed forces (biting/  chewing), but is relatively weak at resisting horizontal  forces (i.e. during most injuries). It has been suggested that  sinuses have evolved to produce this survival advantage.  Much like the chassis of a car, the face crumples, absorbing  much of the kinetic energy during impact. The buttresses  are a key element to facial repair and the support for any  screws.   The temporalis muscle passes beneath the zygomatic  arch to insert into the coronoid process of the mandible.  Displaced fractures of the zygomatic arch can therefore  impede mouth opening by interfering with this. The mus-  cle is invested in the temporal fascia, which arises from the  skull and passes down to insert into the zygomatic arch. This  is an important surgical landmark (Gillies approach). The  masseter muscle passes up from the mandible and attaches  to the body of the zygoma and its arch. This may have a  role in post-operative displacement of fractures which have  not been internally (or externally) fixed. It is argued that  fractures should be treated by open reduction and inter-  nal fixation (ORIF), as displacement may be caused by    masseteric pull over the ensuing weeks. Just because the  bone is accurately reduced immediately after surgery, it  does not mean that it will stay there.   The zygoma and maxilla support many of the perior-  bital and perinasal muscles attached to the periosteum. In  extensive repairs, degloving of much of these bones may  be required. Resuspension of the soft tissues is important  during wound closure to prevent sagging post-operatively.  The infraorbital nerve supplies sensation to the majority  of the cheek and the ipsilateral half of the nose and upper  lip. This passes along the floor of the orbit and exits the  infraorbital foramen approximately 1 cm below the infra-  orbital rim, approximately midway along its length. The  infraorbital canal and foramen form a plane of weak-  ness and fractures often pass nearby. The nerve is at risk  during repair.    A number of classifications exist. A practical one would be  to consider fractures as follows:    With the exception of isolated arch fractures, all  zygomatic fractures extend into the orbit. Following  assessment of the head and neck (remember the ABCs  lairway, breathing, circulation]), the eye therefore takes  priority over any fractures. Check for ocular injury, diplo-  pia and signs of entrapment. Clinical features of a fracture  may include the following:   e Flattening of the malar prominence (often masked by  swelling immediately after injury)   © Dysocclusion (premature contact on ipsilateral molar  teeth, due to flexing of the upper dental arch)    Figure 60.2 Downward displacement results in vertical  ocular dystopia and an anti-mongoloid slant.   ® Plain radiographs - occipitomental (OM), lateral face  and submental vertex (SMV). Look carefully - some-  times the only clue is a fluid level in the antrum.   ® Computed tomography (CT) scan, both axial and coro-  nal. These are increasingly used in patient evaluation.  Indications include high-energy injuries (is the orbital  apex involved?), suspected orbital floor involvement,  comminuted or severely displaced fractures, other mid-  face fractures suspected and assessment of the arch.   ® Ultrasound has been reported as useful for detecting  fractures, but is not commonly used.   ® Maxillary sinus endoscopy for orbital floor fractures  (not commonly used).    These fractures do not require urgent intervention and  can be assessed as an outpatient. In the interim, patients  should be advised not to blow their nose, in order to avoid  surgical emphysema. The concern here is not the air, but  the associated contamination (mucus, etc.), which can  pass into the orbit and soft tissues of the cheek through  the fracture. This can result in orbital cellulitis, both a  sight- and life-threatening condition if untreated. Patients  may also be advised not to fly, although there is no good  evidence base for how long in the literature; the author’s  advice is for 3 weeks. Some units may prescribe prophy-  lactic antibiotics.    When there is clinical and radiological evidence of a  displaced zygomatic fracture, indications include the  following:   © Sensory nerve deficit thought to be due to nerve  compression    Timing of treatment depends on the degree of swelling  and the general condition of the patient (notably any head  or ocular injuries). Surgery does not need to be carried    out on an emergency basis, although on occasion it can  be undertaken ‘immediately’ (ie. within a few days).  However, significant swelling may interfere with accurate  clinical assessment, both as an indication for treatment  (do not just look at the x-ray) and an on-table assessment  (is this adequately reduced?). It also makes aesthetic inci-  sion placement particularly difficult. Furthermore, swell-  ing may be exacerbated by surgical manipulation, so  care should be taken if there is any proptosis. Surgery is  therefore often carried out either immediately or about  5-10 days following injury. In the author's experience,  acceptable results can still be obtained up to 5 weeks after  injury, but all the fractures need to be openly reduced, cal-  lus osteotomized and accurate reduction becomes much  more difficult. This may be necessary only in exceptional  circumstances.    This depends on the fracture configuration and the degree  of displacement. In determining treatment, consider the  following:   Does the lateral buttress look comminuted on imaging?  If so, some sort of fixation may be required to prevent  collapse of the cheek. Do not use percutaneous hooks  blindly - they may comminute this more.   ©@ Is the zygomatic arch ‘greensticked’ or telescoped? The  arch is important for cheek projection and may need to  be reduced and aligned fully to maintain this. If tele-  scoped, access to it for fixation may be required.   Is the infraorbital rim comminuted? If so, it may need  repair.   ® Does the orbital floor also need exploration and/or  repair(s) (see Chapter 58)?    If none of the above applies, a closed reduction may suf-  fice. Case selection is very important both pre-operatively  and ‘on the table’, to identify those patients which are  unlikely to relapse post-operatively due to lack of any fixa-  tion. Closed reduction techniques include the following:    All of these involve making an incision somewhere on  the patient and could therefore technically be argued as  open techniques.    Figure 60.3 A Gillies lift. (a) Fracture site marked. 2-cm skin incision in the temple. (b) Following skin incision blunt dissect down  to temporalis fascia (TF). Watch out for superficial temporal artery. (c) TF is incised and lifted off the temporalis muscle. A curved clip  is good for this. (d) The elevator is passed deep to the TF towards the zygoma. Try passing a Howarth’s periosteal elevator before  - it helps open up the correct plane. (e) Make sure the elevator is under the bone before lifting (do not use the skull as a fulcrum).  Schematic/operative view immediately prior to lift. (f) Surgical anatomy of lift.    Figure 60.4 A malar hook. (a) Entry point marked. (b) Stab incision. (c) Hook introduced and rotated under malar bony  prominence. (d) Carefully lift ‘up and out’.    Figure 60.5 A buttress plate. (a) Mucosa marked allowing cuff to close. (b) Incision with knife or cutting diathermy (care with  metal retractors). (Continued)    Figure 60.5 (Continued) (C) Subperiosteal dissection to expose fractures. (d) Following fracture reduction (Gillies, hook or via    More recently, there has been a general move towards  ORIF, placing at least one plate (usually either a ‘buttress’  plate or one across the FZ suture). This is based on the  concerns regarding masseteric and other forces acting  on an unsupported reduction over the ensuing weeks.  A buttress plate can be placed transorally and a FZ plate  via a small upper blepharoplasty incision (Figure 60.6).  In both cases, scarring is virtually invisible. However,  this is still a matter of personal preference for each sur-  geon and closed techniques still have an important role  to play in management. Exposure to the infraorbital rim  should be avoided if at all possible. These scars may be  more noticeable, contraction can distort the lower eye-  lid, there is a risk of injury to the infraorbital nerve and  the fixation is the weakest of all the fracture sites. It may  be necessary, however, to access the orbit and/or repair  multiple rim fragments.   Sequencing is a matter of choice. This author’s approach  is generally as follows:    1. Address the FZ suture first, if it is significantly dis-  placed. The purpose of the fixation is to re-establish  the vertical height of the fracture and hopefully  the correct height of the lateral canthal/Whitnall’s  attachments.   2. If necessary, reduce and repair the arch. This is only  required occasionally and in significantly telescoped  arches, but it does necessitate a posterior approach  (pre-auricular or cutaneous incision). The arch is key to  cheek projection. Careful assessment is necessary, even  if not telescoped it may be bowed laterally and needs at  least digital reduction.   . Reduce and repair the lateral buttress. This is under-  taken via an intra-oral approach. In many cases, this  may be the only procedure required, if (1) and (2)  are not significantly displaced. This plate provides  mechanical stability.    4. Assess the infraorbital rim/orbital floor (force duction  test) and expose if necessary.   5. Consider the need for bone grafting the buttress. This is  rare and more likely in high-energy injuries.    A step-wise approach is therefore needed and patients  need to give informed consent appropriately. In many  cases, either a closed approach or ‘buttress’ plate will suf-  fice, usually the latter.    These can often be reduced via a Gillies approach or tran-  sorally. They are usually stable, but occasionally can fall  back down. If so, they may need support. Alternatives  include the following:   e Suturing an external splint along the arch (suture is  passed deep to the arch and tied over the splint)   @ Balloon inflation deep to the arch (a foley catheter will  suffice)   @ ORIF via a pre-auricular or overlying incision (beware  the facial nerve)    By and large, these are rare, since reduction and a simple  buttress plate can be undertaken relatively quickly in many  cases. External fixation (Figure 60.7), like the mandible,  may have a small role to play. Alternatively the zygoma can  be ‘kebabed’ using a trans-antral K-wire. This is certainly  quick, but is a blind procedure with risks to both eyes if  incorrectly performed.    Figu re 60.6 AnFZ plate, via upper blepharoplasty incision. (a) Site of incision marked in upper eyelid. (b) Following skin incision,  dissect down to periosteum. (c) Incise periosteum and elevate to expose fracture. (d) Some fractures are easily elevated and plated.  If very displaced, screw plate to lower half of fracture first. (e) Use a small hooked instrument or wire to lift and reduce the fracture  by applying force through an unused upper hole (do not damage the plate). Drill and screw the other hole. (f) Place second screw.  If correctly reduced, this will accurately restore the vertical height.    ANTIBIOTICS, STEROIDS AND TETANUS cephalosporin) and metronidazole is one option,  PROPHYLAXIS but many exist. Some surgeons prescribe steroids  SSS — — — SS (dexamethasone/methylprednisolone) to reduce post-  Protocols may vary between different units. Antibiotics operative orbital swelling.    Figure 60.7 External fixation (see Chapter 58 for sequence). (a) Stab incision and trochar over cheek. (b) Following drilling, pin  screwed into bone. (c) Procedure repeated for frontal pin. (d) Final assembly. Leave some space between joints and skin for hygiene    The main concerns here are to ensure that the fracture stays  in the correct position and serious complications such as  loss of sight and severe infections do not develop. As patients  wake up, they may be initially agitated and the repaired site  must be protected from inadvertent injury. Various ways  of achieving this are possible, but having the site clearly  marked and an alert recovery/ward nurse go a long way  to achieving this. Swelling and bleeding behind the globe  can occur, which unrecognized can result in loss of vision.  Careful observation of the eye is therefore important, at  least until the patient is awake. Various regimes exist.  Antibiotics and steroids may be continued for a variable  time and patients should be advised not to blow their nose.    Proptosis following injury or repair needs to be evalu-  ated quickly and carefully. The concern here is loss of    sight following retinal/optic ischaemia. For this reason,  the eye is put under careful observation, usually until the  next day, although they can probably be stopped when  the patient is fully awake. Progressive pain, deteriorat-  ing vision, proptosis and ophthalmoplegia are the main  signs to check. Traditionally, acute proptosis is considered  to be a retrobulbar haemorrhage (RBH), although in the  author’s experience (and as published) RBH is rarely the  cause. Once the orbit/zygoma has been reduced, the orbit  becomes a closed space and swelling is contained, result-  ing in an orbital compartment syndrome (OCS). For this  reason, steroids are variably prescribed post-operatively.  The key to urgency of treatment is the visual acuity, if the  vision is normal, decompression is not required. Rarely  do such cases need to be returned to theatre, but if they  do it should be remembered that an OCS may not release  blood, in which case if the proptosis is that severe, decom-  pression will be required. Intravenous acetazolamide,  mannitol, steroids and a lateral canthotomy buy time  while theatre preparations are being made. If in doubt,  globe tension should be measured by a ‘tonoper’ or other  suitable device.    If the eyelids are swollen, gently pressing on them (not  the globe) for a few minutes reduces this sufficiently to  assess visual acuity.   Numbness of the cheek and upper lip is an important  sign that should generate a high index of suspicion for  orbital or cheek bone fracture.   Isolated arch or simple fractures which are incomplete at  the FZ suture are those most suitable for closed reduction.  Arch fractures with associated coronoid fractures are at  risk of ankylosis.    Correct alignment of the sphenozygomatic suture  (lateral orbital wall) is a good on-table indication that the  fracture is correctly reduced.   A force duction test should be performed at the end of  any reduction. As the fractures realign, orbital soft tissues  may become trapped.   Beware of late enophthalmos - follow up patients closely.  Place sticky tape over the repaired site. Do not draw on  the patient —- they may try and rub it off.    Arthroscopy of the human temporomandibular joint (TMJ)  was first introduced by Ohnishi in 1975.! The current  diagnostic and operative technique will be presented.  Meticulous attention to detail is required to successfully  perform the procedure. Any alteration or compromise of  the step-by-step surgical sequence will alter the ability to  complete the planned procedure and will compromise the  outcome. Operations are done in the superior joint space  unless disc perforations exist which allows entry into the  inferior joint space.    The TMJ is a synovial joint subject to similar pathology  as with other synovial joints. A basic difference, however,  exists in that fibrocartilage rather than hyaline cartilage  lines the articular surface. Fibrocartilage consists mainly of  collagen types I and II, and is a mixture of dense fibrous tis-  sue and cartilaginous tissue. Hyaline cartilage is composed  primarily of type II collagen and is primarily cartilaginous  tissue. Osteoarthritis is the end point of the natural history  of degenerative disease. This may develop primarily or as a  result of the traumatically dislocated interposing articular    disc. Important structural anatomy of the TMJ is shown in  Figure 61.1.   The displaced disc causes pain and mechanical locking  of the mandible. Synovial adhesions often accompany  the herniation of the disc into the anterior recess. Central  perforations of the disc occur in primary osteoarthritis.  Perforation of the posterior ligament occurs in chronic  dislocated discs secondary to micro- or macro-trauma.  A conservative surgical cascade is advocated to manage the  disease process. Evidence-based research has shown that  restoration of normal anatomy or removal of the diseased    Figure 61.1 Anatomy of the temporomandibular joint  (TMJ) as it relates to arthroscopy.    perforated disc is not always needed to obtain a return to  relatively pain-free function.    Although there are exceptions, patients who undergo  initial consultation for TMJ pain, pain with joint noise  or restricted mouth opening should undergo conser-  vative non-surgical therapy prior to any type of surgi-  cal intervention. This essentially includes teaching the  patient about limiting eccentric jaw movements, elimi-  nating any pathologic habits (gum chewing, opening  mouth excessively wide etc.), having the patient undergo  Boering therapy which is educating the patient about  their problem, and instructing them to partake of a  softer diet and to habitually perform non-clenching tech-  niques. In addition, these patients should begin a regi-  men of oral anti-inflammatory medications to decrease  any acutely inflamed process, and wear a soft orthotic  device to either eliminate a bruxing habit or to soften the  load placed on the TMJs during bruxism. The chronic  bruxer can also benefit from an oral muscle relaxant to  minimize the load as well. The exceptions to this general  rule will include, of course, those patients who present  for initial consultation who have already undergone the  aforementioned conservative therapy with little or no  positive results.   After 2-4 months of conservative therapy, the patient is  re-evaluated for their condition. Sometimes, the problem(s)  will be resolved with these measures and no additional  treatment is warranted. However, there are many patients  who are refractory to this conservative approach, and who  desperately wish for a resolution to their problem. This  is where a discussion with the patient about minimally  invasive TMJ surgery is indicated.    The patient is made aware that arthroscopic TMJ surgery  may not alleviate the patient’s symptoms and that open  joint surgery is indicated if more conservative treatment  modalities fail. Additionally, the patient is informed of the  possibility of seventh nerve deficits secondary to extra-oral  punctures, malocclusion following surgery, possible scar  formation from the punctures, as well as the possibility for  pain, bleeding, swelling, and post-operative infection.   The next step is making a decision on the type of  arthroscopic procedure that the patient will receive. This  obviously must be ascertained based on the diagnosis made.  For example, a patient with a clicking joint, intermittent  pain and 35 mm maximal incisal opening (MIO), with a  Wilkes’ stage II may benefit from a lysis of adhesions with  lavage of the superior joint space to relieve the symptoms  (lysis and lavage procedure). Then again, a patient who is  in extreme pain with an anteriorly dislocated disc, which is  non-reducing on magnetic resonance imaging (MRI), an  MIO of 20 mm, with a preliminary Wilkes’ stage IV, may  benefit from a surgical arthroscopy procedure consisting of  anteriorly releasing the disc with posterior repositioning,  and fixating the disc to the condylar head arthroscopically  (arthoscopic discopexy procedure) (Table 61.1).    When the patient is ready for surgery, it is important to  wrap the patient’s head with a sterile drape prior to enter-  ing the operating room to keep hair out of the operative  field. When the head is wrapped securely, it allows the pro-  cedure to be clean and less cumbersome. In addition, the  possibility of infection is minimized.   The procedures for TMJ arthroscopy are best performed  under general anaesthesia via nasal intubation. It is crucial  that the assistant is able to manipulate the mandible and  close the jaw into occlusion without the endotracheal tube   II First few episodes of pain, occasional joint tenderness and _ Slight forward displacement and beginning anatomic  related temporal headaches, increase in intensity of deformity of disc, slight thickening of posterior edge  clicking, joint sounds later in opening movement, of disc  beginning transient subluxations or joint locking   Ill Multiple episodes of pain, joint tenderness, temporal Anterior displacement with significant anatomic  headaches, locking, closed locks, restriction of motion, deformity/prolapse of disc, moderate to marked  difficulty (pain) with function thickening of posterior edge of disc, no hard-tissue    symptoms, variable and episodic pain, chronic restriction  of motion, difficulty with function    getting in the way. If, however, the surgeon and patient  elect to do a procedure such as arthroscopic arthrocen-  tesis in an office setting under local anaesthesia and light  sedation, the patient must be able to follow commands of  moving the jaw open and closed and into lateral excursions  during the procedure. A diagram of patient positioning in  the operating room setting is shown in Figure 61.2, and  arthroscopic set up is shown in Figure 61.3.   Peri-operative medication considerations are crucial to  attaining optimal results with TMJ arthroscopy. The use of  prophylactic antibiotics to prevent post-operative infection  is controversial. The orthopaedic literature in regards to  arthroscopy is scant with good prospective studies, since the  incidence for infection following arthroscopic procedures is  so low. The American Academy of Orthopaedic Surgeons  has not produced an advisory statement regarding the issue.  However, literature does exist essentially stating that antibiotic  prophylaxis for arthroscopic procedures is not indicated for  healthy patients. It is the opinion of the authors that antibiotic  usage is indicated for those prone to infection. These include  patients with diabetes, compromised immunity, or skin dis-  orders. When antibiotics are indicated, 1 g of cefazolin given  intravenously 1 hour prior to the procedure provides good  coverage to prophylactically manage these patients.   Intravenous administration of corticosteroids prior to the  procedure is an important consideration to prevent post-  operative oedema. In the immediate post-operative period  following TMJ arthroscopic procedures it is crucial to ini-  tiate mandibular motion and mouth opening exercises to  prevent arthrofibrosis, haemarthrosis, and train the muscles  of mastication to stretch. Oedema interferes with this abil-  ity to achieve the goal of improved mandibular functioning.  Because of this, it is advisable to administer post-operative  dosing regimens of corticosteroids in a tapered fashion.   As discussed earlier, the importance of instructing the  patient to move the mandible post-operatively cannot be  overemphasized. Patients are given these directions for jaw  hinge exercises the day of or the day following surgery. These  exercises are classified as stages I and II. Stage I exercises con-  sist of taking the tongue, rolling it as far back on the palate    as possible, and opening as wide as possible without disen-  gaging the tongue. The second of these exercises is to move  the jaw in lateral and protrusive excursions as far as possible.  Both sets of exercises are to be performed for 20 repetitions, 4  times per day. Stage II exercises involve the pry bar, painting  of teeth and rubber tubing. The pry bar is placing the thumb  on the upper incisors, the middle finger on the lower inci-  sors, and prying to maximum incisal opening. The painting  of teeth involves taking the tip of the tongue and starting at  the buccal surface of the most posterior molar, painting all  of the teeth from right to left and back again. Lastly, a piece  of rubber tubing is placed between the canines on one side  and moving into lateral excursions whilst lightly biting on  the rubber tubing. Each of these exercises is performed for  20 repetitions, 4 times per day.   Most patients are instructed to follow stage II exercise,  but stage I exercises are indicated for patients under cer-  tain circumstances. For example, patients who undergo  semi-rigid discopexy repair with the suture technique to  treat anterior disc dislocation could very easily relapse back  into the anterior disc position if translation is initiated too  early. The same is true for those patients who receive pos-  terior retrodiscal scarification procedures to treat slightly  dislocated discs. Also, in those patients treated for condylar  subluxation who undergo posterior retrodiscal release need.  to undergo opening exercises in reverse after surgery. This  is to say that they need to prevent translating their condyles  to allow the disc to settle into correct position. In all three  of these instances, the patient is only gradually worked into  full function due to the instability of the disc position, and  potential for relapse of an anteriorly dislocated disc.    Regardless of the pathology the recommended surgical  cascade is as follows:    A diagrammatic view of the relevant TMJ anatomy as it  relates to puncture is shown in Figures 61.4 and 61.5.    This procedure essentially involves the single puncture  technique. The single puncture technique is shown in  Figure 61.6.   The thumb is used to palpate the maximum concavity  of the glenoid fossa at the junction between the periosteum  and synovial capsule. The bony landmark is the maximum    concavity of the inferior aspect of the zygomatic and temporal  bones. To facilitate precision of the technique, this puncture  should be done with a sharp trocar. Throughout the punc-  ture into the superior joint space, the trocar and cannula are  advanced deeper into tissues utilizing a twisting and rotational  motion to prevent injury to the facial nerve and to provide  better control of the sharp instrument. After puncturing skin,  the trocar is used to scrape off soft-tissue attachments sub-  periosteally at the maximum concavity of the glenoid fossa.  The trocar and cannula are then redirected medially to enter  the superior joint space. A depth of 20-25 mm indicates a safe  puncture. Any more and the risk of perforating through the  medial synovial drape increases. It is important that the scope  enters the joint as supero-lateral as possible for best visualiza-  tion. Once inside the joint, the lavage of the joint ensues, and  irrigating needle is placed for outflow. The 22-gauge irrigating  needle can be inserted 5 mm anterior and 5 mm inferior to  the first puncture. It is important to insufflate with 2-3 cc of  fluid prior to placing the irrigating needle to prevent collapse  of the joint space (Figures 61.7 through 61.9).    This procedure involves the double puncture technique.  The fossa portal is created as described by the single    instrumentation such as holmium lasers, shavers, graspers,  straight probes, hook probes, as well as certain medica-  ments if they are needed. The size of the working cannula  can be increased as needed (Figures 61.10 through 61.14).    Figure 61.10 (a) Measuring second puncture point.  (b) Measuring second puncture point.    puncture technique. Once the arthrosopic cannula with  arthroscope is inserted, the articular eminence portal is then Ng pP  created by triangulation. To perform this technique, the ic  most superior, anterior and lateral aspects of the articular  eminence are targeted. The lavage needle is removed, and a  2.0 trocar and cannula is introduced into the superior joint  space. The second cannula inserted is known as the work-  ing cannula. The working cannula is used to accommodate Figure 61.11 Triangulation concept.    This procedure, which is the most complex, involves three  to four punctures into the superior joint space. For rigid  discopexy (fixating the reduced disc with resorbable screws  or nails), three punctures are utilized. In addition to the  arthroscopic cannula and the working cannula as previously  described, the third puncture involves creation of the fixa-  tion portal for insertion of the fixation cannula. For semi-  rigid discopexy (fixating the reduced disc with sutures),  four punctures are utilized. The arthroscopic cannula,  working cannula and fixation portal which accommodates  two needles for sutures: one anterior and one posterior.  For either rigid or semi-rigid discopexy, an anterior  release must be performed prior to fixation. The anterior    release is best performed through the working cannula with  a holmium laser. The disc-synovial crease is delineated and  scored with a hook probe, and the laser is used to cut along  scored area, making sure to detach the superior head of  the lateral pterygoid from the disc tissues. After adequate  release is performed, the straight probe is utilized to reduce  the disc posteriorly, whilst the mandible is in the forward  position. The retrodiscal tissues, at this time, can be ablated  with bipolar cautery or a holmium laser as a means to scar  the tissues and keep the disc reduced.   For the rigid discopexy procedure, the fixation portal  is created whilst a straight probe in the working cannula  reduces the disc posteriorly. The trocar and cannula targets  the posterior lateral disc attachment. A 22-gauge needle is  used to sound the area predicted for puncture. Whilst the  mandible is in the forward position, the fixation portal is  created 20 mm inferior to the fossa portal.   Rigid fixation of the disc to the condylar head can  now be performed through the fixation cannula which is  approximately 3.0-3.5 mm in diameter. Fixation is done  with either resorbable screws or nails, and can be done  with 1, 2 or 3 depending on the amount of access that is  available. Post-operative rehabilitation consists of immedi-  ate functioning with stage II exercises, as disc position is  secure. The correct position of the three cannulas is shown  in Figure 61.15, whilst pictures of the technique is shown in  Figures 61.16 through 61.18.   For semi-rigid fixation, or suture discopexy, the fixa-  tion portal is created the same way as in the rigid fixation  technique. The anterior release is shown sequentially in  Figure 61.19a through c. Through the fixation cannula,  a vector is aimed at the postero-lateral attachment.  A straight meniscus mender is then punctured under the  reduction cannula to the condylar head then superiorly  through the posterior lateral portion of the disc. A second  meniscus mender is then punctured through skin and is  used to catch the suture (Figure 61.20). A 0-PDS suture  is then passed anteriorly and a snare is used to catch it  posteriorly (Figure 61.21). The location of the suture    Figure 61.19 (a) Outlined location of anterior release.  (b) Making anterior release. (c) Anterior release completed with  associate anatomical structures.    when it is pulled through skin is parallel and inferior to  the apex of the tragal cartilage. A small skin incision is  made after the suture is passed through, and a surgeon’s  knot is tied to capsule and disc (Figures 61.22 through  61.25). Post-operative rehabilitation for these patients  is slow and requires only limited amount of jaw mobil-  ity initially, gradually increasing to stage II exercises and  beyond.    Figure 61.21 Suture discopexy. A snare is used to catch  the PDS suture.    Figure 61.22 Suture discopexy. The two ends of the  discopexy suture emerge through the overlying skin.    Overall, TMJ arthroscopy is a safe procedure. It is mini-  mally invasive, and can be performed in an outpatient  setting. Complications do, however, exist. These include  facial nerve trauma, arthrofibrosis, infection, perfo-  ration into the ear canal or tympanic membrane and    Figure 61.23 Suture discopexy. The sutures are then  passed deep to the skin using the needles prior to tying the  surgeon’s knot.    Figure 61.25 Suture discopexy. The disc is anchored to the  joint capsule and the surgeon’s knot is buried under the skin.    subdural or epidural haematoma from perforation into  the middle cranial fossa. Management of these complica-  tions is outside the scope of this chapter, however, with  good surgical technique and attention to detail, as well as  procedure selective post-operative rehabilitation, these  complications can be reduced to almost none.    Patient positioning is paramount. If you start behind,  you will become flustered for the entire procedure. Make  sure the patient’s head is turned and flat on the table,  which will facilitate an easier puncture. Each step of  arthroscopy is dependent on the successful completion  of the previous one. It is impossible to perform advanced  procedures if this principle is not strictly adhered to.  Always use landmarks. It is easy to become lost dur-  ing a puncture. If you feel like no progress is being  made, then back away, orient yourself with the known  landmarks (zygomatic process of temporal bone, gle-  noid fossa and condylar head) and use these to make  an accurate puncture. Use the vectoring measuring  system for all multiple punctures.   Make sure to gather all information. Once inside the  joint, a thorough diagnostic arthroscopy is crucial  to treating the condition. Make note of everything  that comes into view (perforated disc, hyperaemic  retrodiscal tissues, amount of dislocation etc.) and  use this knowledge to come up with the best possible  treatment.   Do not rush. The temptation to rush through a part or all  of this procedure will most likely lead to unfavourable  results. Make sure to take extra time to explore the entire  posterior pouch, the anterior recess, and if the second  or third punctures are not entering the joint space in a  timely fashion, be patient and do it right. It is not the job  of the practitioner to make the patient worse.   Be aware of all danger zones inside the joint space. It  is important to keep the depth of fossa puncture to  25 mm or less and the vector of puncture anterior.  Failure to do so may result in perforation of the tym-  panic membrane. Never move the operative can-  nula instrumentation posteriorly unless under direct  arthroscopic control. Blind manoeuvres risk perforation  of the medial synovial drape and the risk of injury to  the tympanic membrane and or perforation through  the glenoid fossa into the middle cranial fossa. Always    arthroscopically visualize the insertion and movement  of the operative cannula in the anterior recess. Blind  manoeuvres may lead to a laceration of the middle  meningeal artery and or the lingual nerve.   e Make sure to prevent extravasation. Avoid careless  multiple punctures. Always maintain a patent irriga-  tion system. Lack of a good lavage needle to drain the  insufflated joint space will result in extravasation of irri-  gating fluid, which can be seen clinically as a swelling  of the affected side of the face. Extravasation into extra  capsular tissues can lead to trismus, pain, malocclusion,  facial nerve paresis, and increased recovery time. In  addition, if an anterior release of the disc is performed,  the fluid could extravasate into the pterygoid space  and further into the lateral pharyngeal space, leading  to a very difficult airway situation.    1. Ohnishi M. Arthroscopy of the temporomandibular  joint. Jap Stomatol Sot. 1975; 42: 207.    Bert J, Giannini D and Nace L. Antibiotic prophylaxis for  arthroscopy of the knee: Is it necessary? Arthroscopy.  2007; 23: 4.   Smolka W and Iizuka T. Arthroscopic lysis and lavage in  different stages of internal derangement of the tem-  poromandibular joint: Correlation of preoperative  staging to arthroscopic findings and treatment out-  come. J Oral Maxillofac Surg. 2005; 63: 471-478.   Wilkes CH. Internal derangements of the temporomandib-  ular joint: Pathological variations. Arch Otolaryngol  Head Neck Surg. 1989; 115: 469.    Arthrotomy refers to the direct surgical exposure of a  joint. A temporomandibular joint (TMJ) arthrotomy is  technically one of the more difficult surgical dissections  in the maxillofacial region. Whilst the close proximity  of the facial nerve is the main reason for the difficult  surgical access, other important anatomical structures  such as the complex distribution of the superficial tem-  poral vessels also add to the complexity of the dissec-  tion. With the middle cranial fossa above, the internal  maxillary artery medial to the TMJ, and the middle ear  behind the TMJ, there is little room for surgical error as  these anatomical structures are only a few millimetres  away from the joint itself.    Surgery to the TMJ is undertaken for a wide range of joint  disorders. Indications for surgical intervention are divided  into absolute and relative.   Absolute indications: TMJ surgery has a definite and  undisputed role in the management of uncommon joint  disorders such as the following:    Relative indications: The role of TMJ surgery in the man-  agement of common disorders such as traumatic injuries,    internal derangement and osteoarthrosis is less clear and  often ill-defined. The indications may be further divided  into the following:    1. General indications  a. Where the joint disorder remains refractory to non-  surgical therapy involving occlusal splints, medica-  tion and physiotherapy    b. Where the TMJ is the source of the pain and  dysfunction hence    i. Pain localized to the TMJ  ii. Pain on functional loading of the TMJ  iii. Pain on movement of the TMJ  iv. Mechanical interferences within the TMJ    Note: The more localized the symptoms are to the TMJ, the  more likely surgery will have a favourable outcome.    . Specific indications: Confirmation of significant joint  disease on computed tomography (CT) scan or mag-  netic resonance imaging (MRI) associated with symp-  toms of intolerable joint pain and joint dysfunction.    TMJ arthrotomy is performed under general anaesthesia  using a naso-endotracheal tube to permit manipulation  of the mandible that will help identify the position of the  mandibular condyle during surgical approaches to the joint.    The patient is positioned in the reverse Trendellenberg  slant with the level of the head slightly above the the rest  of the body to minimize bleeding. The head is turned away  on a 60 degree angle.    Hair is shaved in front of the ear to the level of the superior  tip of the pinna. Three-inch (9-10 cm) wide waterproof  tape (‘sleek tape’) is placed horizontally above the ear and  another length of tape is placed vertically behind the ear to  cover the hair (Figure 62.1). A marking pen is used to out-  line the proposed incision line. The surgical site, including  the adjacent ear and ear canal, is liberally prepped with  antiseptic solution. A sterile ear pledget with vaseline is  inserted to protect the ear canal. A turban head drape is  wrapped around the head which covers the anaesthetic  tube exiting the nose (Figure 62.2). Marcaine (0.5%) with  1:200,000 is infiltrated into the subcutaneous tissues along  the incision line and into the joint proper.    Whilst there have been numerous surgical approaches to the  TMJ described in the literature, the author uses either a dou-  ble curved pre-auricular (Figure 62.3) or more commonly  an endaural incision (Figure 62.4) with a small temporal  extension as his surgical approach. It allows direct surgi-  cal access to the joint and provides excellent access for most  TMJ surgical procedures including total joint replacements.    A 5-6-cm curvilinear pre-auricular incision, peaked  posteriorly at the level of the tragus (Figure 62.3), is  made through skin and subcutaneous tissues. The    pre-auricular incision runs around the anterior inser-  tion of the pinna, extending down to the lower border  of the insertion of the ear lobe to pre-auricular skin.  Alternatively, the inferior incision is made over the crest  of the tragus down to cartilage (Figure 62.4), taking care  not to cut into the tragal cartilage. Superiorly, a small  temporal extension of the incision is made in a forward  arc about 45° relative to the zygomatic arch down to sub-  cutaneous fat.    Beginning superiorly, the temporal part of the incision is  carefully dissected deep towards temporalis fascia with  fine curved dissection scissors such as Iris or Tenotomy  scissors. Any superficial temporal vessels encountered are  either surgically cut and tied or carefully retracted into the  anterior flap that is extended anteriorly by blunt dissection  with a periosteal elevator.    Inferiorly, the flap is developed with fine curved scis-  sors in a relatively avascular plane parallel to the base of  the external auditory (tragal) cartilage (Figure 62.5) which  runs anteromedially or along the plane of the tragal carti-  lage if the endaural approach is used (Figure 62.6).    Once the pre-auricular temporal flap is sufficiently devel-  oped to expose the underlying temporalis fascia, the assis-  tant manipulates the mandible whilst the surgeon uses his  index finger to feel for the movement of the condyle under  the temporalis fascia. Once the position of the condylar  head is established, a 2-cm horizontal incision is made  through the temporal fascia down to the bone along the  root of the zygomatic arch (Figure 62.7). Brisk venous  bleeding from deep temporal tissues can be cauterized.  Beginning posteriorly, a 45° incision is made inferiorly  and the triangular flap created (Figure 62.8) is sharply  dissected to lift the temporalis fascia off the lateral TMJ  ligament.   Using a sharp periosteal elevator, a flap is developed  forwards by blunt dissection exposing the root of the  zygomatic arch. Once again, the surgical assistant should  manipulate the mandible so the surgeon can palpate for  and identify the position of the moving condyle.    A sturdy periosteal elevator is used to expose the root of  the zygomatic arch as far forwards as the articular emi-  nence. From the pocket created over the root of the zygo-  matic arch, the lateral ligament (Figures 62.9 and 62.10)  is identified inferiorly by sharp and blunt dissection. The  lateral ligament is then progressively raised forwards by    Figure 62.5 Raising full thickness skin flap to expose  temporalis fascia.    blunt dissection over the capsule and lateral margin of  the glenoid fossa. This layer is relatively avascular, except  inferiorly where branches of the superficial temporal ves-  sels will be encountered and may be cauterized. Access  may be extended anteriorly and inferiorly depending on  the degree of joint exposure required. At this point, more  Marcaine 0.5% with 1:200,000 adrenaline is injected  through the capsule.    With the condyle distracted inferiorly by the surgical assis-  tant, pointed scissors are used to bluntly enter the superior    joint space and opened to reveal the superior surface of the  articular disc.    1. Exposure of superior joint space: With a small blade,  the opening is extended anteriorly and posteriorly  by cutting along the lateral aspect of the eminence  and fossa (Figure 62.11). The capsule is reflected later-  ally to reveal the superior joint space (Figures 62.12  through 62.14). A broad periosteal elevator such as  a Seldin is then inserted into the superior joint space  to help further distract the joint and expose the superior  joint space as well as the glenoid fossa and eminence.    elevator, the periosteum covering the lateral aspect  of the articular eminence is stripped off with for-  ward blunt dissection along the root of the zygomatic  arch. Once the anterior and posterior slopes are fully  exposed, a small sharp periosteal elevator is directed  medially below the greatest convexity of the articular  eminence. The medial dissection through the capsule  will expose the inferior aspect of the articular eminence  which makes up the anterior boundary of the glenoid  fossa (Figure 62.15).    3. Exposure of inferior joint space: An incision is made  along the lateral attachment of the disc to the condyle  within the inferior recess of the capsule (Figures.62.16  through 62.18). Brisk haemorrhage may occur if the  posterior attachment of the disc is cut. A fine periosteal  elevator is inserted into the inferior joint space to sepa-  rate the disc from the condylar head and retract the disc  superiorly to expose the articular surface of the condyle.   4. Exposure of the condylar head: To further expose the  condylar head, a vertical relieving incision is made  downwards behind the condyle.    Special right angle condylar retractors may then be  inserted behind and in front of the condyle to fully expose    and stabilize the condyle (Figures 62.19 and 62.20).  Anteriorly, the condylar retractor may be inserted below  the attachment of the lateral pterygoid muscle to the fovea  of the condyle.    The articular disc plays a pivotal role in the complex  mechanics of joint function. Any change in its physical  structure, integrity or position may result in pain and joint  dysfunction referred to as internal derangement.    Figure 62.18 Coronal view of surgical approach to inferior  joint space.    The two most common surgical procedures performed posterior to the posterior band of the meniscus is  on the articular disc are disc repositioning and discectomy. excised using fine scissors, leaving a rim of vascular-  ized tissue 2 mm from the avascular posterior band of    Howarth periosteal elevator or Seldin is inserted to Buried horizontal mattress sutures (5-0 mersilene) are  help free up the disc anteriorly and medially. The used to fix the disc to the remaining retrodiscal tissues in  assistant then manipulates the mandible to deter- its new position (Figure 62.22). Various anchoring devices  mine the functional position and integrity of the disc attached to the condylar head, such as the Mitek mini  (Figure 62.21). At this point, Marcaine (0.5%) with anchor, have also been reported as more stable fixation  1:200,000 adrenaline is injected into the posterior point for the disc.    disc attachment and bilaminar tissues before the disc  is freed up posteriorly and the vascular retrodiscal  tissues are exposed. With minor anteromedial dis-  placements, sufficient redundant tissue within the  bilaminar zone can be surgically removed and the  disc repositioned posteriorly and laterally. Multiple  4-0 interrupted (non-resorbing) mersilene sutures  are placed to anchor the disc to the bilaminar tissues.  In situations where the disc is severely displaced, the  inferior joint capsule is also exposed (Figure 62.18).  A blunt instrument is inserted into the inferior joint  space to release the disc from the condylar head and  mobilize it further. Redundant tissue lateral and    2. Discectomy: In cases where the disc is found to be unsal-  vageable, it is completely excised. Both upper and lower  joint spaces are exposed (Figures 62.14 and 62.18) and  a vascular clamp is placed across the retrodiscal tissues  (Figure 62.23). As the assistant distracts the mandible  (and condyle) downwards and forwards, the postero-  lateral part of the disc is first excised with fine pointed  scissors. The remaining anteromedial part of the disc is  then clamped with Allis tissue forceps to help retract  it laterally and posteriorly to facilitate excision of the  remaining part of the disc (Figures 62.24 and 62.25).  Infiltration with local anaesthesia and judicious dia-  thermy of bleeding points will help reduce bleeding in  the resultant joint cavity.    Many surgeons, however, leave the space empty  following discectomy with good long-term results, whilst  most other surgeons prefer to use pedicled temporalis  muscle flaps.    The articular eminence is often surgically remodelled in  cases of recurrent dislocation. It may also be surgically  altered to accommodate a fossa prosthesis during total  joint replacement. Surgical procedures to the disc may  also involve reduction of the articular eminence to facili-  tate the free movement of the operated disc. The articular    Anteriorly displaced disc Excision of retrodiscal tissue Posterior repositioning  and plication of disc    Figure 62.22 Excision of retrodiscal tissues (a) and (b) and posterior repositioning of disc (0).    eminence may either be surgically reduced (eminectomy)  or augmented with osteotomies and/or grafts.    1. Eminectomy: The base of the eminence is identified by  scoring the bone with a fine bur in a horizontal line  joining the anterior and posterior slopes (Figure 62.26).  The lateral part of the eminence is best removed with a  fine curved chisel (Figure 62.27). The medial extension  of the eminence is not as prominent as the lateral part  and so bone files mounted on a reciprocating powered  handpiece can be used to reduce the bony prominence  (Figure 62.28) until the glenoid fossa is flush with the  root of the zygomatic arch.   2. Eminence augmentation: A number of augmenta-  tion procedures have been described to prevent the    forward movement of the condyle in cases of recurrent  dislocation. Unfortunately, the success of the follow-  ing techniques is limited, especially where the condy-  lar head is small or atrophic and may slip medial to the  augmented site:    a. Dautrey’s osteotomy: This is where the zygomatic  arch is divided just in front of the eminence and  is then infractured. No fixation is used to hold the  infractured arch which is held in position by fric-  tion alone (Figure 62.29).   b. Onlay graft: Autogenous bone or allograft car-  tilage blocks are secured to the anterior slope  of the eminence with miniplates and screws  (Figure 62.30).    c. Interpositional graft: A horizontal osteotomy is  made along the base of the articular eminence. The  inferior portion is downfractured and an autog-  enous bone graft is placed as an interpositional  graft which is secured with bone plates and screws  (Figure 62.31).   d. Alloplastic fixation: Metallic screws or plates are  secured to the inferior surface of the eminence and  left prominent to act as a physical barrier to the for-  ward translation of the condyle.    The condyle is pivotal to the development, form and func-  tion of the mandible. Trauma, disease or developmental  disorders which afflict the condyle will also have a sig-  nificant impact on the mandible, in particular, the occlu-  sion. Surgery to the condylar head may range from simple  smoothing of irregularities in the fibrocartilagenous artic-  ular surface, and removal of osteophytes, to complete  amputation of the condyle itself in cases of severe disease  or tumours. The following are some of the surgeries:    1. Debridement: Upon entering the lower joint space  (Figure 62.18), close inspection of the condylar  head may reveal irregularities or defects within the    Figure 62.30 Augmentation of eminence with onlay grafts  fixed with plate and screws.    fibrocartilagenous articular surface (Figure 62.24).  With the condyle inferiorly distracted, a Molt currette  is used to gently shave the surface irregularities.   . Removal of osteophytes: these bony projections are often  found on the lateral pole of the condyle and should be  removed with fine osteotomes rather than powered  handpieces so as to minimize surgical trauma to the  condyle itself.   . High condylar shave: With the lateral pole of the condyle  exposed, the top 5 mm layer is surgically removed with  an osteotomy cut from the lateral aspect of the con-  dylar head which is completed medially by chisel. The  remaining surface is surgically smoothed with a bone  file, ensuring there are no sharp margins around the  circumference of the osteotomy site.   . Partial condylectomy: The lateral pole of the condyle  may be excised (Figure 62.32) with the deep margin  up to half the width of the condylar head. The aim  is to preserve the medial pole of the condyle in order    to maintain the height of the ascending mandibu-  lar ramus. A diagonal osteotomy is made from the  posterior aspect of the condylar head (Figure 62.33)  which is completed with chisels. Any sharp edges  in the remaining defect are smoothly rounded with  bone files.   5. Total condylectomy: Blunt dissection is carried infe-  riorly to expose the neck of the condyle to the level  of the sigmoid notch (Figures 62.19, 62.20 and 62.34).  With two condylar retractors helping to stabilize  condyle, a reciprocating saw is used to section the  condylar neck. A fine chisel is used to complete the  osteotomy. The amputated condylar fragment is then  held with bone holding forceps whilst the medial  attachment of the articular disc is released with .  sharp scissors. Anteriorly, the thick attachment of Figure 62.33 Sagittal ostectomy of lateral pole of condyle.  the lateral pterygoid muscle is released with dissec-  tion scissors as a traction force is placed on the con-  dylar fragment with the bone holding forceps. Once  the condylar process is extracted (Figure 62.35) from  its tissue bed, attention must be paid to the multiple  bleeding sites.    Total joint replacement with autogenous grafts or  alloplastic prosthesis should always be considered at  the same time as the condylectomy to prevent severe  mandibular functional and structural deformity (see  Chapter 64).    Gap arthroplasty is used for the management of TMJ  ankylosis. Ankylosis release involves the removal of a Figure 62.34 Osteotomy used for high condylectomy.    Figure 62.35 Ostectomy (a) and gap arthroplasty (b) for  surgical release of TMJ ankylosis.    block of bone either the complete condyle (condylec-  tomy) or full-thickness section of condylar neck which  is referred to as a gap arthroplasty. The gap must be as  wide as possible.   A new joint space is created below the original joint  space (Figures 62.36 and 62.37) and an interpositional  graft is inserted within the new joint space to prevent bone  union or re-ankylosis. Due to loss of ramus height, some  post-operative occlusal derangement occurs and, if per-  formed bilaterally, an open bite results. The author uses  abdominal dermis-fat graft to fill in the gap that is effec-  tive in preventing re-ankylosis and avoids the unsightly  defect in the temple when a temporalis muscle flap is used.    Careful attention to haemostasis is essential prior to  closure. The surgical wound should be repaired in layers,  ie. capsule, temporalis fascia, subcutaneous tissues and  skin. Resorbable 4-0 sutures such as vicryl are used for the  deep layers and 5-0 nylon may be used for skin either as  simple interrupted (Figure 62.38) or subcuticular sutures  that are removed after 7 days. A mastoid-type pressure  dressing (Figure 62.39) is applied for 24 hours. The ear  must be padded with gauze or cotton before placing the  dressing. Drains are rarely indicated.    1. Poor patient selection  a. Patient is an unreliable historian - secondary gain  or compensation seeking  b. Patient has unrealistic expectations of surgical  outcome  c. Psychiatric history  d. Significant medical history  2. Inexperienced clinician  a. Poor diagnostic skills  b. Limited experience in TMJ surgery  3. Poor surgical technique    4. Malocclusion  a. Condylar resorption  b. Overzealous arthroplasty and disc surgery  5. Limited mouth opening  a. Adhesions  b. Fibrosis  c. Ankylosis  6. Persistent symptoms  a. Failure to continue supportive non-surgical therapy  b. Poor patient compliance - cannot follow instructions  c. Misdiagnosis - chronic pain syndrome    e The operating table should be slightly inclined with  the head elevated above the level of the heart to help  reduce intra-operative bleeding.   e A condom like rubber finger projection cut out of a  urology drape is inserted in the mouth and taped to  the lips to allow the surgical assistant to manipulate  the mandible during surgery without desterilizing the  surgical field.   e The skin/fascia flap should be developed down to the  temporalis fascia which is preserved if the temporalis is  not going to be used as an interpositional flap.   e Recovery is much quicker and morbidity is substantially  reduced when the temporalis fascia overlying the tem-  poralis muscle is left intact and not surgically breeched.   e Keeping a small periosteal elevator firmly on bone, the  soft tissues enveloping the condylar process can be  bluntly dissected off the condyle as far inferiorly as the  level of the mandibular notch.   e The role of disc repositioning surgery has diminished in  the light of the success of less invasive procedures such  as TMJ arthroscopy and arthrocentesis.   e Bleeding is best controlled with a curved vascular clamp  that is placed across the retrodiscal tissues immediately  behind where the wedge excision of redundant tissue  takes place (Figure 62.23).    The author uses autogenous dermis-fat graft procured  from the patient’s lower abdomen to fill the resultant  joint cavity.   Aggressive debridement of articular cartilage must be  avoided as this will result in severe remodelling of the  condyle.   Avoid using burrs to section the condyle and always use  oscillating saws which do little harm to the surrounding  soft tissues.   Deliberately ignoring the original joint anatomy, a  wide segment of ramus above lingula is resected, leav-  ing the ankylosed mass attached to the base of skull  (Figure 62.37).    Dimitroulis G. The role of surgery in the management of  disorders of the temporomandibular joint: A critical  review of the literature; Part 2. Int J] Oral Maxillofac  Surg. 2005; 34: 231-273.   Dimitroulis G. A critical review of interpositional grafts fol-  lowing temporomandibular joint discectomy with an  overview of the dermis-fat graft. Int J Oral Maxillofac  Surg. 2011; 40: 561-568.   Quinn PD and Granquist EJ. Color Atlas of  Temporomandibular Joint Surgery, Second Edition.  Ames, IA: Wiley-Blackwell; 2015.   Resection of the ankylotic tissue  Costochondral grafting  Costochondral graft harvest  Reconstruction    Ankylosis or anchylosis (from Greek &ykv\oc) is a stiffness  of the articulation and rigidity of the bones of the joint,  which may be the result of injury or disease such that  movement is either not possible or is greatly restricted.  With regard to the temporomandibular joint (TMJ), the  disorder is usually classified as intra-capsular or extra-  capsular according to where the restriction occurs. A par-  ticular type of extra-capsular ankyloses can occur when  fusion takes place between the mandibular coronoid pro-  cess and the adjacent zygomatic arch or maxilla.   The aetiology is usually due to trauma and/or infec-  tion although it can be the endpoint of degenerative or  rheumatoid diseases, bone or other malignancy, repeated  operation (iatrogenic) or agenesis of the joint. In the  Western world, the usual cause of ankylosis is post-  traumatic following intra-capsular condylar fractures or  iatrogenic. These may result in ossification of post-trau-  matic fragments of bone, causing fusion between the man-  dible and the glenoid fossa.    This should be considered according to the age of the  patient affected.    639  639  640  640  640  640  640  642  643  644  645  645    It is unusual to see ankylotic disease in the first few months  of life. Agenesis, infection and birth trauma all may lead  to fixity of the TMJ, as may overgrowth of the mandibular  coronoid process. The aims of treatment in this age group  are to restore movement and function, leaving reconstruc-  tion to later in life. Permitting mobility may allow func-  tional growth and therefore early mobilization and may  also permit decanulation where there is associated airway  compromise requiring tracheostomy.    Up to 15 ankylosis may be caused by trauma or infection  (for example, from the middle ear or mastoid). As facial  development is incomplete, joint fusion may also affect  growth from the condylar growth centre leading to a  deranged occlusion and marked facial asymmetry, with  occlusal cant upwards and centreline discrepancy towards  the affected side as maxillary growth is also impaired.  Additionally, there will be loss of vertical ramus height  with associated undergrowth of the maxilla.   Treatment is aimed at restoring function and move-  ment of the TMJ with an associated attempt to prevent  recurrence. This is usually achieved with a gap arthroplasty    and autogenous reconstruction often with a costochondral  graft. Some lengthening of the ramus and occlusal levelling  can be achieved by over-lengthening the ramus and con-  trolling the eruption of the mandibular teeth orthodonti-  cally, permitting maxillary dentoalveolar growth on the  ipsilateral side of the ankylosis.   Subsequent correction of any residual occlusal and cos-  metic deformity proceeds in the late teens with bimaxillary  surgery or in the early teens with the assistance of distrac-  tion osteogenesis of the mandible. Both techniques should  level the occlusal cant and in the growth phase, this may  be achieved by levelling the mandible and holding back  mandibular dentoalveolar growth permitting maxillary  dentoalveolar growth to correct the cant. This requires  close orthodontic cooperation. Alternatively, secondary  alloplastic reconstruction can achieve occlusal plane level-  ling with associated contralateral ramus osteotomies and  maxillary osteotomy to level the occlusal plane.    Ankylosis in this age group (where dentofacial devel-  opment is complete) is usually the result of trauma,  inflammatory arthropathy or multiple previous proce-  dures. Treatment is aimed at restoration of satisfactory  movement and function and prevention of recurrence.  Rare occlusal discrepancies are dealt with by standard  orthognathic surgery, although an anterior open bite and  other mandibular mal-alignments may be corrected dur-  ing joint replacement surgery, possibly with associated  orthognathic surgery.    Routine clinical assessment should be supplemented with  adequate imaging of the degree of ankylosis. This is best  achieved with computed tomography (CT) scanning,  preferably with 3D reformatting. Vascular assessment of  the infra-temporal fossa may require magnetic resonance  angiography to determine the extent of involvement of  the maxillary artery and great vessels. The ankylotic pro-  cess may extend widely and it is important to determine  the extent and risks of the procedure pre-operatively to  adequately prepare and consent the patient. In addition,  patients with ankylosing spondylitis and rheumatoid  arthritis may need respiratory and spinal assessment.  Modification of their drug regimes may also be required.    These patients require specialist anaesthetic services with  capability to provide fibre-optic intubation as their mouth  opening is so restricted. This can be guided with the aid  of the CT scan showing access to the nasal passage. If this  is not possible then pre-operative tracheostomy may be    required either in the standard open fashion or by a per-  cutaneous dilatational technique. Weight loss and dietary  compromise may also be an issue, which may require  pre-operative enteral feeding to supplement oral intake.  Hypotensive anaesthesia aids the dissection particularly of  the deep tissues and an anti-Trendelenberg table (30° head  up) with no neck flexion will also reduce venous filling.    The aim of treatment in the child is not only to regain  mobility and function but also to permit ongoing growth.  For this reason, prosthetic joint replacements are usually  contra-indicated in the child and autogenous reconstruc-  tion is preferred. Several clinicians are now investigating  whether secondary functional growth occurs following  adequate mobilization and alloplastic reconstruction,  although this remains controversial. Costochondral and  sternoclavicular grafts permit the possibility of ongoing  growth although this is unpredictable. In addition, they  are more likely to re-ankylose and the patients and parents  should be warned of these possibilities. Should the graft  fail later in life (post-puberty) it should be converted to  a prosthesis. Alternatives include simple gap arthroplasty,  temporalis interposition, dermal grafts and free bone  grafts. The stability of these grafts is limited and growth  will not occur leading to the need for secondary recon-  struction later in life. The advantage is less morbidity at  the first procedure resulting in less morbidity in subse-  quent reconstructions.    The aim of treatment is to restore adequate movement of  the TMJ. Extra-articular ankylosis, such as that due to  fusion of the coronoid process, may require simple intra-  oral coronoidectomy, possibly with trimming of bone  from the upper point of fixity - zygomatic arch or maxilla.   Prosthetic replacement of the TMJ is now the gold  standard in developed countries for restoration of func-  tion of the TMJ following ankylosis surgery. It provides a  good ‘gap’ of greater than 1 cm and good function in the  immediate post-operative period with the additional use  of a Therabite device as patient provided passive motion.  It reduces the risks associated with the harvest of a costo-  chondral graft and reduces hospital stay, with low morbid-  ity and a predictable long-term outcome.    The patient should rinse their mouth in the anaesthetic  room with chlorhexidine mouthwash to reduce intra-oral  colonization. Preparation of the patient involves shaving  the temporal region to provide a clean field for wound  closure without the intervention of hairs. The patient is    placed in a stable head ring (Rubens pillow) with the nasal  tube secured in the midline over the patient’s forehead.  Skin preparation should be carried out with Betadine.  Draping should cover the mouth separately as during  the procedure the occlusion will need to be secured. The  anaesthetic tube may be most safely secured using a clear  adhesive dressing (such as op-site), although this should  be left clear of the mouth. Two of these can be used in a  bilateral case with the mouth free in the middle for intra-  operative access. The face is left clear of the other drapes to  permit visualization for ‘twitching’ of the facial nerve dur-  ing the procedure (Figure 63.1). The ear canal is cleansed  and covered with op-site.   Upper and lower arch bars or other means to achieve  intermaxillary fixation should be placed at this stage if  access permits with the face covered with a separate towel.  All instruments used in this stage of the procedure should  be kept separate to maintain sterility of the facial opera-  tion site. Gowns and gloves are changed, the incision sites  are marked and injected with local anaesthetic contain-  ing adrenaline to reduce oozing. Five minutes should be  allowed for it to take effect.    The joint is approached via a pre-auricular incision with  temporal extension to gain access to the capsule. The cap-  sule of the joint is opened with a vertical incision along the  posterior border of the condyle and at the level of the disc  from the base of the zygomatic arch. Bipolar diathermy  should control any haemorrhage during this dissection.  The anterior and posterior borders of the condylar neck  are exposed in the sub-periosteal plane and the condylar  neck exposed with the aid of Dautrey, Wolford or similar    retractors (Figure 63.2). This permits the lifting of the  periosteum from the posterior surface of the condylar  neck as the maxillary artery lies a few millimetres deep to  this area (with the mandibular division of the trigeminal  nerve emerging from the foramen ovale just deep to this).    There are various approaches to the ramus of the mandi-  ble. The submandibular approach, whilst safe stretches the  tissues somewhat and makes the upper dissection of the  condylar neck difficult to achieve. The Kent modification  of this approach described in the first edition of this book  reduces the stretching whilst providing excellent access to  the ramus. It does increase the risk to the marginal man-  dibular division of the facial nerve, but allows easier access  to the external carotid artery in cases of vascular catastro-  phe. The author prefers a retromandibular access. Whilst  this carries risk of damage to the marginal mandibular  branch, this has not persisted in primary cases as any  branches traversing the wound can be seen and retracted  if blunt dissection is used through the parotid. It provides  a rapid access and permits access to the external carotid  and retromandiblar vein if required.   The periosteum of the posterior border of the ramus is  incised continuing along the lower border to release the  pterygomasseteric sling and sub-periosteal dissection is  continued to expose the lateral and posterior surfaces of  the ramus up to the sigmoid notch and to join the supe-  rior dissection. A sigmoid notch retractor is useful and a  swan neck retractor around the posterior border of the  ramus permits exposure of the condylar neck from below  whilst maintaining the closely related vessels out of the  surgical field.   A proximal condylectomy from above reduces the  amount of bleeding when removing this fragment  although it may be easier to complete the condylectomy  from below as the periosteum on the medial surface of the  condylar neck is easier to retract without stretching the    temporal branch of the facial nerve from above. The use of  a piezo saw reduces the risk of bleeding and is particularly  useful in ankyloses cases due to the proximity of the deeper  vessels. If using a drill, the initial cut is marked by postage  stamping in a 45° angle from the sigmoid notch postero-  inferiorly to the posterior border of the ramus. This should  be completed on the lateral cortex but the inner cortex  should be left intact to permit final separation of the con-  dylectomy by insertion of a broad periosteal elevator (such  as a Howarth) to prevent inadvertent drilling or osteo-  tome placement through the medial periosteum into the  maxillary or masseteric vessels. In any case as much of the  medial tissues as possible are held away sub-periosteally  by retraction. The lower portion of the resection is now  complete and removal of the residual ankylotic mass can  now proceed, mostly from above.    This stage of the procedure is different in every patient  and only general guidelines can be given. The ankylotic  mass can extend a long way along the base of the skull and  therefore resection may be compromised by cranial nerves  emerging from the skull base, the maxillary, middle men-  ingeal and ultimately internal jugular and carotid vessels.  It is for this reason that pre-operative vascular imaging  may be useful and the assistance of a vascular or skull base  surgeon may be required.   The upper limit of the ankylosis may be defined by a  fine line in the bone exaggerated by either pulling down  on the ramus prior to making the condylar cuts or by  using a Juniper distractor across the joint. This may facili-  tate one plane of the upper dissection. Once the lower  condylectomy cut is made then the periosteum should  not be transgressed. Although the condylectomy cut may  generate some mobility, do not be tempted to pull on the  fragment as this may avulse some deeper structure and  haemorrhage control down a deep dark hole can prove  troublesome! Proceed to carefully dissect around the  mass anteriorly and posteriorly with the aid of bipolar dia-  thermy to maintain a clear operative field. Using the upper  plane as an initial guide to deeper drilling helps to reduce  the risk of intracranial perforation. Carefully remove as  much as possible of the mass until ready to fashion a new  glenoid fossa. This may be a piecemeal process if the mass  does not readily come out intact.   The mouth opening should be assessed at this stage.  According to the Kaban’s guidelines if opening is less  than 30 mm an ipsilateral coronoidectomy should be per-  formed. Following this if opening remains below 30 mm  a contralateral coronoidectomy should be performed.  Whilst the former can be achieved through the operative  wound, access to the contralateral side can be achieved  perorally as described elsewhere. When required, coro-  noidectomy can be achieved by direct vision either via the  upper or via the lower approach (Figure 63.3). Smooth all    the remaining bone surfaces prior to accepting the final  defect and irrigate the wound to remove bone debris which  may predispose to re-ankylosis. At this stage, it is useful to  place a finger in the wound to palpate for any bony inter-  ferences. Also check that the joint is fully mobilized and  that haemostasis is satisfactory. The defect is now ready for  reconstruction.   The mouth can now be thoroughly examined and any  dental or periodontal condition dealt with. If the occlusion  has been deranged by the disease process, once mobility  has been assured, the teeth can be placed in the desired  occlusion and held with temporary inter-maxillary fixa-  tion. In edentulous patients, gunning splints may be used.  If there has been maxillary underdevelopment in a child  then an intermediate wafer providing space for levelling  the occlusal plane with ongoing alveolar growth may also  be used. Gown and gloves are again changed, ensuring  that the instruments used in the mouth do not contami-  nate the facial operative field.   At this stage in the procedure, the method of recon-  struction varies between the child (costochondral graft)  and the adult (prosthetic joint replacement). Following  completion of the reconstruction abdominal free fat may  be packed around the reconstruction just prior to wound  closure This may help to reduce the risk of recurrence of  the ankylosis.    This provides the main alternative to total joint replace-  ment in the adult, but is a second option in the authors’  opinion due to the risk of re-ankylosis, overgrowth or col-  lapse. One of the pre-requisites to management in the adult    is to achieve an adequate gap between the bone surfaces.  On occasion, the costochondral graft may be preferred  due to either local factors such as a heavily irradiated bed,  allergy to implant materials (although titanium only pros-  theses can now be produced), lack of surgical expertise to  perform prosthetic replacement or financial factors where  a prosthesis is refused due to cost. Microvascular graft-  ing may be considered although this adds considerably to  operative time and complications and has the same poten-  tial for re-ankylosis for the same reasons as costochondral  grafting. Certainly where multiple previous procedures  have been performed the revascularization of costochon-  dral grafts will be limited whilst alloplastic reconstruc-  tions do not share this issue.   In the child, costochondral grafting remains the man-  agement of choice as a prosthesis cannot grow with the  child and would inevitably require revision at cessation  of growth. There has been limited evidence of functional  growth following alloplastic reconstruction although at  present this remains a controversial primary reconstruc-  tion option in the child. Costochondral grafts can permit  ongoing growth, although this is unpredictable. For these  reasons, the technique for costochondral grafting in the  child will be described. The approach in the adult follows  the same choices of access to the mandible as for resec-  tion of the ankylotic mass. In the child, a lower cervical  incision may be considered as with growth this may rise  towards the lower border of the mandible and if initially  too high, ultimately end as a scar on the face. Alloplastic  reconstruction is described in Chapter 64.    In the child, usually a contralateral rib provides the best  curvature with the left rib being used for the right side and  vice versa. The patient and anaesthetist should be warned  of the possibility of pleural puncture and therefore, the    necessity for chest drainage post-operatively and difficul-  ties with oxygenation intra-operatively.   In the female with breast development, the incision  should be made directly below the breast skin fold. This  leaves an almost invisible scar which in any case is cosmeti-  cally more acceptable. In the male, the approach should be  lower and aimed at the sixth or seventh rib. The incision  should follow the line of the ribs (Figure 63.4) unless guided  by the infra-mammary fold, and dissection is continued to  the rib periosteum. Meticulous haemostasis permits better  visibility and at this stage, the periosteal envelope should be  preserved. Carry the dissection under the periosteum com-  mencing at the maximum curvature of the rib and devel-  oping the plane inferiorly, ensuring the preservation of the  neuro-vascular bundle which lies on the inferior surface  of the rib. Raise the periosteum superiorly (Figure 63.5)  until continuity with the lower dissection is achieved. It  may then be possible to insert a Doyen retractor initially to  retract and subsequently elevate the periosteum.   The incision through the periosteum should now be con-  tinued towards the costochondral junction. About 1 cm  from this junction makes the incision diverge in a “Y’ fash-  ion, continuing onto the cartilage side to bring the incision  edges back together and to complete a ‘diamond’ shape.  The cartilage may then be incised, with the remaining  periosteum helping to maintain continuity with the rib  and thus the costochondral junction. Finally, the length  of rib required should be determined. The inner dissection  is continued with a curved rib raspatory (Figure 63.6) or  Howarths and the lateral rib cut completed with a curved  rib cutter (Figure 63.7). The rib is harvested and placed in  saline soaked gauze. Check for a pleural tear by pouring  saline into the wound and looking for bubbles prior to clo-  sure. If present, a chest drain should be placed in the usual  manner in the midclavicular line. The wound is closed  in layers with deep resorbable sutures to the periosteum  to aid rib regeneration. Vacuum suction drainage can be  placed above this layer and the skin is closed.    Figure 63.5 Sub-periosteal dissection of the rib towards the costochondral junction with retraction of the pleura on the deep    Figure 63.6 The inner dissection is continued using a  curved rib raspatory taking care to preserve the pleura.    The rib is trimmed and a temporalis fascial interposition  graft may be placed prior to rib fixation with the cartilage  portion in the glenoid fossa (Figure 63.8). The rib is held  with either cortical screws or plates to the lateral border    Figure 63.7 The lateral rib cut is completed with a rib  cutter.    of the ramus in the desired position (Figure 63.9). The lat-  eral aspect of the mandible may be pre-prepared to enable  direct fixation of the rib to cancellous bone permitting a  more accurate fit. The rib may also be greenstick fractured  to permit more accurate adaptation. The wound is closed  in layers over suction drainage.    Figure 63.9 The costochondral graft is secured to the  mandible with miniplate or bicortical screws.    Management of ankylosis requires a collaborative  approach with the anaesthetic team to provide a secure  airway during surgery. Resection of the ankylosis should  be performed carefully with due attention to the associated    neurovascular structures on the medial surface. An ade-  quate gap should be achieved prior to appropriate func-  tional reconstruction and adequate mouth opening should  be achieved, if necessary combined with coronoidecto-  mies. Post-operative physiotherapy is essential to main-  tain the opening achieved intra-operatively and ideally  should commence in the first post-operative days. This  is facilitated when an alloplastic reconstruction is used.  Subsequent follow-up should be at least 10 years to check  for recurrence and manage this early.    e Ankylosis of the TMJ is an uncommon problem in the  Western world and should only be dealt with by a sur-  geon with experience in this area. The surgeon should  have experience with the various approaches and meth-  ods of reconstruction and access to a neurosurgeon.   e Consider pre-operative vascular imaging in patients  with extensive ankylosis or several previous procedures  as the vessels can lie in the ankylotic mass.   e Access to the carotid can be achieved by deepening the  retromandibular wound onto digastric and anterior to  the sternocleidomastoid muscles.   e Always group and save these patients as blood loss can  be sudden and catastrophic.   e Rapid access to the joint is facilitated by the pretempo-  ral fascial dissection approach.   e Ensure adequate mobilization post-operatively by  regular use of the Therabite device.    Kaban LB, Perrott DH and Fisher K. A protocol for man-  agement of temporomandibular joint ankylosis.  J Oral Maxillofac Surg. 1990; 48(11): 1145-1151; dis-  cussion 1152.   Mercuri LG, Edibam NR and Giobbie-Hurder A. Fourteen-  year follow-up of a patient-fitted total temporoman-  dibular joint reconstruction system. J Oral Maxillofac  Surg. 2007; 65: 1140-1148.   Sidebottom AJ and Gruber E. One-year prospective out-  come analysis and complications following total  replacement of the temporomandibular joint with  the TMJ Concepts system. Br J Oral Maxillofac Surg.  2013; 51: 621-624.    Total replacement of the temporomandibular joint (TMJ)  has been an option since the nineteenth century, but the  recent prosthetic choices arose following the develop-  ment of the Christensen prosthesis in 1963. Initially, these  were individually made prostheses of cobalt-chromium  alloy fossa and ramus component with an acrylic condy-  lar cap. Subsequently, this prosthesis was standardized  and remained one of the prostheses of choice until the  conversion of the condylar cap to an all cobalt-chromium  condylar component in 1997 to give a metal-on-metal  prosthesis. The Christensen prosthesis was removed from  the market and there are currently two commonly used  prostheses available on the UK market as either a stock or  custom-made variants (TMJ Concepts and Biomet). Hemi-  arthroplasty using the Christensen prosthesis has also been  used although this seems to fail over the medium term of  5-10 years requiring revision to a total joint prosthesis due  to condylar head wear.   During the 1970s, the Kent prosthesis (VK I) came into  and went out of vogue due to the reaction of this prosthesis’  proplast-teflon component (on the fit surface of the pros-  thesis) to the surrounding tissues causing destructive oste-  olysis and making revision of these prostheses extremely  difficult. The adjusted VK II prosthesis, although success-  ful, was withdrawn due to the litigation associated with its  predecessor.   Techmedica developed a titanium ramus prosthesis with a  cobalt-chromium condylar head anda titanium-based high-  molecular weight polyethylene fossa in 1989. This company    was taken over and the prosthesis is now made by TMJ  Concepts. This is a custom-made prosthesis and is currently  the authors’ first choice of prosthesis. It requires a Protomed  3D CT scan to create a CAD-CAM model on which the sur-  gical cuts are determined and the prosthesis is subsequently  made. The construction technique can be seen from the  illustrations (Figure 64.1). In patients with component part  allergy to cobalt-chromium alloy, an all titanium condylar  component can be constructed although the wear charac-  teristics of a hardened titanium surface are less certain than  cobalt-chromium alloy. The prosthetic fit is superior with  a custom-made prosthesis compared to a stock prosthesis  and therefore less mobility in theory should lead to better  success rates based on simple orthopaedic principles.   Biomet (formerly Lorenz) make a stock and custom  prosthesis with similar components to the Concepts system  (Figure 64.2). The Concepts system fossa has a titanium  mesh back, whereas the Biomet fossa is all ultra-high-  molecular weight polyethylene. The Biomet stock prosthe-  sis has five choices of ramus component and three choices  of fossa size. This requires eminoplasty to permit the fit of  the fossa and is hence a less accurate fit suggesting the pos-  sibility of micromotion, which in orthopaedic terms is one  of the causes of failure. It also requires accurate pre-opera-  tive assessment of the ramus and base of skull anatomy to  determine whether the ramus component will actually fit  against the fossa component, as varieties of ramus yaw and  fossa lateral and sagittal angulation may not permit this to  occur in a proportion of cases.    Figure 64.1 Illustration of three-dimensional model, resection, wax up and prosthesis on model using the TMJ Concepts    The issues of metal-on-metal prostheses with a glide  component in both orthopaedic knee implants and lat-  terly with the Christensen metal-on-metal have led to the  abandonment of this type of prosthesis in orthopaedic  devices. The cause of these problems are not clear, but may    be related to implant allergy at the time of placement or its  development during implant wear and exposure to com-  ponent wear particles. Around 10% of the general popu-  lation are nickel allergic with less than 1% allergic to the  other alloy components and a type 4 hypersensitivity reac-  tion may develop in allergic individuals. There may also  develop an immune-mediated response to wear debris.  Approximately 10% of metal-on-metal TMJ prostheses  in a UK series have failed and been found to have a giant  cell foreign body reaction surrounding them.! For this rea-  son, it is essential that all patients are at least patch tested  for allergy to nickel, cobalt, chromium and molybdenum  individually and if necessary proceeding to lymphocyte  transformation testing prior to recommending a cobalt-  chromium alloy-based. prosthesis. Unfortunately, at time  of publication titanium only prostheses cannot be rou-  tinely used as they are not Food and Drug Administration  (FDA) approved and a suitable indication for their use  needs to be demonstrated, although the 1 year outcomes of  both prostheses are similar.’    Prosthetic choice depends on indications, presumed bene-  fits, personal preference and cost. Whilst thereare goodlong-  term outcome studies for both the Biomet and Concepts  prosthesis (90% or more long-term survival) these studies  should be taken in the light of studies involving orthopaedic  implants. The long-term Christensen studies utilized the  acrylic condylar head, which has now been discontinued  due to excessive wear leading to anterior open bite forma-  tion after 15-20 years. These studies cannot be correlated  with the newer metal-on-metal Christensen introduced  in the late 1990s. Likewise, although the outcomes for the  custom-made Concepts prosthesis are even more impres-  sive, they only extend to 20 years at present.* The outcomes  for total knee replacement persist to 15 years but then dete-  riorate due to wear and it remains to be seen whether this  will also be the case for the metal on high-molecular weight  polyethylene TMJ prostheses (TMJ Concepts and Biomet).  Patients should be warned of the possibility of long-term  failure and for this reason prosthetic replacement should  only be considered as a last resort according to National  Guidelines* and should only be used by high-volume sur-  geons aware of the complications of insertion in order to  give the best possible outcomes. Revision surgery carries  more significant risk of morbidity particularly related to  the facial nerve, and certainly should only be contemplated  by an experienced surgeon. TMJ replacement is not for the  occasional surgeon as suggested by the UK NICE (National  Institute for Health and Care Excellence) guidelines.    The indications and contraindications for total replacement  of the TMJ published by a UK consensus study group? can  be seen in the tables. The indications for surgery are more  stringent than for an orthopaedic total joint replacement  (Table 64.1). It is essential, prior to consideration of pros-  thetic replacement, that an appropriate trial of conserva-  tive management (including arthroscopy if possible) has  been attempted and failed. Diagnosis of condylar disease  should be made with the aid of computerized tomogra-  phy (CT) or magnetic resonance imaging (MRI) scan as a  minimum (not just plain radiographs). CT scan is prefer-  able as it shows the bony anatomy in more detail and is  required using a Protomed protocol (3D) if a custom made  prosthesis is to be constructed.   The clinical indicators (Table 64.2) give an idea of the  severity of disability of the patient (similar to walking dis-  tance for total hip replacement) and also permit assessment  of outcome following the procedure. Contraindications  are rare (Table 64.3) but include severe local infective pro-  cess or radiation reaction or associated severe immune  compromise. These are relative, however, as most rheu-  matoid patients are on disease modifying drugs, and with  appropriate short-term adjustment of medication, pros-  thetic replacement can be safely carried out with minimal    Table 64.2 Clinical indicators for total prosthetic  replacement of the TMJ    Dietary score of <5/10 (liquid scores 0, full diet scores 10)  Restricted mouth opening (<35 mm)  Occlusal collapse/anterior open bite/retrusion    Pain score >5 out of 10 on visual analogue (in combination  with any of above)    added risk. Bisphosphonate use does not seem to cause  any issues.   Dental status should be checked pre-operatively  and any teeth restored with compromised teeth being  removed. Post-operative dental infection risks prosthetic  biofilm infection with the required removal of the pros-  thesis. Revision surgery carries a significant increase in  morbidity in addition to the cost of around US$10,000 per  prosthesis. Any dental infection post-operatively should  be dealt with aggressively, preferably with extraction.  Prophylactic antibiotics are recommended according to  the American Association of Orthopaedics guidelines  for invasive dental procedures for the 2 years following  prosthetic insertion.    Intravenous antibiotic prophylaxis aimed at the common  skin commensals should be given on induction and con-  tinued for 24 hours intravenously with 5 days orally post-  operatively. Catheterization will aid in fluid monitoring,  but should aim to be removed at the end of the procedure.  Hypotensive anaesthetic techniques and a head up table  help to reduce blood loss peri-operatively.   The standard pre-auricular and _ retromandibular  approaches to the TMJ are adopted. The patient is anaes-  thetized with a centreline tube extending over the vertex  of the head (see Chapter 63). Consideration of anaes-  thetic technique should be borne in mind when planning  surgery as fibre-optic aided intubation or tracheostomy  may be required due to restricted mouth opening. Arch  bars are placed and the operating field around the mouth  kept totally free from contaminating the operating field of  the prosthetic replacement. The mouth is covered by the  opsite free ends (see Chapter 63) and local analgesic with  adrenaline is infiltrated into the pre-auricular and retro-  mandibular incision sites. The joint is exposed from below  and above (see Chapter 63). The required condylectomy is  carried out and the soft tissues of the capsule, disc, lateral  pterygoid and periosteum dissected gently with copious  diathermy to maintain a blood-free field, whilst trying  not to extend the dissection too far medially where the  maxillary, middle meningeal and masseteric vessels and  the mandibular division of the trigeminal lie within a few  millimetres. It is essential that all disc and capsular tis-  sue is removed to provide sufficient space for the prosthe-  sis. Residual disc tissue in particular may interfere with  prosthetic function and the disc can be removed most  safely with the aid of diathermy and subsequent scissor  freeing from the lateral pterygoid, which tends to ooze  if just cut. If adequate mouth opening (>30 mm) is not  achieved the coronoidectomy can be completed through  either the superior or inferior wound under direct vision.  Contralateral coronoidectomy may also be required if  opening still does not exceed 30 mm.   Once the fossa is completely cleared of soft tissue the  prosthetic fossa is tried in. The fossa is irrigated with  gentamicin containing saline and the fit of the prosthesis  checked and if necessary the fossa adjusted if there is any  rocking. The different types of prosthesis require slightly  different techniques at this stage and will not be further  described. The following will be a description of the tech-  nique of placement of a custom-made prosthesis.   The fit of the fossa is confirmed. The patient is placed  in intermaxillary fixation (IMF) to the desired occlu-  sion and then all gowns and gloves are changed and the  instruments for the intraoral procedure kept totally sepa-  rate. The fossa is again trialled to ensure that adequate  condyle and coronoid have been removed to enable free  fitting of the fossa and rotation of the condylar compo-  nent on mouth opening. There should be at least a 5-mm  gap between the prosthetic fossa and the mandibular  stump. The cavity is again irrigated with gentamicin    solution and the fossa fitted and secured with usually 3-4  screws into the zygomatic arch.   The lower incision is now entered and the fit of the con-  dylar component checked. It may be necessary to smooth  down the lateral border of the mandible according to the  pre-operative planning on the CT model. This has usu-  ally been necessary at the mandibular gonial angle due  to eversion of the bone tissues in this area at the lower  attachment of masseter. Once the fit to the lateral border  has been confirmed, the fit into the fossa component is  confirmed. This should match that seen on the photos of  the prosthesis on the model (Figure 64.3). Usually it lies  about 1/2 to 2/3 of the way into the fossa. If the head lies  too superficial to this it suggests that insufficient condy-  lar neck has been removed and this can be confirmed by  direct vision and usually the prosthesis will rock in the  supero-inferior plane. If necessary more condylar neck  can be removed with extreme care not to damage the in  situ fossa prosthesis. If necessary this should be removed  prior to further bone removal.   Once the fit of the condylar prosthesis is confirmed  this is secured initially with three screws to the length  marked on the diagrams supplied by the company. The  IMF is removed and the occlusion is checked. If this is  not correct the position of the prosthesis requires adjust-  ment. Once the position and occlusion are correct, at least  five bicortical screws should be inserted using copious    Figure 64.3 Fit of the condylar component in the fossa on  the model and in situ should match.    irrigation. At least three bicortical screws should be used  with the most important one being the most proximal,  which is the point of maximum torque. Movement of  the prosthesis should now be assured in function. If less  than 30 mm movement can be achieved, either the posi-  tion is incorrect or a coronoidectomy may be required. If  there is dislocation then light IMF elastics will be required  post-operatively for 1 week until the vertical stability is  re-established. This can occur following previous coro-  noidectomy or with closure of anterior open bites, where  the vertical pull of the temporalis has been reduced.° Once  the occlusion is satisfactory again gown and gloves con-  taminated intraorally are changed. The fit and movement  of the condyle within the fossa are checked and the wound  is irrigated with gentamicin solution. If all is satisfactory  the wounds can then be closed.   The author prefers a single 12 suction drain introduced  through the upper wound extending over the prosthesis  into the lower wound subperiosteally as this covers all the  areas of potential wound leakage. This is secured behind  the ear with black silk and is removed on the first post-  operative day.   At this stage, the abdominal fat graft is placed if desired  and packed around the articulating surfaces. The upper  wound is closed with continuous resorbable sutures  (Vicryl or PDS) to the temporalis fascia and periosteum  to cover the joint but ensuring that the drain is not inad-  vertently held too tightly into the wound. The subcuta-  neous tissues are the closed with interrupted Vicryl to  bring the wound edges together and the skin with 6/0  monofilament. The lower wound is closed with continu-  ous vicryl to the parotid fascia and subcutaneous tissues.  This avoids involving the branches of the facial nerve in  the closure. Monofilament is used to close the skin. The  masseter is not directly closed as this shortening may  reduce post-operative myofascial pain due to the muscle  shortening achieved.   If there has been no dislocation intraoperatively then  the arch bars can be removed and the patient recovered.  Antibiotics should be continued intravenously for 24 hours  then for 5 days orally. The author prefers the patient to  have low-dose NSAIDs for 6 weeks (if tolerated) as there  is some evidence of a reduction in heterotopic bone for-  mation in orthopaedics and this may reduce the likelihood  of re-ankylosis. In any case, they provide good analgesic  properties suitable to this form of surgery. Therabite pas-  sive mobilization should be commenced the first post-  operative day and continue for at least 6 months along the  minimum recommended protocol of seven seconds open-  ing seven times at least seven times a day, initially aiming  to improve opening by 1-2 mm per day. The opening at the  start of the day will have declined compared with the night  before, so the measurements should be taken at the same  time every day. Most primary joint replacement patients  should achieve opening of above 25 mm within 6 weeks  and 30 mm by 3 months, with the pain scores diminishing  rapidly towards zero. Dietary improvements take a little  longer to achieve.    Post-operative stay is between 24 and 72 hours in most  instances. The patients should be advised according to the  American Society of Orthopaedics guidelines to have pro-  phylactic antibiotics prior to invasive dental surgery for  2 years following prosthetic insertion. Prosthetic failure  secondary to a dental and ear infection is disastrous and  can be prevented by early aggressive surgical management  and antibiotics. Infection in the early post-operative period  secondary to dental infection can be prevented by ensur-  ing good pre-operative dental state. Drains are removed at  24 hours and sutures are removed at 5-7 days.   All patient details should be entered into a database for  long-term assessment of outcome and for comparison of  outcomes of prostheses within a national/international  database when available. The UK database has now been  established for 5 years. The companies monitor failures as  a requirement for the American FDA.    This can occur from the superficial temporal vessels, the  retromandibular vein behind the ramus, the masseteric  vessels deep to the sigmoid notch/ condylar periosteum,  the pterygoid venous plexus or occasionally deeper ves-  sels medial to the condyle such as the maxillary artery,  the middle meningeal and even the internal jugular vein,  which can be in close proximity either with a large anky-  lotic mass or following contracture due to previous sur-  geries. It is often difficult to control haemorrhage through  the 1 cm x 1 cm wound following condylectomy hence the  best method of control of haemorrhage is prevention by  a careful technique. Blood should have been group and  saved as transfusion is occasionally required. Usually the  haemorrhage can be temporarily controlled by pressure.  The former sites are definitively controlled in the usual  manner of ligation or diathermy, paying attention to the  position of the facial nerve branches. Occasionally, more  proximal ligation of the external carotid or jugular may  be required (Figure 64.4) and these can be accessed by a  suitable extension of the retromandibular wound. Surgicel  and pressure can also be used to control pterygoid oozing.  Drainage of the wound will show any late re-opening of  vessels due to the hypotensive anaesthesia being reversed  and the blood pressure should be permitted to rise prior to  wound closure.    Dislocation of the prosthesis is rare and usually associated  with previous coronoidectomy reducing vertical stability of    Figure 64.4 Exposure and tie of the terminal external  carotid artery may be required when uncontrollable haemor-  rhage persists.    the joint. Occasionally, closure of an open bite will cause a  similar effect. If this occurs intraoperatively then the arch  bars should be left in situ and 1 week light IMF elastic used  to control inadvertent wide opening. By the end of 1 week  sufficient vertical stability has been regained. Post-operative  dislocation may also due to joint malpositioning or dystonic  contractions. The patient should be returned to theatre to  check the occlusion. If this is stable following relocation,  which often occurs with inferiorly directed light pressure,  then a means of obtaining IMF should be achieved and  the patient placed in light elastics for 1 week. The wounds  should only be opened as a last resort as this will markedly  increase the risk of infection. If the prosthesis is malposi-  tioned then immediate revision may be the only option.    Facial nerve palsies are common post-operatively particu-  larly in the temporal branch and especially following revi-  sion surgery.’ They are usually temporary due to stretching  of the tissues to gain adequate access for placement of the  prosthesis. Permanent palsies can be dealt with by brow lift  and other ‘cosmetic’ procedures.    Infection of any prosthesis is often staphylococcal and  occasionally acinetobacter-related and appropriate prophy-  lactic antibiotics should be used. The author recommends  prophylaxis for invasive procedures causing bacteraemia sim-  ilar to those for bacterial endocarditis prevention for 2 years  post-operatively according to the American Association of  Orthopaedic Surgeons guidelines. Infection may present  with obvious signs of redness and drainage of pus from the  wounds. Usually low grade infection will present as increas-  ing restriction of opening and pain. Prosthetic removal is  almost inevitable and should be followed by a period of occlu-  sal stabilization with a gentamicin containing acrylic spacer.  Biofilm formation — whereby colonies of bacteria are covered    by an almost impermeable polysaccharide membrane - may  present more insidiously with ongoing pain and restriction,  but with no other clinical or haematological signs of infec-  tion. Antibiotics cannot penetrate the biofilm and prosthetic  removal as above is indicated.    Allergy to the prosthetic material can occur to any of the  components of the prosthesis. Prevention by appropriate  allergy testing pre-operatively may reduce this phenom-  enon although there is a suggestion that patients with failing  prosthetic hip replacements develop allergy due to sensiti-  zation and lymphocyte activation. Whilst most orthopae-  dic patients are not tested for metal allergy, these findings  cannot be confirmed, however, approximately 10% of the  population are allergic to one or more component of cobalt-  chromium alloy (usually nickel), whilst 20% with a function-  ing prosthetic hip are and 60% with a failing prosthesis are.  Other factors may be involved, however, where allergy is  suspected the ongoing swelling may lead to traction facial  nerve palsy and the prosthesis requires removal and ultimate  revision to an all titanium prosthesis (Figure 64.5).    This is most common in patients who started with  marked restriction of mouth opening and tends to start  around 6 weeks when post-operative mouth opening  tends to exceed the pre-operative level. Some surgeons  commence low-dose tricyclic medication immediately  post-operatively whilst others will commence this when  myofascial pain develops. In any case, it can usually be dis-  continued at 1 year when the mouth opening has reached  a maximum and has been stable for several months.  Botulinum injections provide an alternative for those    Figure 64.5 Traction palsy of facial nerve due to swelling  consequent upon chromium allergy. This resolved following  replacement of the prosthesis with all titanium.    unable to tolerate the occasional sedative side effects of  low-dose tricyclics.   Long-term complications are rare and the majority of  patients gain significant improvements within 1 year in  pain scores (90%), dietary scores (90%) and mouth open-  ing which persist for more than 10 years.    Prosthetic replacement has a growing place in the man-  agement of end stage disorders of the TMJ, but should  be confined at present to a few high-volume operators to  adequately assess outcomes. The introduction of NICE  guidelines and a National Database permits medium- and  long-term assessment.    1. Sidebottom AJ, Speculand B and Hensher R. Foreign  body response around total prosthetic metal-on-metal  replacements of the temporomandibular joint in the  UK. Br J Oral Maxillofac Surg. 2008; 46: 288-292.   2. Hussain OT, Sah S and Sidebottom AJ. Prospective  comparison study of one-year outcomes for all tita-  nium total temporomandibular joint replacements  in patients allergic to metal and cobalt-chromium  replacement joints in patients not allergic to metal.  Br J Oral Maxillofac Surg. 2014; 52: 34-37.   3. Mercuri LG, Edibam NR and Giobbie-Hurder A.  Fourteen-year follow-up of a patient-fitted total tem-  poromandibular joint reconstruction system. J Oral  Maxillofac Surg. 2007; 65: 1140-1148.   4, NICE Guidelines. IPG 500. Total prosthetic replace-  ment of the temporomandibular joint. Guidance,  September 2014.    5. Sidebottom AJ. UK TMJ replacement surgery, British  Association of Oral and Maxillofacial Surgeons.  Guidelines for the replacement of the TMJ in the UK.  Br J Oral Maxillofac Surg. 2008; 46: 146-147.   6. Mustafa EM and Sidebottom AJ. Risk factors for  intraoperative dislocation of the total temporo-  mandibular joint replacement and its management.  Br J Oral Maxillofac Surg. 2014; 52: 190-192.   7. Sidebottom AJ and Gruber E. One-year prospective  outcome analysis and complications following total  replacement of the temporomandibular joint with  the TMJ Concepts system. Br J Oral Maxillofac Surg.  2013; 51(5): 620-624.    e Consider pre-operative vascular imaging in patients  with extensive ankylosis or several previous procedures  as the vessels can lie in the ankylotic mass.   e Access to the carotid can be achieved by deepening the  retromandibular wound onto digastric and anterior to  the sternocleidomastoid muscles.   e Always group and save these patients as blood loss can  be sudden and catastrophic.   e Assess all patients for metal allergy if an alloplastic  prosthesis is to be used and use an all titanium prosthesis  if allergy exists.   e Rapid access to the joint is facilitated by the pretemporal  fascial dissection approach.   e Always check for dislocation of the prosthesis  intraoperatively and place in light elastic traction for  one week if this can be achieved.   e Ensure adequate mobilization post-operatively by  regular use of the Therabite device.   Introduction 657  Objectives of cleft lip repair 657  The South Wales cleft team technique for cleft lip repair - advancement/rotation lip   repair with an inferior triangular flap 660  Common techniques of cleft lip repair 667  Acknowledgement 670  INTRODUCTION Skoog, Trauner, or Malek), the quadrangular flap    Clefts of the lip and/or palate (CLP) are the most common  craniofacial birth anomalies and are among the most com-  mon of all birth anomalies, with birth prevalence ranging  from 1 in 500 to 1 in 2000 depending on the population.  Successful management of patients born with cleft lip and/  or palate requires multidisciplinary, highly specialized  team management from birth to adulthood. The technique  of repairing a unilateral cleft lips is outlined.    The essential objectives of cleft lip repair are the restora-  tion of normal function and appearance of the lip and  nose. This is achieved by re-establishing normal insertions  of all the nasolabial muscles and correct anatomical posi-  tion of the other soft tissues, including the mucocutaneous  elements. Therefore, an anatomic and functional balance  between the soft tissues and the skeleton is re-established.    1. Skin: The skin is corrected in both vertical and horizon-  tal orientation. To restore normal height of both sides  of the cleft relative to the non-cleft side, it is necessary  to restore the normal length of the skin on the cleft side  using various techniques, such as the rotation advance-  ment design (Delaire and Millard), undulating wavy  flaps (Pfeiffer), straight-line design (Rose-Thompson),  lower lip Z-plasties/triangular flaps (Tennison—Randall,    (Le Mesurier), or a combination of the advancement  rotation and wavy-line techniques (Afroze). The skin of  the lip on the medial element is short as a consequence  of the change in normal muscular actions. Careful  reconstruction of the nasolabial muscles allows the  overlying skin to lengthen to the correct lip height.    anatomic muscular reconstruction, particularly with  respect to anchorage of the complex nasolabial mus-  cles of the cleft side to the nasal septum and muscles  on the non-cleft side (Figure 65.1). It is necessary to  reconstruct the nasolabial muscles of the cleft such that  the skin margins are not under tension at the moment  of skin closure (Figures 65.2 and 65.3). If the primary  nasolabial muscle reconstruction is good, anatomy,  function, skeletal growth, and total facial aesthetics can  be excellent.   Nose: The nasal septum is deviated in unilateral cleft lip.  There are two reasons:    ® Position of the anterior nasal spine (ANS) - it is posi-  tioned towards the non-cleft side and therefore pulls  the septum which is attached to it towards the non-  cleft side.   Muscle attachments of the medial side - the most  nasal and deep bundles of orbicularis muscle insert  into the mucoperichondrium and anterior nasal sep-  tum and therefore they pull the caudal part of the  septum towards the medial side.    Aim is to anchor muscles on cleft side to the nasal  septum and muscles on the non-cleft side    Septal deviation causes the upper lateral cartilage to  buckle depressing the radix, and also causes the lower  lateral cartilagenous framework to shift and thereby  collapsing the dome on the lateral side (Figure 65.4).    Septoplasty at the time of lip repair produces a  straighter nasal septum positioned in the facial mid-  line and restores the patency and natural width of the  nostril (Figure 65.5). To achieve the proper midline    Figure 65.5 Septoplasty with repositioning of the caudal aspect of the nasal septum.    position and attitude of the nasal septum, the surgeon  must perform a wide subperichondrial dissection on  both sides of the septum. Once the deviated nasal sep-  tum is repositioned, nostril patency is re-established on    The nasal floor is also reconstructed to eliminate the  vestibular oral nasal communication if the palate is  involved. A vomer flap is used when possible to repair  the anterior hard palate in continuity with the floor of  nose. There is no evidence to support the hypothesis    and lesser segments is proportional to the width of the  cleft lip. The segments will be approximated from pres-  sure exerted on them by the repaired cleft lip moulding  the anterior element of the greater segment.    . Anterior hard palate: A vomer flap is raised and inset    into the cleft margin (Figure 65.6) to close the anterior  hard palate at the time of repair of the cleft lip to estab-  lish continuity of nasal floor closure (Figure 65.7). There  may be some narrowing of the width of the posterior  cleft palate following vomer flap closure.    THE SOUTH WALES CLEFT TEAM 1. An advancement/rotation repair of the cleft lip  TECHNIQUE FOR CLEFT LIP REPAIR - incorporating an inferior triangular flap addressing  ADVANCEMENT/ROTATION LIP REPAIR WITH the medial shortening and lateral displacement while   . Achieving a functional muscular repair by restoring the  displaced muscles to their correct anatomical position  and recreating the muscular rings of mid and lower face.    The authors close the cleft lip at 3 months of age and the  repair involves the following key steps:    The South Wales cleft team technique for cleft lip repair 661    3. Using a vomer flap to repair the anterior hard palate in  continuity with the repair of the floor of nose.   4. Performing a McCoomb’s nasal dissection if required to  release the lower lateral cartilage allowing it to sit in a  correct anatomical position.   5. Straightening of the caudal aspect of the nasal septum  to place the septum in its correct central anatomical  position.    The key surgical steps in the authors’ surgical protocol  are as follows:    1. Left complete cleft lip: Identification of key surgical  landmarks, show both on an illustration and clinical  photograph (Figure 65.8).   2. Skin markings: The skin markings include the following  key landmarks (Figure 65.9):    © Cupid’s Bow markings: Non-cleft-side peak, trough  and peak on the cleft side (a point on the cleft side  equidistant from the trough of the cupid’s bow)   © First change in the appearance of the white roll on the  lateral element: The point of first change of the white  roll and where the white roll and vermilion start to  converge    3. Medial element incision: Curved incision along the short  medial element (Figure 65.10). The aim is to place the  scar in the line of the natural philtral ridge. The medial  side of the philtrum must be lengthened to match the  non-cleft length. The incision does not extend along  the base of columella at its superior aspect. The incision  extends from the base of columella on the cleft side to  the cleft side peak of the cupid’s bow curving parallel to  and just above the white line. It is curved medially and    medial side-equidistant  from the trough compared  with the non cleft side    extends from the alar base along the junction of the nasal  and lip skin to meet the mucosa at 90° (Figure 65.11).  The incision then extends from this point along the  white roll parallel to the skin/mucosal junction to meet  the upper point of the lateral triangular flap.    incorporated along the incision in the lateral element  and is inset into a backcut in the medial element to  lengthen the deficient medial element (Figure 65.12).  The triangle and the backcut must be the same height  above the white roll. The addition of an inferior triangle  to the advancement/rotation repair of a cleft lip allows    full restoration of length without the overextension of  the medial incision under the base of the collumella.  The lip length must not be shorter than the normal side  at end of the surgery.    © The incision on the medial element extends at a tan-  gent to the curved incision extending into the floor  of the nose along the nasal/oral mucosal junction. It   with mucosa along the white  roll to the point of first change  in the white roll    Inferior triangle placed just above the white  roll on the lateral side and is inset into the   backcut on the medial side to lengthen the  skin deficiency on the medial side    The South Wales cleft team technique for cleft lip repair 663    will connect to the vomer flap and the flap raised will   @ The incision on the lateral element is a continua-  tion of the lateral element incision into the nose  parallel to the junction of the skin-mucosal junc-  tion. This incision extends to the alveolus and sits  just below the inferior turbinate.    © The incisions are extended across the white roll  medially and laterally at 90° to the white roll. They  extend through the wet-dry junction and then up  into the nose. The mucosa outlined is the sterile  mucosa.    9. Advancement/rotation: Advancement rotation skin  markings with an inferior triangle (Figure 65.15). The  Vermilion border is tattooed with ink - these points  act as landmarks to allow accurate reconstruction of  the white roll. Local anaesthetic is infiltrated and the  marking incised. The sterile mucosa is excised and  the muscle edges are identified along both sides of the  cleft margin.   10. Muscle dissection: The muscle is dissected on both  sides of the cleft to separate the muscle from the  mucosa and dermal layers.    ® On the medial side, dissection of the muscle is car-  ried out to relieve the abnormal attachments from    Advancement of the lateral element  to upper landmark to base of columella  mark on the medial segment    Advancement of lateral element triangular  flap to the back cut on the medial segment    Tangental curve extending  into the floor of the nose along  the nasal/oral mucosal junction    Continuation of the lateral  element incision into the nose  parallel to the junction of the  skin-mucosal junction    the ANS and the columella allowing lengthening  and rotation of the skin deficiency on the medial  element (Figure 65.16).   On the lateral side, muscle dissection is done to  identify and mobilize the head of the transverse  nasalis and the length of orbicularis (Figure 65.17).    Subperiosteal dissection: This is peformed if the  transverse nasalis muscle will not reach the ANS.  After the muscle dissection is completed, an incision  is made in the buccal sulcus up to the nasal margin  of the cleft. A wide subperiosteal dissection is made  from the vestibule on the cleft side over the piriform  rim, nasal bone, infraorbital and malar regions to  lift the facial mask taking care to protect the infra-  orbital nerve (Figure 65.18).   McCoomb nasal dissection: As required if the lower  lateral cartilage will not sit in the correct position    when the nasal muscle is approximated. Access is  gained to the lower lateral cartilages through a medial  approach allowing blunt dissection of the cartilage  from the overlying skin/nasal mucosa. The plain of  dissection is subdermal and submucosal. The lower  lateral cartilage can also be approached from the  lateral aspect if required, but this is not commonly  performed (Figure 65.19).The McCoomb’s dissec-  tion reduces the buckling effect of the lateral crus of  the lower lateral cartilage allowing it to sit in a more  natural position.   Septoplasty: Correction of the caudal aspect to the  deviated nasal septum provides stability and exact  positioning of the previously lifted alar crus of the  cleft side and nasal tip. This allows the nose to grow  in a balanced way with equal muscular force being  exerted on both sides. The caudal aspect of the nasal    The South Wales cleft team technique for cleft lip repair 665    Figure 65.20 Exposure of the deviated caudal aspect of  the nasal septum.    septum is then carefully isolated and freed through  the same cleft incision by splitting and raising the  perichondrium on both sides (Figure 65.20).    © The septum is detached from its attachment to the  nasal spine and maxillary crest, straightened and  repositioned centrally (Figure 65.21).    Nasal floor reconstruction: The nasal floor is recon-  structed by suturing the hair-bearing nasal mucosa  on both sides, posteriorly closing the lateral nasal  floor to the vomer flap (Figure 65.22).   Suturing of transverse nasalis to ANS/septum: This  is to secure the position of the base of the septum  (Figure 65.23).    Figure 65.21 Detachment and straightening of caudal  aspect of nasal septum.    ® The orbicularis is approximated and sutured to a  natural position maintaining the muscle length  (Figure 65.24).    © Tension free skin closure is performed (Figure 65.25).  This is made possible by the subperiosteal dissection,  radical mobilization and suturing of the transverse  nasalis and orbicularis muscles.    Suturing of transverse nasalis to anterior :  nasal spine (ANS)/septum. Fi : Tension free closure of skin.    The Millard repair is based on a rotation flap on the medial  cleft side coupled with an advancement flap on the cleft  lateral side. The incision then bowed in a curvilinear  fashion near the base of the columella crossing the phil-  trum towards the far lateral extent of the columellar base  (Figure 65.26). In one form or another, it is the most widely  practiced method today.   The rotation advancement technique relies on a ‘cut  as you go’ strategy that allows continuous modifications  during the design and execution of the repair. It does not  adhere to strict geometrical principles or measurements.    However, it may leave a scar crossing the midline at the  base of the columella and cause shortening of the lip on  the cleft side with resultant vermilion notching and whis-  tle deformity.    Delaire’s cleft lip technique incorporates a curvilinear  incision that extends up and parallels the medial cleft mar-  gin but stops near the medial edge of the base of the colu-  mella. The lateral lip element advancement incision curves  outward and then medially as it extends superiorly before  it again extends to the alar base (Figure 65.27).   Delaire does not incorporate an inferior triangle into  his cleft lip repair, which limits the extra length that can  be gained. A Delaire repair does not include a vomer flap.    Pfeifer described a wavy-line repair that allowed down-  ward rotation as the curves were approximated into a  straight line. The two curves are brought together such  that the highest and lowest points of one curve are approx-  imated with the corresponding highest and lowest points  of the other, thus creating a straight line (Figure 65.28).  The Pfeiffer repair achieves good vertical length soft-tissue  reconstruction, but in some cases this can be at the expense  of soft-tissue reconstruction in the horizontal dimension.   The Afroze incision is a combination of two incisions —  the Millard incision on the medial cleft side and the  Pfeiffer incision on the cleft side (Figure 65.29). The flap  is designed so that the Millard flap on the cleft side rotates  downwards and the peak of the distal curve on the Pfeiffer    flap is positioned in the triangular defect formed by the  downward movement of the Millard flap.   The lip scar does not lie along the philtrum - this is the  only disadvantage of this technique. However, the scar  heals exceptionally well as the wound is closed under no  tension whatsoever.    The triangular flap repair was initially described in 1952  by Tennison. Tennison’s technique made use of an inferior  backcut that begins not far above the cleft-side peak of the  Cupid’s bow of the medial lip element and angled supero-  laterally. Precisely measured triangle flaps allow verti-  cal lengthening of the medial lip element while enabling  lengthening of what is often an otherwise short transverse  lateral lip element without compromising the ideal basal  position of the philtral column incision (Figure 65.30).  The main disadvantage of the triangular flap repair  technique is that the philtrum on the cleft side is violated    by the triangular flap. Some authors believe this leaves a  more noticeable scar. Another potential disadvantage is  the difficulty in modifying the repair or performing sec-  ondary revision at a later stage due to the zigzag scars.    The repair allows for a repair line that ascends the lip at  the seams of anatomical subunits. Applying the principle  of anatomic subunits to cleft lip repair, the ‘ideal line of  repair’ should be one that ascends the lip from the cleft-  side peak of Cupid’s bow to the base of the nose along a  line exactly mirroring the non-cleft-side philtral column  (Figure 65.31). These manoeuvres help to preserve natural  subunit boundaries allowing for rotation and medial lip  lengthening at the expense of narrowing the philtrum to  a degree.   Fisher often adds a small inferior triangle just above  the cutaneous roll for additional rotation and feels that  this accentuates the pout of the lip. While this tech-  nique is included in the category of rotation/advance-  ment repairs, it is clearly a hybrid of multiple principles,    including triangle-flap techniques and use of geometric  and curvilinear incisions to approach a vertically ori-  ented closure.    The repair of the incomplete cleft lip follows the same prin-  ciples as outlined for the repair of the complete cleft lip. The  incision is modified to divide the nasal skin from the lip  skin in a line along the base of the nasal sill (Figures 65.32  and 65.33). The texture of the nasal skin is different to the  texture of the skin of the lip and the incision line is placed  between the junction of both skin types. The texture of the  skin that is excised is abnormal due to the lack of underly-  ing muscle insertion. A small wedge excision into the nasal  sill may be used to prevent a prominence of scar tissue from  developing in this area. The authors do not include this  extension into the nasal sill as it may lead to nostril narrow-  ing and flattening of the nasal sill. If a tissue prominence  should develop, it can be easily treated with a wedge exci-  sion at a later date.   The post-operative result for an incomplete cleft lip  repair is illustrated in Figure 65.34.    Figure 65.34 Post-operative result for the repair of an  incomplete left side cleft lip.    Illustrations by Steve Atherton and Heather Goodrum,  additional graphics by Amy Shorter and additional pho-  tography by Belinda Colton of Medical Illustration,  Abertawe Bro Morgannwg University Health Board, Heol  Maes Eglwys, Morriston, Swansea, Wales.    Careful identification of anatomical landmarks and  respect for anatomical boundaries between the nose and  lip.   + Identification of the anterior border of the septum, sub-  perichondrial undermining of the nasal septum and  release of ala cartilage from the vestibular skin.   + Identification and dissection of the nasalis and orbicu-  laris muscle.   + Reconstruction of the upper and middle muscle rings  with fixation of the nasalis muscle to the periosteum,  just below the ANS, and fixation of the oblique part of  orbicularis to the ANS and septum.   + Correct alignment of the ala base, anterior septum and  columella.   How to handle the premaxilla  Definitive primary repair of bilateral cleft lip  Position    © The prolabium located centrally is devoid of muscle and  consists of skin, vermillion and oral mucosa.   © There is no definitive line of demarcation between the  columella and prolabium.   upwards to join the alar base. This is because both the   © The septum and premaxilla are attached to the vomer  as a thin stalk.    ©@ The ideal age for lip repair is 3 months.  ® In less-informed societies, patients may present at  any age.  ® Protocols for primary repair of bilateral cleft lip pre-  senting at any age is as follows:  e 3months to 2 years: lip repair  e 2-7 years: palatoplasty first and then lip repair  e 7 years to adulthood: palatoplasty first and then lip  repair with alveolar bone grafting    When the patient presents for surgery after the age of  7 years, the premaxilla may be severely displaced and may  occasionally require surgical repositioning.   LLS - levator labi superiosis. LAO - levator anguli oris.  M-modiolus. DAO - depressor anguli oris. OO - orbicularis oris    @ In minimally displaced premaxilla in the newborn or  when the child presents early (at less than 3 months of  age), strapping of prolabium with dynaplast or elastics  is helpful.   @ In the more displaced premaxilla, nasoalveolar mould-  ing with specially developed plates with nasal prongs  to guide premaxillla and lateral segments into position  can be fitted. It requires repeated visits to the clinic to  adjust the plates (Figures 66.2 through 66.4).    This is a surgical procedure which allows mobilization of  the nasal layer and closure of the lateral segment margins  with the prolabium without mobilization and anastomosis  of the orbicularis oris muscle. This allows repositioning  of the premaxilla and definitive repair at the second stage  some 3 months after the lip adhesion (Figure 66.4).    Primary premaxillary osteotomy is performed using  longitudinal mucosal incision, use of cutting instruments  to perform a predetermined oblique ostectomy, separation    Figure 66.2 (a) Premaxilla at the tip of the nose, absence  of columella and deficient prolabial tissue; (b) protruded  premaxilla and deviated nasal septum.    Figure 66.4 Treatment progression using an appliance  and strapping to guide the premaxilla.    of the nasal septum from the vomer and retroposition-  ing the premaxilla and stabilization with resorbable bone  plates. After 3 months, primary repair of lip can be under-  taken (Figure 66.5).    Patients are given general anaesthesia, using an oral endo-  tracheal, reinforced tube.    Patients are positioned with the neck extended and a  mouth gag applied.    After the mouth gag is applied, marginal incisions are  made along the medial aspects of the palatal shelves up to  the end of the hard palate. On the premaxilla, a Y-shaped  incision is made with the two short limbs encircling the  premaxilla and the long limb along the vomerine muco-  periosteum. The nasal layers are elevated using Mitchell’s  trimmer or a plastic instrument. A single layer mucosal  closure of the nasal lining is achieved from the lip to the  hard palate using interrupted resorbable Vicryl 4/0 sutures  with the knots inverted into the nasal cavity. The mouth  gag and neck extension are then removed.   Next, lip marking should be planned, the key points  to mark on the prolabium being: the apparent junction  between columella and prolabium. Mark Al and A2 at  the corner of the base of the columella on either side. Two  divergent lines are drawn down to the white roll to end at  Bl and B2 as shown (Figure 66.8), B1 and B2 being slightly  wider than Al and A2. Point C is the midpoint between  B1, B2 and it is the lowest point of the Cupid’s bow. On the  cleft side’s right and left points, D1 and D2 are marked to  represent the commissure of the lips. Points El and E2 are  marked at the spot where the white roll just begins to fade.  Thus, D1-E1 is equal to D2-E2. At El and E2, a perpendicu-  lar line is drawn towards the free margin of the lip. Points  Fl and F2 are marked such that E1-F1 is equal to E2-F2 is  equal to B1-C is equal to B2-C. F1-E1 continues along the  white roll into the internal aspect of the nostril on either  side. The incision is made using a no. 15 blade starting from  Al to B1 and then again on the other side from A2 to B2.  The two are joined together across C. The incision goes  through the skin and incorporates a little of the underlying  tissue. On the cleft sides, that is the lateral sides, incisions  are started at El and continued along the white roll into  the nostril and extended laterally to the point F1. At E1, the  incision is also taken perpendicular to the white roll to the  free margin of the mucosa and a mucosal flap is elevated on  right side. A similar flap is elevated on the left side.   Once the incisions are completed, the orbcularis oris  muscle is dissected free from its abnormal attachments  on either side of the base of the ala and maxilla. The mus-  cle is freed from its attachments to the skin, mucosa and  vermillion using a no. 15 blade up to a distance of about  5 mm (Figure 66.9). Superiorly, where the abnormal    1 -prolabium. 2 - premaxilla. 3 - vomerine stalk. 4 - vomerine mucosa.  5 - osteotomy site. 6 - vomer exposed. 7 - osteotomy site after reduction.  8 - resorbable bone plates.    (a and b) Model analysis prior to premaxillary  osteotomy. (a) Pre- and (b) post-operative photographs.   B, B, — highest point of Cupid’s bow. C - lowest point of Cupid’s bow.  D, D, - commisure of lip. E, E, - white roll fades.   F, F, - back cut along white roll such that E, F,;=E, F,=B, C=B, C.    1 - prolabial skin flap. 2 - excess skin and mucosa. 3 - premaxilla.  4 - unoperated side showing orbicularis oris muscle bundle under  intact skin/mucosa. 5 - exposed orbicularis oris muscle.    insertion of the muscle into the ala is seen, the muscle is  freed using a combination of sharp and blunt dissection  to free the entire corpus of orbicularis oris muscle along  with the bundles of the nasalis and the other associated  muscles. To mobilize the lip completely, the muscles are  also freed from the underlying maxillary bone in a sub-  periosteal manner. The orbicularis and nasalis muscles  are freed as far as the base of the alar margin and a sulcu-  lar incision is made into the depth of the sulcus from the  free margin of the lip up to the premolar area. The sub-  periosteal dissection is carried out to elevate the entire  lip complex along with its underlying and associated  muscles away from the maxillary wall. The tissues are  freed along the pyriform margin and also extended into    the lateral aspects of the ala of the nose on either side. The  incision along the white roll towards the nostril is carried  on until it reaches the inferior aspect of the inferior tur-  binate mucosa. The mucosal flaps are raised to coincide  with the nasal layer of the anterior aspect of the palatal  mucosa. On the prolabial side, the incision B1-A1 is car-  ried further backwards along the nasal mucosa over the  vomer bone, such that the nasal flaps can be elevated on  either side. This helps in having a continuous nasal lin-  ing from the palate forwards into the lip. As soon as the  mobilization is complete, it will be seen that the lateral  segments of the lip now assume a very comfortable hori-  zontal position and they can be brought together with  minimal or no tension at all. The excess lip mucosa which  is medial to points El and E2 is used to form the sulcus of  the future upper lip.    Blunt dissection of the lateral crura of the lower lateral car-  tilages on either side using a curved blunt-tipped tenotomy  scissors. The scissors are placed through the lateral inci-  sion and blunt dissection is proceeded along the superior  and inferior and the outer and inner aspects of the lower  lateral cartilage up to the dome (intermediate crura). The  medial crura of the lower lateral cartilage is approached  from the prolabial side and also freed on all aspects. This  mobilizes the lower cartilage completely and allows it to  attain its natural form during closure of the lip.    Closure is performed in three layers (Figure 66.10). First,  the nasal layer is closed in continuity with the closure of the    premaxillary nasal mucosa which was performed earlier.  Once the nasal layer closure is complete, the mucosa on  the inner aspect of the upper lip on either side is sutured to  the prolabial mucosa to form the sulcus of the oral cavity.  Closure is obtained using 4/0 Vicryl sutures (5/8 of a circle  cutting needle).   The next layer of the closure is the muscle. The nasalis  is identified on either side by pulling it medially and see-  ing the inwards movements of lower lateral cartilage and  the base of ala on either side. The orbicularis oris proper  muscles are also identified and three sutures are placed  using 4/0 Vicryl to bring together the orbicularis and  nasalis muscles comfortably in the midline over the pro-  labial mucosa. Along its length, skin hooks are positioned  actively, giving a slight downward traction to the lip, to  ensure that the entire nasalis and orbicularis muscles have  been brought together.    The prolabial skin is allowed to fall gently upon the closed  orbicularis muscles, and the two lateral segments are  then gently pulled across and held together with two skin  hooks held in parallel along the long axis of the body of  the patient (Figure 66.11). Any excess skin in the lateral  segments resulting from the closure of the muscles can  be incised to accommodate the prolabial skin in the mid-  line and the wound is closed using 5/0 proline sutures.  The vermillion and the oral mucosa are closed using 4/0  Vicryl. Care is taken to achieve a central tubercle in the  midline of the lip, thus giving the upper lip a pleasant and  natural appearance. Bolster sutures are placed through the  dome (intermediate crura) of the lower lateral cartilages    1-dome. 2 - lower lateral cartilage. 3 - prolabial skin.  4 - lateral element skin. 5 - Cupid’s bow. 6 - vermillion.  7 - central tubercle. 8 - bolster stitch with 3.0 prolene.  9 - skin closure with 5.0 prolene.    to hold them up in a new position allowing the skin and  the mucosa to adapt and heal in the new relaxed positions  of the cartilages. The skin sutures and bolster sutures are  removed after 7 days.    Steri strips are placed immediately after the suturing and  they are removed after 2-3 days to inspect the wound  and clean it. The wound is meticulously cleaned with  normal saline and hydrogen peroxide and betadine and  steri strips are replaced. On the seventh day, the sutures  are removed under sedation, the wound is cleaned again  and new steri strips are placed. The parents are advised  to apply vitamin E cream to the wound post-operatively  for a period of 3 months and massage the lip gently every  day. Gentle massage of the lips is continued for at least  3 months.    The results of primary closure of bilateral cleft lip surgery  are shown in a series of different patients in Figures 66.12  through 66.15.    The premaxilla is continuous with the vomer along a very  thin stalk and may sometimes be traumatized, especially  if it is protuberant either prior to the surgery or during the  procedure.    AVULSION OF THE PREMAXILLA  This is a rare, but unacceptable, iatrogenic complication.    The wound may get infected, especially in chronically  malnourished children in developing countries due to  decreased immunity. Use of antibiotics and local wound  management should salvage the surgical procedure.    As a sequela to either wound infection or tension dur-  ing closure, partial breakdown of the surgical repair may  occur. Conservative management is followed by secondary  correction after 6 months.    Partial breakdown of the nasal layer may lead to small  oronasal communications in the region of the premax-  illa and lateral segments. Definitive repair of the fistula    Pre- and post-operative photographs. Pre- and post-operative photographs.  (a) Preoperative and (b) postoperative. (a) Preoperative and (b) postoperative.    Pre- and post-operative photographs. Pre- and post-operative photographs.  (a) Preoperative and (b) postoperative. (a) Preoperative and (b) postoperative.    in two layers is taken up as a secondary procedure after  6 months.    Mismatch of the white roll during suturing or wound  contracture may lead to a deformed Cupid’s bone, which  is corrected with Z-plasties or scar revision.    Generally, this is a severe deformity due to inadequate  mobilization of nasalis and orbicularis oris muscles or  dehiscence of these muscles due to closure with tension.  Secondary repair is carried out in the form of a complete  revision cheiloplasty.    Hypertrophic scar is a common sequel due to excessive  tension in skin closure and is all the more apparent in  pigmented skin (types IV-VI). Hypertrophic scars can be  managed initially conservatively using vitamin E cream,  massage, contratubex ointment etc. Minimally hyper-  trophic scars can be resurfaced with erbium YAG lasers.  Severely hypertrophic scars would need excision and resu-  turing in a tension-free environment.    The incisions of the lip which extend in to the nasal cavity  along the inferior margin of the lower lateral cartilage  is continued to meet the prolabial incision at the medial    crude. This allows a complete reflection of prolabial and  columellar skin to expose the dorsal aspect of the right  and left lower lateral cartilages completed up to its attach-  ments laterally to the pyriform rim.   Next, the nasal mucosa is freed from the inner aspect of  the lower lateral cartilages from lateral to medial to mobi-  lize the lateral crura completely. The superior end of the  lower lateral cartilage is freed from its fibrous overlapping  attachment with the upper lateral cartilage.   The lateral crura is now free floating whilst the  medial crura continues to be attached to the columel-  lar mucosa.   An interdomal stitch is taken after medialization of the  two lateral crura such that, a new better projected nasal tip  is achieved.   Closure is then achieved by redrawing the columello-  prolabial skin, and suturing the infra-cartilaginous  incision.   The rest of the lip, nose correction is exactly as  before.   The nasal septum is generally addressed at the same  time and it is excess mobilized and trimmed along the  axillary crest.   This allows the septum to swing freely and reposition  itself in the midline as balance is restores between two  sides of facial and lip muscles.   There was a hypothetical concept that nasal and facial  growth might be affected if an open lip, nose correction  were to be performed. However, this is not the case as can  be seen in 10-year follow-up of patients.   The results of mobilization - open technique is shown  in Figures 66.16 and 66.17.    Figure 66.16 (a) Pre- and (b) post-operative photographs of a patient treated with the ‘open’ technique.    Figure 66.17 (a,b) Pre-and (c) post-operative photographs  of a different patient treated using the ‘open’ technique.   e The premaxilla may be situated centrally or asymmetri-  cally in three dimensions.   e The ideal age of repair of the bilateral cleft lip is  3 months, but patients may present at any age in less  informed societies.   e There are several techniques to manage the premaxilla  which include simple strapping (common), nasoalveo-  lar moulding (common), lip adhesion (less common)  and premaxillary osteotomy (occasionally).   e In the definitive repair of the bilateral cleft lip, it is  important to first repair the nasal floor.   e Further important steps include careful marking of the  incisions and meticulous mobilization of the muscles.   e The lip-nose complex is treated simultaneously and  hence careful closed dissection and mobilization of the  lower lateral cartilages are performed.   e During mucosal closure, care is taken to achieve a good  sulcus and, on the labial side of the alveolus, a gingivo-  alveolar periosteoplasty is achieved.   e Skin closure achieves symmetry of the lip and nose,  and pleasing Cupid’s bow, philtral ridges and central  tubercle.   e Potential complications though rare include intra-  operative fracture or avulsion of premaxilla, postop-  erative infection or dehiscence of the wound, and late  problems such as oronasal fistula, whistling deformity,  hypertrophic scars etc.    Bardach J. Salyer & Bardach’s Atlas of Craniofacial and  Ceft Surgery: Cleft Lip and Palate Surgery, vol. 2.  Philadelphia, PA: Lippincott; 1999.   Bishara SE and Olin WH. Surgical repositioning of the pre-  maxilla in complete bilateral cleft lip and palate. Cleft  Lip Palate J. 1972; 42: 139-143.   Cronin TD, Cronin ED, Roper P, Millard, DR Jr and  McComb H. Bilateral clefts. In: McCarthy J (ed.),  Plastic Surgery, vol. 4. Philadelphia, PA: WB Saunders;  1990. Pp. 2653-2722.   Delaire J, Precious D and Gordeef A. The advantage of wide  subperiosteal exposure in primary surgical correction  of labial maxillary cleft. Scand J Plast Reconstr Surg  Hand Surg. 1988; 22: 147-151.   Jackson IT, Yavuzer R, Kelly C and Bu-Ali H. The central  lip flap and nasal mucosal rotation advancement:  Important aspects of composite correction of the  bilateral cleft lip nose deformity. J Craniofac Surg.  2005; 16: 255-261.   Markus AF. Primary closure of cleft lip. In Langdon JD  and Patel MF (eds.), Operative Maxillofacial Surgery,  1st ed. London: Chapman & Hall; 1998. pp. 189-199.   Markus AF and Delaire J. Functional primary closure  of cleft lip. Br J Oral Maxillofac Surg. 1993; 31:281-291.   Mulliken JB, Wu JK and Padwa BL. Repair of bilateral cleft  lip: Review, revisions, and reflections. J Craniofac  Surg. 2003; 14: 609-620.   Mucosal incisions and formation of bipedicled longitudinal flaps  Muscle dissection and formation of a nasal mucosal layer  Muscle repair    The first major step towards modern cleft palate surgery  was made in 1862 by Bernhard von Langenbeck'  (1810-1887) at the Charité in Berlin. He suggested clos-  ing the palate with two medially mobilized bipedicled  mucoperiosteal flaps. In principle, this method is still in  use today.   With the invention of local anaesthetic, surgical  procedures could be refined as speed was no longer an  issue. The first significant modification was introduced  by F. Ernst in 1925 who suggested suturing of the mus-  cles, division of the palatine vessels and the formation of  parapharyngeal pouches to reduce tension to the midline  sutures.   Victor Veau from Paris refined the procedure in 1931  by dissecting the nasal mucosa, thus closing the soft pal-  ate in three layers. He furthermore developed a method  using posteriorly based unipedicled flaps which helped  to lengthen the velum according to the principle of a V-Y  plasty. A similar procedure was developed by the British    681  682  682  683  683  683  684  684  685  685  686  687  687  689  689  689  689    surgeons Kilner” (1890-1964) and Wardill’ in the late  1920s and early 1930s. In 1959, this so-called ‘pushback’  procedure was modified by Widmaier* who suggested a  supraperiosteal dissection of the flaps to reduce growth  impediment of the maxilla. He introduced the use of  a caudally based vomerine flap, first described by the  British surgeon A. Campbell in 1926, to close the hard  palate.   In 1970, the German surgeon Kriens* from Hamburg  published an article emphasizing the importance of an  anatomically correct repair of the velar muscles which  includes the detachment of the wrongly inserted muscu-  lature from the posterior aspect of the palatine bone. This  concept of an intravelar veloplasty is still the basis of most  modern techniques in primary and secondary cleft palate  surgery.   In the 1950s, the ear, nose and throat (ENT) surgeon  Wolfram Schweckendiek pioneered a method of a  two-stage repair, previously described by Gillies and  Fry® in 1921, which included an early soft palate and  a late hard palate repair to prevent maxillary growth    disturbances which had been seen in many cases with  the previous techniques. According to his protocol,  he carried out the hard palate repair on a patient aged  12 years. Schweckendiek’ popularized this two-stage  procedure in many cleft centres worldwide when he pub-  lished excellent long-term results in 1978.   In 1976, Leonard T. Furlow introduced a completely  different method involving a double opposing Z-plasty  to close and simultaneously lengthen the soft palate. This  procedure had already been published in principle in 1966  by Karl Schuchardt. When Furlow® presented some very  encouraging results in 1986, the method gained popular-  ity and is nowadays a very well-established procedure in  many cleft centres around the world.    The main target of the primary repair of the cleft palate is to  reinstate the function of the soft plate. This is most impor-  tant as the formation of certain speech sounds requires  normal function of the velum. During the formation of,  for example, explosives like [b], [p], [d] and [t], the nasal  airway has to be sealed off by a craniodorsal movement of  the soft palate. If this is not possible air escapes through the  nose and the air pressure, which is necessary to form these  sounds, cannot build up and speech sounds hypernasal. A  nasal air escape can be noticed. This pathophysiological  phenomenon is called velopharyngeal insufficiency (VPI)  or velopharyngeal dysfunction (VPD). Therefore, it is par-  amount to repair the velar muscle layer in an anatomically  correct position as pointed out by Otto Kriens in the 1960s.   A measure for VPI is the nasalance which is a quotient  of nasal and oral acoustic energy. It can be measured by a  nasometre (acoustic energy) or an aerophonoscope (air flow).   In order to lay the foundations for normal speech devel-  opment, the repair of the soft palate should be carried out  before onset of speech, i-e. in the first year of life.   A no less important aim of palate repair is to install  the natural separation of the oral and nasal cavities and  to establish two separate nasal cavities. This avoids nasal  regurgitation of food, which can be socially very trouble-  some and prevents contact of food with the nasal mucosa.   On the other hand, an early intervention could lead to  maxillary growth retardation and hypoplasia especially if  the alveolar periosteum is detached during the procedure.   For this reason, some cleft surgeons advocate closure  of the hard and soft palate in separate procedures. There  is still some controversy about the question of whether a  one- or two-stage palate repair is preferable. The two most  common basic protocols are as follows:    1 Lip repair (uni- or bilateral) at the age of 3-6 months  followed by a one-stage hard and soft palate repair at the  age of 6-12 months   2 Lip repair (uni- or bilateral), in combination with soft  palate repair followed by a hard palate repair at age  15 months to several years (in extreme cases, early teens)    In a two-stage procedure, early periosteal stripping of  the hard palate can be avoided; however, it is still unclear if  this gives a significant advantage for the midfacial growth.  In fact, some scientific studies suggest that differences in  maxillary growth might not be significant. The disadvan-  tage of persistent nasal regurgitation of food and fluids has  to be taken into account.   Despite all the improvements in cleft palate surgery,  in many cases, speech and language therapy may still be  needed to obtain a good result, but a significant propor-  tion of patients can develop normal speech without any  further therapy. Some patients may need further surgery  for speech improvement later in life. Speech can still  deteriorate during growth periods, such as the early teens,  and special precaution has to be taken when planning  maxillary advancement surgery.   Primary repairs in adulthood have been shown to be  much less successful with regards to speech, but can still  be helpful for the better functioning of dentures and to  avoid nasal regurgitation of food.    The physiological functioning of the soft palate is  essentially due to an anatomically correct restoration and  reorientation of the velar musculature which has to be  detached from the posterior aspect of the palatine bone.  Important muscles of the soft palate are as follows:    © Levator veli palatini, which originates from the petrous  portion of the temporal bone, is attached to the medial  wall of the eustachian (auditory) tube and runs ven-  tral to the tensor muscle into the velum to fuse with  its counterpart on the opposite side. Its function is to  lift the soft palate in a cranioposterior direction. This  muscle is most important for the velopharyngeal seal  and creates the velar ‘knee’ in a lateral videofluoros-  copy. Functionally, it is most effective in a more poste-  rior position.   © Tensor veli palatini which originates from the scaphoid  fossa of the sphenoid bone and the lateral rim of the  eustachian tube runs with a tendon through the sulcus  of the pterygoidean hamulus and forms the palatal apo-  neurosis with the opposite side in the anterior third of  the soft palate. Next to stretching the velum, its main  function is to open the auditory tube.   @ Musculus uvulae are a paramedian pair of muscles run-  ning from the posterior nasal spine to the tip of the  uvula. Supports the levator bulge and thus helps with  the oropharyngeal seal.   © Palatopharyngeus muscle which forms the posterior  pillar of the fauces (pharyngopalatine arch) originates  with a wide base from the posterior and lateral pha-  ryngeal wall and inserts with its posterior fasciculus at  the posterior aspect of the hard palate and the anterior  fasciculus into the soft palate. It can send the small sal-  pingopharyngeus muscle to the eustachian tube, but    this muscle is not always present. Functionally, the  palatopharyngeus elevates the pharynx and larynx,  constricts the isthmus faucium while swallowing and  depresses the soft palate opposing the action of the  levator muscle.   © Palatoglossus muscle runs from the velar aponeurosis to  the posterior superior parts of the tongue. It is another  antagonist of the levator muscle and forms the anterior  pillar of the fauces (palatoglossal arch).   © Superior pharyngeal constrictor muscle arises from the  pterygoid hamulus of the sphenoid bone and the pter-  ygomandibular raphe. The fibres run in a backward  curve to unite in the median pharyngeal raphe with the  opposite side. Its function is a constriction of the upper  pharynx in collaboration with the levator veli palatini  muscle while swallowing. If hyperplastic, this muscle is  the anatomical substratum of the Passavant's ridge. Its  significance for speech is doubtful.    Most children with cleft lip and palate are otherwise  healthy and do not need any further pre-operative precau-  tions. However, in some cases, especially where the cleft  palate is part of a syndrome, attention has to be paid to  other co-morbidities involving especially the heart or kid-  neys. Therefore, it is important to have a paediatrician on  the team to make sure these conditions are not missed.   Audiology and ENT assessment should be arranged  prior to the palate repair as the insertion of grommets  can be carried out simultaneously with the palate repair  if indicated. As the palate repair can lead to significant  haemorrhage, the clotting system should be assessed.   In case the cleft palate is part of a Pierre Robin sequence,  pre-operative sleep studies can be helpful. In these cases,  pre-surgical orthopaedic therapy with a modified Hotz's  plate can be useful to reposition the tongue in a more  anterior position. The forward push of the tongue seems to  stimulate mandibular growth.   As cleft surgery is in principle elective surgery, it should  be carried out under optimal conditions. The procedure  should be postponed whenever signs of common cold,  respiratory tract infections or other acute medical condi-  tions are seen. The parents need to be warned about this  possibility in advance.    The surgery is undertaken under general anaesthetic  which should be administered by an experienced paedi-  atric anaesthetist. Due to their small body volume, infants  are at much greater risk from hypothermia than adults.  A temperature probe should be inserted and the infant has  to be kept warm throughout the procedure. Monitoring  during the entire surgery is most important.    For ventilation, an orotracheal tube is used and it should  be fixed in the middle of the lower lip so it can be pro-  tected by the tongue spatula of the self-holding retractor  (Dingman or similar). As paediatric endotracheal tubes do  not have a cuff, it is paramount to prevent any gas leakage  or fluid aspiration with a carefully placed throat pack.   To prevent a peri-operative wound infection, a single  shot of an antibiotic (co-amoxiclav, combination of cepha-  losporin and metronidazole or similar) at induction is  usually sufficient.   As the palate repair is physiologically stimulating for  the infant, local anaesthetic with epinephrine (adrena-  line) (2% lidocaine with 1:80,000 epinephrine or similar)  should be infiltrated into the soft and hard palate at the  beginning of the procedure to reduce the amount of gen-  eral anaesthetics and to induce vasoconstriction in the  surgical field.   Extubation is the most critical moment after palate  repair and the infant has to be closely monitored during  this process and during the first night afterwards. As the  nasal airway resistance rises due to the surgery, the infants  may experience airway problems and a nasal prong may  have to be used. If this is at all necessary, it can be removed,  in most cases, the next day as the infant adapts to the new  situation and the post-operative oedema of the nasopalatal  mucosa settles.   In children with Pierre-Robin sequence, however, it is  sometimes necessary to keep the nasal airway for a while.    There are a number of different surgical procedures avail-  able to close the cleft palate. The classical palate repair  based on bilateral bipedicled von Langenbeck flaps, the  Furlow repair and the two-stage Schweckendiek repair  will be described in detail in “Two-stage procedure  (Schweckendiek)’.   The patient rests in a supine position with a bulky gel pad  or fluid bag underneath the shoulder. The neck has to be  extended as much as possible to make sure the surgeon  has good access to the palate and sits comfortably in the  12 oclock position with the infant's head in his lap. The  assistants sit at 9 and 3 o'clock (Figure 67.1). It is advisable  to wear a head light.   The first step of any palate repair is the insertion of a  self-holding retractor (Dingman or similar) which serves  as a mouth gag, retracts the tongue and cheeks and pro-  tects the orotracheal tube (Figure 67.2). Once the retractor  is in its final position, sufficient ventilation has to be con-  firmed by the anaesthetist.    Figure 67.1 The surgeon's position at 12 o'clock with the  infant's head in his lap.    The local anaesthetic is injected into the mucosa of the  hard and soft palate. In order to give the adrenaline time  to be effective, one should wait with the first incision until  the bleeding in the injection channels stops.    The procedure is started with the surgeon's right hand  at the patient's left-hand side. Using a size No. 15 blade,  an incision is made along the borderline of the oral and  nasal mucosa with excision of a little mucosal triangle at  the medial aspect of the hemi-uvula (this creates a con-  tact surface for the unification of both hemi-uvulae)  (Figure 67.3). In the area of the hard palate, the incision  goes right on to bone.   In wider clefts, lateral releasing incisions in the transition  zone between alveolar and maxillary mucosa are necessary    and should extend from the area above the space of Ernst  posteriorly to the level of the anterior extension of the cleft  (Figure 67.4). The incision is made right on to bone and an  anterior pedicle should be preserved at this stage. The flap  is now undermined subperiosteally with a curved sharp  elevator and after thorough haemostasis the neurovascular  bundle is luxated a few millimetres out of the palatine canal  using a curved elevator anterior and posterior to the bundle.  This step can be rather frightening for the inexperienced  surgeon, but it is important because otherwise the flap can-  not be mobilized towards the midline without tension. Care  has to be taken in order not to damage the palatine artery.    The muscle dissection and precise reconstruction are  of paramount importance and should be carried out as  carefully as possible. Loops with a magnification factor    of 2.5-3.5 or a surgical microscope are most useful, but  not indispensable.   The dissection begins with the detachment of the  wrongly inserted musculature from the posterior aspect  of the palatine bone. This is best undertaken with a sharp  Freer's periosteal elevator and a Mitchell's trimmer. The  nasal mucosa is detached from the nasal aspect of the pal-  atal shelf with a fine sharp curved periosteal elevator to  stretch it to the midline and thus make the closure with  the opposite side possible.   The muscle is then lifted up with a skin hook and kept  under tension to be dissected off the nasal mucosa laterally  as far as the pterygoid plates. The dissection can be car-  ried out with a pair of sharp pointed scissors or a size No.  15 blade. It is important to keep the musculature attached  to the oral mucosa because otherwise the blood supply to  the mucosa can be compromised and oronasal fistulas are  more likely to occur.   After analogous dissection on the patient's right side  with the surgeon's left hand, an incision is made along the  vomerine ridge with small release incision posteriorly at  an angle of about 45° (Figure 67.5). The mucosa tends to  bleed quite intensively due to its excellent blood supply.   Small vomerine flaps are formed and each of them  is united with its adjacent counterfoil of nasal mucosa  across the cleft using 5-0 monofilament resorbable sutures  (Monocryl® or similar). The stitches should be inserted  indirectly in order to place the knots towards the nasal cav-  ity, so that two separate tubes of nasal mucosa are formed  (Figure 67.6).   Next, the nasal mucosa of the velar area should be  repaired from front to back in the same way using the  same sutures.    The muscle repair is the most important step and should  be carried out with slowly resorbing monofilament sutures  (4-0 polydioxanone, i.e. PDS® or similar). Corresponding  parts of the musculature are stitched together starting from  the back to the front with three to four sutures. It is impor-  tant to achieve a symmetrical result at this stage and the oral  mucosa should align without tension after the completion  of the muscle repair. As a result of the repositioning of the  muscle in a more natural posterior position, there should be  a significant gap between the anterior aspect of the repaired  muscle and the posterior ridge of the palatine bone.    The oral mucosa should be closed with 5-0 monofilament  resorbable sutures. It is best to start the repair of the oral  mucosa with two to three deep stitches which engage all  layers (use 3-0 monofilament resorbable sutures) in the  area of the hard/soft plate junction (Figure 67.7). They are  placed and temporarily fixed with an arterial clip from  back to front to be then tied one after the other from front  to back. This is important to avoid a haematoma between  the different layers which again reduces the risk of fistula    Figure 67.6 Cross section of the anterior palate,  reconstruction of two separate nasal tubes with vomerine  flaps.    formation. Furthermore, these stitches help to shape the  typical palatal vault.   Next, the first 5-0 stitch is applied to the tip of the uvula.  It should be used as a stay suture which can be attached to  the retractor or clamped to the head towel (Figure 67.8).  Following this, the stitches to the posterior aspect of the  uvula can be put in easily. The stay suture is cut short and  the oral mucosa can now be sewn without any tension  from the back to the front using mattress stitches all along.   If the cleft is very wide, it is sometimes necessary to sac-  rifice one or even both of the anterior pedicles to close the  anterior mucosa of the hard palate which would otherwise  not be possible (Figure 67.9).    To avoid post-operative haemorrhage from the lateral  releasing incisions which remain at least partly open,  some sort of haemostatic sponge (Surgicel®, Spongostan”  or similar) can be introduced. They are fixed with two or  three retaining stitches which should not be tied too tight  in order to avoid tension at the primary closure site in the  midline (Figure 67.10).   The releasing incisions will heal through free granula-  tion and cannot be distinguished from the local mucosa  with the naked eye after a few weeks.    The advantage of a two-stage palate repair is the fact that  the velum can be closed before onset of speech without  undermining the palatal periosteum which might lead to  growth retardation. In theory, good speech results can be  achieved without compromising on maxillary growth.  The velar incisions are similar to the von Langenbeck pro-  cedure, but the incision line at the border of oral and nasal  mucosa stops in the area of the hard and soft palate junction  to turn laterally at a right angle. Lateral to the pterygoid ham-  ulus, a small back cut in the posterior direction is advisable.  The incorrectly inserted musculature has to be  detached from the posterior aspect of the palatine bone    Figure 67.8 Tip of the reconstructed uvula fixed with a  stay suture to access posterior aspect of the uvula for closure.    (Freer, curved periosteal elevator) followed by a sharp  dissection off the nasal mucosa with a blade or pointed  pair of scissors (Figure 67.11).    Figure 67.11 Incisions for stage one of two-stage  procedure (isolated soft palate repair).    The next step is the repair of the nasal mucosa with 5-0  monofilament resorbable (Monocryl or similar) inter-  rupted sutures. As previously mentioned, the knots should  be placed towards the nasal cavity. The muscle is now  repaired as described for the one-stage procedure. The last  step is the repair of the oral mucosa with 5-0 monofila-  ment stitches in analogy to what was mentioned earlier.   In wide cases, an oral mucosa gap will remain at the hard  and soft palate junction parallel to the posterior border of  the palatine bone. It should not be closed with tight stitches  as this would shorten the velum. In these cases, some resorb-  able haemostatic foam (Surgicel, Spongostan or similar) can  be introduced and fixed with some retention sutures.   As a result of this repair, a scar forms in transverse  direction. This could lead to a narrowing of the posterior  hard palate due to scar contraction.    The closure of the remaining hard palate defect is car-  ried out according to the particular protocol between  18 months and about 13 years of age. Nowadays, the ten-  dency goes more towards early repair. Quite often, one will  only find a relatively narrow but longitudinal defect as the  gap tends to decrease with time. If the protocol involves a  relatively late repair of the hard palate, a cover plate should  be considered to reduce the inconvenience caused by the  remaining oronasal communication.   The surgery is performed under general anaesthesia and  follows the principles of a fistula repair. A two-layer clo-  sure is desirable. In order to create a nasal layer, the nasal  mucosa has to be stretched and/or mucosa from the oral  cavity has to be borrowed and turned over into the nasal  floor. The remaining increased defect of the oral mucosa  can then be closed with a rotation or sliding flap (similar  to von Langenbeck flap) (Figure 67.12). It is important to  design the oral mucosa flap as large as possible to avoid the  reappearance of an oronasal fistula.    This technique follows a completely different approach to  close the cleft palate. It uses an oral layer and a nasal layer  Z-plasty that oppose each other. Thus, a lengthening of  the palate, as well as a reorientation of the muscles, can  be achieved. The major disadvantage is that it produces an  asymmetrical scar which is partly transversely orientated  and could lead to some narrowing of the maxilla.   In a first step, a large Z-plasty is designed in the area of  the velum with the end points of the lateral limbs lying in  the area of the pterygoid hamuli, which can be palpated  through the mucosa. The central limb lies parallel to the  cleft (Figure 67.13).   The posteriorly based triangle has to be prepared as a  myomucosal flap containing oral mucosa and tensor, as  well as the levator veli palatini muscles. The muscles have    Figure 67.12 incisions for second stage of two-stage pro-  cedure (hard palate repair).    Figure 67.13 Incisions of oral mucosa for repair with  double opposing Z-plasties (Furlow). Please note the sagittal  direction of tensor/levator fibres.    to be detached from the posterior aspect of the palatine  bone with a sharp Freer's elevator or Mitchell's trimmer  and dissected off the nasal layer which stays intact at this  stage. Nasal and oral mucosa have to be elevated from the  bony shelves of the hard palate with a curved periosteal  elevator, Mitchell's trimmer or Freer's (Figure 67.14).   The opposite side in now dissected in the opposing  way leaving the musculature attached to the nasal layer  (Figure 67.15).   Next, the opposing nasal Z has to be designed with the  end points of the lateral limbs situated just a few milli-  metres medial to the mouth of the eustachian tube. As a    Figure 67.14 Dissection of anteriorly based triangle of oral  mucosa at the right-hand side.    result, a posteriorly based oral myomucosal flap opposes  an anteriorly based oral mucosa flap (Figure 67.16).   The nasal Z-plasty now has to be completed, creating a  posteriorly based nasal myomucosal flap. As already per-  formed on the opposite side, the muscle has to be detached  from the posterior aspect of the palatine bone. Next, the  Z-plasty flaps can be transposed, interposing the corre-  sponding mucosa flap between the posterior aspect of the  palatine bone and the myomucosal flap. A 4-0 monofila-  ment stay suture is now placed through the base of the oral  myomucosal flap engaging the tip of the nasal myomucosal  flap and going back through the oral mucosa. This leads to  an overlap of the musculature thus creating a muscle sling  (Figure 67.17).   The nasal mucosa is now closed with a 5-0 monofila-  ment resorbable suture and the stay suture can be tied  (Figure 67.18).    Figure 67.16 Dissection of anteriorly based triangular  nasal mucosa flap at the left and posteriorly based triangular  nasal musculo-mucosal flap at the right-hand side.    Figure 67.17 Situation after anterior nasal mucosa closure  under formation of two separate nasal tubes and exchange of  nasal triangular flaps just before exchange of oral triangular  flaps in opposite direction (long arrows).    Figure 67.18 Situation after closure of oral mucosa. Please  note the transverse direction of tensor/levator muscle fibres.    The undermined mucosa of the hard palate can be  closed in analogy to the above described procedure. A  repair without tension, however, is not possible in very  wide clefts as lateral releasing incisions are not provided.   The final result is a z-shaped scar with a transverse  direction of the central limb is obtained. This procedure  could be carried out in two stages, closing the soft palate  first, leaving the hard palate open for a later repair.   Furthermore, it can be used as a modification in sec-  ondary palate surgery if lengthening of the velum as well  as an intravelar veloplasty is required.    For post-operative pain control, body weight adjusted  intravenous (iv) morphine administered by a pump as  nurse-controlled analgesia (NCA) overnight is beneficial.  Usually the morphine can be stopped after 24 hours and it  should be replaced by regular paracetamol and ibuprofen  for about 7 days. Under this regime, post-operative drink-  ing and feeding is usually not a problem and should be  encouraged immediately after the procedure. However, it  is not unusual that infants refuse fluids and get on much  better with puréed food as sucking can be more uncom-  fortable than feeding from a spoon.   The infants should be monitored with pulse oximetry  during at least the first 24 hours after the procedure, as  post-operative swelling and a naturally increased nasal  airway resistance could lead to hypoxia. The post-operative  administration of antibiotics is usually not necessary in  otherwise healthy children.    Generally, speech and growth outcome after cleft palate  repair have improved significantly over the last decades.  The question of whether a single- or two-stage repair pro-  duces consistently better results has still to be answered.  There is more agreement among cleft surgeons about the  timing of the soft palate closure. An early repair before  the onset of speech in the first year of life seems to lead  to the best speech results. Nevertheless, a good propor-  tion of children with cleft palate need speech and language    therapy and should be regularly monitored for their speech  outcome starting at the age of about 2 years. A minority of  these children will need further surgery at a later stage to  improve speech or to treat maxillary hypoplasia.    1. Von Langenbeck B. Die Uranoplastik mittels  Ablésung des mucésperiostalen Gaumeniiberzugs.  Archiv fiir Klinische Chirurgie. 1862; 2: 25.   . Kilner TP. Cleft lip and palate repair techniques.  St Thomas Hospital Rep. 1937; 2: 127.   . Wardill WEM. Cleft palate. British J Surg. 1928; 16:  127-148.   . Widmaier W. A new technique for closure of cleft  palate. Chirurgie. 1959; 30: 274-278.   . Kriens OB. An anatomical approach to veloplasty.  Plast Reconstr Surg. 1969; 43: 29-41.   . Gillies HD and Fry WK. A new principle in the sur-  gical treatment of ‘congenital cleft palate’ and its  mechanical counterpart. Br Med J. 1921; 1: 335-338.   . Schweckendiek W and Doz P. Primary veloplasty:  Long-term results without maxillary deformity.  A twenty-five year report. Cleft Palate J. 1978; 15:  268-274.    Holland S, Gabbay JS, Heller JB, O'Hara C, Hurwitz D,  Ford MD et al. Delayed closure of the hard palate  leads to speech problems and deleterious maxillary  growth. Plast Reconstr Surg. 2007; 119: 1302-1310.   Kriens OB. Fundamental anatomic findings for an intrave-  lar veloplasty. Cleft Palate J. 1970; 7: 27-36.   Mommaerts MY, Combes FA and Drake D. The Furlow  Z-plasty in two-staged palatal repair modifications  and complications. Br J Oral Maxillofac Surg. 2006;  44; 94-99,   Ross RB. Treatment variables affecting facial growth in  complete unilateral cleft lip and palate. Cleft Palate J.  1987; 24: 5-77.   Evaluation and correction of secondary cleft lip deformities  Cutaneous lip problems   Minor notching of the vermilion  Asymmetries and/or white roll misalignment  Philtrum problems    Secondary cleft surgery can present a reconstructive  challenge significantly greater than that of the initial  deformity. The surgeon is frequently managing post-  surgical deformities after having little or nothing to do  with the primary procedure as teams and protocols evolve  over time and surgeons move. International ‘mission’  surgical revision poses the additional challenge of under-  qualified surgeons performing cleft surgery in suboptimal  conditions resulting in scarring and acquired deformities  that are exponentially more difficult to deal with. The cleft  surgeon must be a student of the techniques of past years  such that they are able to deal with the unique challenges  of scarring and compromised blood supply present in  these previously operated patients. Additionally, one must  stay abreast of one’s own outcomes so that appropriate and  effective secondary surgery can be offered to your patients  with reasonable expectations.    The appearance and function of the mended cleft lip  are greatly impacted by the initial repair at infancy.    691  691  692  692  693  694  695  697  698  698  698  701  701    The simultaneous reconstruction of functional nasal and  labial muscles dictate the growth and development of the  underlying facial skeleton as well as the appearance of the  lip and nose.'* The aesthetic form of the lip is the result  of both a carefully designed skin incision and the mus-  cle repair at the initial surgery. Paramount to the normal  appearance of this central region of the face is the nasal  repair. The nose is at least as important as the lip in terms  of overall appearance and perhaps more so in terms of its  implications of future surgery. More specifically, the posi-  tion of the ala as well as the nasal sill is quite difficult to  manage in revision surgery, especially when the cartilage  growth has been distorted and magnified over many years.  Nostril symmetry and good form of the rim are important  to achieve as well.   Of the multiple skin incisions that have been used, the  geometric triangular and quadrangular incisions violate  the subunits of the upper lip (with the exception of the more  recently described anatomic subunit repair), whilst the  advancement rotation and its modifications more accurately  replicate normal anatomic structures.*-> Furthermore, dis-  advantages of most geometric designs include the tendency  to create a long lip with incisions that cross the philtral col-  umn and can be difficult to correct secondarily, with con-  version to a more anatomically appropriate skin incision  impossible if eventual revision is required.    As the habilitation of cleft lip and palate consists of  a series of procedures whose timing is dependent on  chronological and developmental milestones through-  out life, the initial lip/nose repair, which is often the first  of many interventions, sets the tone for all procedures  that follow it. It is also important to keep in mind that  the staged reconstruction of these patients is a stepwise  process and that careful consideration must be given to  each procedure and its downstream effects on growth and  blood supply such that ‘bridges’ are built and not burned.  Whilst the construction of the labial and nasal muscu-  lar rings guides the eventual appearance and symmetry  of the lip and nose, the individual’s innate ability to heal  and scarring tendencies also play a key role in the aes-  thetic appearance of the repair.!? Certain technical short-  comings in the repair can also lead to less than optimal  results, as can infection, inadequate nutrition and poor  post-operative care.   The underlying skeletal platform must be considered  when planning a lip revision, as the presence or absence of  a bony alveolar cleft or maxillary hypoplasia also greatly  impacts the appearance of the nasolabial structures as  the child grows. When the ala is left behind in the initial  surgery, regardless of attempted soft-tissue correction and  camouflaging techniques, facial harmony can only be  accomplished when the hard tissue problems have been  addressed. Therefore, it is recommended that depending  on the age of the child and the degree of skeletal dysplasia,  major soft-tissue revisions be deferred until bone grafting  or LeFort osteotomy has been accomplished when pos-  sible. This is, of course, guided by the psychosocial status  of the patient as well as the magnitude of the secondary  deformity.   When trying to determine whether a minor revi-  sion or a complete takedown of the lip is required, an  understanding of the initial deformity and the goals  of primary surgery are important. Understanding the  secondary deformity and its global functional and aes-  thetic shortcomings are also crucial. Lesser procedures,  transpositions and simple scar revisions can be used to  address minor height mismatches of the white roll, ver-  milion notching or vermilion fullness when the muscle  is otherwise noted to be functional and united across the  cleft. If applied inappropriately, however, these ‘minor’  procedures might only serve to amplify the deformity,  increase scarring or leave the patient well short of a  complete correction. A complete takedown of the lip  should be considered if there are significant issues with  lip height or symmetry, nasal symmetry, substantial  vermilion/white roll mismatches or a dehiscent orbicu-  laris oris. Lastly, when there is significant damage and  scarring to the cleft adjacent tissue, especially in the case  of the bilateral cleft lip, one may have to recruit nearby  tissue to reconstitute the philtral complex and recon-  struct the muscular ring.   Re-opening the lip may also be advantageous in that it  provides an excellent opportunity and additional access to  address residual nasal and septal deformities or turbinate    issues. Whilst nasal revision is often times simply an  extension of lip revision surgery, it will be covered in detail  in another chapter of this book.   Note on sutures: Unless otherwise specified, the author  uses 4-0 chromic gut or polyglactin on tapered needles  for mucosal closure, 4-0 polyglactin or polydioxanone for  muscle approximation, 5-0 or 6-0 polyglactin or poligle-  caprone on cosmetic cutting needles for deep dermal facial  sutures and 5-0 or 6-0 nylon or fast gut on cosmetic cut-  ting needles for skin. Suture selection depends somewhat  on the age and size of the patient.    The long upper lip is infrequently seen with the predomi-  nance of advancement rotation repairs performed today.  Excessive lip length was primarily a problem of the trian-  gular and quadrangular repairs, but can be encountered  as the result of a long lateral lip incision with overzealous  rotation in an advancement rotation. The long lip can be  a difficult problem to correct as the muscle and skin have  accommodated and grown over time, frequently requiring  the horizontal excision of tissue at the supravermilion level  or in the subalar region. The scars left by these revisions,  though reasonably well camouflaged by the white roll and  the alar crease, respectively, are less than optimal in appear-  ance. If lip fullness is encountered in the vermilion region  as an isolated problem with the cutaneous lip appropriately  symmetric, care must be taken with the orientation of the  excision so as not to lengthen the incision in the wrong  plane whilst removing volume. To remove an isolated bulge  in the vermilion, a T-shaped excision can be effective, with  the bulk of tissue transversely excised from the wet mucosa  and closed inwardly towards the oral cavity.    Subalar excisions or supravermilion excisions can be used  to adjust the height of a lip when excessive lip length is  encountered. Either form of excision can be combined  with philtral modifications, and both generally require  the removal of skin, muscle and possibly mucosa. Both the  subalar and the supravermilion excisions can be designed  symmetrically or asymmetrically to address specific  length issues (Figures 68.1).    The tight upper lip can stem from overly aggressive  soft-tissue excision at the time of primary or secondary  repair or be the result of a protuberant premaxilla. The  appearance of tissue deficiency can be further accentu-  ated by maxillary hypoplasia or a full lower lip. Further lip  revision that includes soft-tissue excision might only serve  to enhance the problem unless distant tissue is recruited    in the form of an Abbé flap. This pedicled cross lip flap,  based on the labial artery, will add width and appropri-  ate bulk, whilst decreasing the width differential between  the upper and lower lip. The Abbé flap may also be of  value when the prolabial tissue has been severely dam-  aged by scar. One must take care, however, to keep the  philtrum reconstruction within the normal range of phil-  trum width.    When the philtral region has been destroyed by scar or  when there is a significant full-thickness tissue deficiency,  a pedicled Abbé flap or lip switch flap is designed based on  the labial arterial pedicle of the lower lip. The flap as well as  the inset defect can be customized based on the recipient  site requirements for height and aesthetics (Figure 68.2).°    (aand b) Reduction of lip height. (-f) Mucosal bulge of the red lip amenable to a T-shaped excision of the wet  mucosa. This will prevent visible scarring, by keeping the incision at the wet-dry line and extending inward.   © One side of the flap remains pedicled at the vermilion,  based on the labial artery.   The pedicle is divided after 14 days and the remainder of    The short upper lip may be the result of several dif-  ferent shortcomings in the primary lip repair. Most  commonly, it is the result of an under rotated, improperly/  incompletely repaired or dehiscent muscle and this will  require a re-repair of the lip. In this case, the original  repair scar can be used to access the nasal and labial    muscles for an exacting functional repair. If conversion to  an advancement rotation from a geometric repair is fea-  sible, it should be considered, as this places the cutaneous  scars in a more natural position. Vertical scar contracture  might also play a role in the short lip and can be broken  up by small z-plasties in the cutaneous and vermilion lip.  When the muscle is found to be intact and is dynamically  symmetric and the height discrepancy or contracture  involves only one aspect of the lip, such as the vermilion  or the vermilion—cutaneous junction, this can sometimes  be corrected with a more limited cutaneous or musculo-  cutaneous revision.    Vermilion Z-plasty: Vermilion muscle flaps are created at  the site of the notch and transposed to fill the vermilion  defect. Once the flaps are raised, they can be transposed  with skin hooks and the incisions then more specifically  extended or trimmed to fill the given defect.   Vermilion V-Y plasty: A V-shaped musculomucosal incision  is created approaching the vermilion notch with the apex  of the ‘V’ pointing towards the maxillary vestibule. The    Figure 68.2 (a-g) Recruitment of distant tissue. (h) Mutilated upper lip. This patient could benefit from an Abbé    incision is then closed as a Y, advancing the leading edge  of the incision into the notch (Figure 68.3).    Wavy line excision: A wavy line excision of an unaesthetic  scar can be used to create symmetry of the Cupid’s bow  when it is peaked and there is otherwise no notch of  the lip. This is based on Pfeiffer’s wavy line lip closure,  where the wavy line helps to lengthen the skin of the lip  along the philtral column (Figure 68.4).’   Diamond excision: Similar to the wavy line, a diamond-  shaped excision can be used to eliminate white roll  misalignment and Cupid’s bow asymmetry, based on its  geometry and ability to lengthen (Figure 68.5).   Z-plasty: When the defect simply involves a white roll  misalignment, a simple z-plasty can be performed  (Figure 68.6).   Complete revision: The cleft deformity is re-created and  a complete muscular reconstruction and cutaneous  revision is accomplished. Anatomic points are marked  as they would be for a primary lip repair.   1 - Point marks base of the columella on the cleft side  (A-A’-1-B should form a parallelogram)   2 - Point from B-1 extended to the best skin adjacent to  the scar (separates nasal skin from lip skin)   5 - Point at the junction of alar base and lip   6 — Point on the cleft side skin adjacent to the scar, where  a line from 5-6 separates nasal skin from lip skin   8 - Point at the wet-dry line perpendicular to line drawn  from 7, coincides with widest portion of dry vermilion    mild notching, a widened left Cupid’s bow point  and a depressed left alar base. She underwent  total lip revision without rhinoplasty.    Additional length in the repair can be obtained  through the use of a wavy line as the incision approaches  the mucocutaneous junction or by creating a small  triangular flap from the non-cleft side to be inserted  above the white roll. This should enable 1-3 to equal  B-D in length.   Careful attention is given to dissecting and recon-  structing the transverse nasalis and the orbicularis  oris muscles at the cleft edges. Care should be taken  to minimally undermine the muscle on the non-cleft  side so as not to efface the philtral dimple. Wide  subperiosteal undermining of the anterior max-  illa, anterior zygoma and cleft side perinasal bone  should be utilized as needed to facilitate advance-  ment. Periosteal scoring can also be utilized as  needed.    Bilateral cleft: The skin is marked similar to that of a  primary repair, and for this, I favour a modification  of Delaire’s skin markings with functional muscular  repair (Figure 68.8a).°   B - Lip point lateral to the philtrum scar that will be used  to create new philtrum. Line from A-B delineates the  nasal skin from the lip skin   C - The extent of the back cut (C-D) superior to and  including the best/thickest white roll (D); also lat-  eral contribution to the peak of Cupid’s bow   E - Marks the greatest width of wet-dry line, perpen-  dicular from line D (these turndown flaps, C-D-E,  form the lateral lip that will be used to reconstruct  the central vermilion)   1 - Point marks the superior internal angle of the nostril   4 - Point marks the medial contribution to the peak of  Cupid’s bow (3-4 is straight or slightly concave)    The muscular reconstruction, like the vermilion, is  accomplished via the lateral nasolabial elements. Again,  wide subperiosteal undermining and/or periosteal  scoring can be used as needed to facilitate this process  (Figure 68.8b).    Obliteration of the philtral dimple and Cupid’s bow  asymmetries are occasionally seen following primary lip  repair. A flat Cupid’s bow is sometimes the result of a tri-  angular repair. The philtral dimple can often be preserved  in unilateral clefts with minimal cutaneous undermining  of the non-cleft side at the time of initial repair. A natu-  ral dimple is difficult to restore secondarily. Additionally,  widening of the scar in the philtral column position can  occur as a result of early wound tension, poor suturing,    patient factors or wound breakdown at the initial repair.  This can often be treated with simple excision and    Figure 68.8 (a) Bilateral cleft. (b) Boy with an excessively  wide philtrum and a poor mucosa match of the central lip. This    augmented with other surface treatments such as CO,  laser or dermabrasion.   The philtral column(s) is/are also often left flat. This is  largely due to the fact that we cannot surgically re-create  the dermal insertions of the orbicularis muscle. We are  therefore left to provide surgical camouflage, with care-  fully everted skin edges, dermal grafts/flaps or muscular  closure techniques to augment this area.    Isolated unaesthetic cutaneous lip scarring can be  managed similar to other facial scars, by excision, derm-  abrasion etc. One must keep in mind the orientation  of the philtral column and other local lip structures.  For instance, the horizontal orientation of a running  w-plasty might not suit this area as well as a wavy line  excision to re-create the linear philtral column. One  must also be mindful that the skin of the nose and the  skin of the lip are of different quality and contain differ-  ent adnexa, much as the skin of the cutaneous and red  lip. If the skin of the nose has bled down onto the skin  of the upper lip or conversely, the skin of the vermilion  has bled into the cutaneous lip, this must be addressed  in the revision.    Speech and transverse growth are the primary outcome  measures of cleft palate surgery. Both are highly depen-  dent on the type and timing of the initial repair. Despite  appropriate interventions at the correct time, maxillary  hypoplasia, velopharyngeal dysfunction (VPD) and oro-  nasal fistulae can occur. In order to identify patients in  need of revision surgery, they should be followed and  evaluated by an interdisciplinary team that will provide  interval palatal evaluations, dental care, orthodontic care,  hearing evaluations and speech evaluations. For purposes  of this chapter, the discussion is limited to VPD and oro-  nasal fistulae.    Oronasal fistulae have been reported with a wide range  of occurrence. They are frequently left intentionally at  the alveolus, to be repaired at the time of secondary bone  grafting. They can, however, occur anywhere on the pal-  ate and frequently occur in the middle of the palate at the  hard palate-soft-palate junction. The failure rate of fistula  repair increases with each unsuccessful attempt at revi-  sion. Many techniques have been described, including the  application of local flaps (palatal re-repair), tongue flaps,  pedicled flaps, free tissue transfer and augmentation with  acellular dermis.*”    The palatal re-repair, raising the original hard palatal  flaps and if necessary performing a functional revision  of the soft palate, is most useful in most circumstances  (Figure 68.9). For large fistulae, acellular dermis can be  useful as an additional layer and might facilitate healing  in the eventuality of dehiscence.    ©@ Incisions are made in the mucosa around the fistula and  it is turned in towards the nasal side to allow creation  of a nasal layer (wound edges everted and sutures tied  to nasal side).   © Atwo-flap or von Langenbeck palatoplasty is performed  on the remaining hard palate mucosa, scoring or release  is performed laterally and around the neurovascular  bundle as needed.   @ Acellular dermis can be interposed and secured between  the oral and nasal flaps as needed.    Continuous perceptual speech evaluation is the primary  tool for evaluating VPD. The longitudinal evaluation of    (e-h) Hard palate cleft fistula closed with an interpositional layer of allogenic dermal graft.    speech intelligibility can begin shortly after palate repair.  Early identification and correction of VPD is critical to  avoid the development of compensatory misarticulations.  Characteristics of VPD include hypernasal resonance, nasal  escape, nasal turbulence and inadequate intraoral air pres-  sure.!° In addition to perceptual speech evaluation, videoflu-  oroscopy, nasal endoscopy and nasometry might be useful in  identifying the size and nature of the velopharyngeal defect.   Surgical treatment largely consists of three modalities:  revision palatoplasty, superiorly based pharyngeal flap  and sphincter pharyngoplasty.    Revision palatoplasty in an effort to avoid the morbidity  of pharyngoplasty is an attempt to restore functional con-  tinuity to the palatal muscles and length to the palate,  especially in patients who have had little to no dissec-  tion of the velar muscles. In essence, this represents an  intravelar veloplasty where one has not been previously  performed. Palatal re-repair, if effective for speech, can  avoid the sequelae of some pharyngoplasty techniques,  such as turbulent or disordered night-time breathing and    mucus trapping. In this group, the velar muscle bundles  are seen to be oriented sagitally (Figure 68.10), instead of  transversely as one might see in a submucous cleft pal-  ate. Techniques described for this purpose include radical  intravelar veloplasty with retropositioning of the muscle  sling as described by Sommerlad or the Furlow palato-  plasty.“ Both achieve retropositioning of the velar sling  and have demonstrated efficacy in limited cohorts. These  revision procedures are felt to be more physiologic than  pharyngoplasty and are best utilized for those who dem-  onstrate small to moderate antero-posterior gaps as viewed  by nasoendoscopy or videofluoroscopy. Should VPD per-  sist following 6-12 months of additional speech therapy,  pharyngoplasty is still an option.    Both the pharyngeal flap and the sphincter pharyngo-  plasty have demonstrated value in the management of  VPD, but more than the type of procedure selected or the  orientation of the gap, the velopharyngeal gap size is most  likely to influence the clinical outcome of the operation.    Figure 68.10 (a) Superiorly base pharyngeal flap. (b) Sagittal position of the cleft muscle bundle in a submucous cleft. This is  amenable to an intravelar veloplasty procedure via Sommerlad’s technique or a Furlow repair.    Despite multiple attempts in the literature to delineate the  best operation for specific velopharyngeal defect orienta-  tions (coronal, sagittal etc.), recent randomized controlled  comparisons of sphincter pharyngoplasty and pharyngeal  flap for VPD demonstrated no difference in long-term  speech outcomes between the two.!”4 Therefore, one must  consider specific patient issues and the potential mor-  bidities of the operation when selecting a VPD revision  technique. Videofluoroscopy or nasoendoscopy can be  used to choose the point of placement of the sphincter or  estimate the size of the pharyngeal flap to maximize its  effectiveness.    © The palate is divided in the midline a few millimetres  from the hard palate through the uvula. Lateral inci-  sions (nasal flaps) are made anteriorly and extended  towards the pharyngeal walls.   e A superiorly based flap is elevated at the depth of the  prevertebral fascia approximately two-third the width of  the posterior pharyngeal wall, long enough to reach the  anterior extent of the palatal incision without tension.   © The tip of the flap is inset into the apex of the palatal  incision, the lateral aspect of the flap is sutured to the  lateral edges of the soft-palate flaps.   @ The nasal flaps are closed over the raw surface of the  pharyngeal flap.    ® The palate is retracted superiorly with an instrument or  by a suction catheter passed through the nose and sewn  to the palate (Figure 68.11).    ©® Vertical incisions are made along the anterior aspect of the  posterior tonsillar pillars in a cephalo-caudad direction.   e A similar incision is made on the posterior aspect of  the tonsillar pillars, capturing the palatopharyngeus  muscle in a superiorly based flap.   @ The flaps are transected as low as possible to allow  tension free apposition.   © The superior aspect of the posterior tonsillar incisions is  joined transversely across the posterior pharynx at the  depth of the prevertebral fascia.   @ The pillar flaps are transposed and sutured end to  end (Figure 68.1lc) or in an overlapping fashion  (Figure 68.11d) (to decrease the port size).    e Consider the totality of the lip/nose defect as this  frequently leads to and is best served by total lip  revision and muscular reconstruction.   e The lip and nose are sometimes best addressed in sep-  arate revision procedures as many alar base problems  are more readily addressed with the lip revision. Once  this is allowed to heal, a more predictable foundation  for definitive reconstructive rhinoplasty exists.   e Consider revision palatal surgery for small to moderate  velopharyngeal gaps when an intravelar veloplasty has  not been previously performed; it isa more physiologic  option than pharyngoplasty. If a subsequent pharyn-  goplasty is required, perhaps a less obstructive one can  then be done.   e The first opportunity to close a palatal fistula is the best  one; do not limit your results by performing less sur-  gery than is required. Consider augmenting the closure  with acellular dermis when appropriate.    1. Markus AF, Delaire J, Smith WP. Facial balance  in cleft lip and palate. I. Normal development and  cleft palate. Br J Oral Maxillofac Surg. 1992; 30(5):  287-295.   2. Markus AF, Delaire J and Smith WP. Facial balance  in cleft lip and palate. IH. Cleft lip and palate and  secondary deformities. Br J Oral Maxillofac Surg.  1992; 30(5): 296-304.   3. Markus AF and Delaire J. Functional primary  closure of cleft lip. Br J Oral Maxillofac Surg. 1993;  31(5): 281-291.   4. Millard D. Cleft Craft: The Evolution of its Surgery  Vol. 1: The Unilateral Deformity. Boston, MA: Little,  Brown and Company; 1976. pp. 165-188.   5. Millard DR, Jr. A radical rotation in single harelip.  Am J Surg. 1958; 95(2): 318-322.   6. Millard D. Cleft Craft: The Evolution of its Surgery  Vol. 1: The Unilateral Deformity. Boston, MA: Little,  Brown and Company; 1976. pp. 593-628.   7. Pfeifer G, Schmitz R, Herwerth-Lenck M and  Gundlach KKH. Long term results following pri-  mary lifting of the nose and labioplasty according to  the wave line procedure in unilateral complete clefts.  In Pfeifer G (ed.), Craniofacial Anomalies and Clefts  of the Lip, Alveolus and Palate. Fourth Hamburg  International symposium. New York, NY: Thieme;  1991. pp. 239-246.   8. Kirschner RE, Cabiling DS, Slemp AE, Siddiqi F,  LaRossa DD and Losee JE. Repair of oronasal fistulae  with acellular dermal matrices. Plast Reconstr Surg.  2006; 118(6): 1431-1440.    9. Eufinger H and Machtens E. Microsurgical tissue  transfer for rehabilitation of the patient with cleft  lip and palate. Cleft Palate Craniofac J. 2002; 39(5):  560-567.   10. Abyholm F, D’Antonio L, Davidson Ward SL,  Kjoll L, Saeed M, Shaw W, et al., Pharyngeal flap  and sphincterplasty for velopharyngeal insufficiency  have equal outcome at 1 year postoperatively: Results  of a randomized trial. Cleft Palate Craniofac J. 2005;  42(5): 501-511.   11. Perkins JA, Lewis CW, Gruss JS, Eblen LE and  Sie KC. Furlow palatoplasty for management of velo-  pharyngeal insufficiency: A prospective study of  148 consecutive patients. Plast Reconstr Surg. 2005;  116(1): 72-80; discussion 81-84.   12. Sommerlad BC, Mehendale FV, Birch MJ, Sell D,  Hattee C and Harland K. Palate re-repair revisited.  Cleft Palate Craniofac J. 2002; 39(3): 295-307.   13. Noorchashm N, Dudas JR, Ford M, Gastman B,  Deleyiannis FW, Vecchione L, et al., Conversion  Furlow palatoplasty: Salvage of speech after straight-  line palatoplasty and ‘incomplete intravelar velo-  plasty’. Ann Plast Surg. 2006; 56(5): 505-510.   14. Ysunza A, Pamplona C, Ramirez E, Molina F,  Mendoza M and Silva A. Velopharyngeal surgery:  A prospective randomized study of pharyngeal flaps  and sphincter pharyngoplasties. Plast Reconstr Surg.  2002; 110(6): 1401-1407.   15. Hynes W. Observations on pharyngoplasty. Br J Plast  Surg. 1967; 20(3): 244-256.    Boorman JG and Shivaram Barathwaj V. Secondary  palatal surgery and pharyngoplasty. In Ward  Booth P Schendel SA, Hausamen J-E (eds.), (ed.),  Maxillofacial Surgery, Vol. 1, Second Edition.  St. Louis, MO: Churchill Livingstone Elsevier; 2007.  pp. 1102-1119.   Brusati R, Mannucci N and Mommaerts MY. The  Delaire philosophy of cleft lip and palate repair. In  Ward Booth P Schendel SA, Hausamen J-E (eds.),  Maxillofacial Surgery, Vol. 1, Second Edition.  St. Louis, MO: Churchill Livingstone Elsevier; 2007.  pp. 1027-1047.   Fisher DM and Sommerlad BC. Cleft lip, cleft palate, and  velopharyngeal insufficiency. Plast Reconstr Surg.  2011 Oct; 128(4): 342e-360e.   Talmant JC, Markus A, Precious DS and Mommaerts MY.  Secondary cleft surgery. In Ward Booth P,  Schendel SA, Hausamen J-E (eds.), Maxillofacial  Surgery, Vol. 1, Second Edition. St. Louis, MO:  Churchill Livingstone Elsevier; 2007. pp. 1073-1091.    All surgery in children and adults with clefts of the lip and/  or palate aims to reconstruct in so far as it is possible nor-  mal anatomy and function. The evolution of lip and palate  repair demonstrates this well. Consequently, cleft surgeons  anticipated the need to repair the alveolar cleft long before it  was possible to achieve clinically. It was even recognized that  repair should involve separate nasal and oral layers. Current  clinical practice has focused on what is usually referred to  as ‘secondary’ alveolar bone grafting (ABG), referring to the  placement of a graft at the time of eruption of the secondary  dentition and specifically shortly before the eruption of the  permanent maxillary canine tooth on the cleft side. The term  ‘secondary alveolar cleft bone grafting’ is actually anomalous  as this is a primary cleft operation. The child, for example, with  a unilateral complete cleft of the lip and palate will require  three primary operations: lip, palate and alveolus repair.   Historically, several surgeons have carried out ‘primary’  alveolar cleft bone grafting sometimes using autogenous  rib as the donor material. Timing has varied between  6 months of age, at the same time as lip and palate repair  up to 3-4 years but always in the time of the ‘primary’ den-  tition. The literature demonstrates good initial results but  with later concerns. Mainly, these relate to the impact on  maxillary growth but also that the alveolar bone later often  becomes deficient, too deficient to allow normal eruption  and orthodontics of the permanent dentition and therefore  further bone grafting is required.   In recent years, there also been renewed interest in the use  of periosteoplasty to achieve the same end. Although good  results have been demonstrated, these have not often been  replicated in other units. Interest has also been generated in    the use of bone promoting products such as bone morpho-  genic protein and some good results have been reported.  However, in most studies reported, BMP has been combined  with harvested autogenous bone which rather defeats the  purpose of avoiding a donor site. It also seems to be critical,  how it is prepared and used and it is also very expensive.   Secondary ABG is generally carried out in the age group  8-11 years depending on the skeletal and dental develop-  ment of the child. The most commonly used technique is  essentially that described by Boyne and Sands in 1972! and  popularized by the publication of a large series of excellent  results by Abyholm, Bergland and Semb in 1981.?    The primary aim of alveolar cleft bone grafting is to create  a continuous maxillary alveolus and thus the maxilla as a  single bony structure. The detailed aims are    © To repair oro-nasal fistulae and thus prevent food and  fluids coming out of the nose, avoid a persistent discharge  from the nose, and improve speech   © By repairing fistulae, allow the patient to build up intra-  oral pressure and thus enable them to perform such com-  monplace activities as blowing up balloons and sucking  ona straw   © To provide bone support to teeth adjacent to the alveolar  cleft defect   © To allow the eruption of permanent teeth especially the  canine tooth on the cleft side    © To permit the movement of teeth by orthodontics and  create an intact dental arch   ® To give support to restorations (implant, bridge or den-  ture) in such cases where there are missing teeth and it  is not possible to create an intact dental arch   © To provide support for the alar base of the nose, the lip  and columella   @ By creating a one piece maxilla, to enable if neces-  sary later advance of the maxilla by osteotomy in one  piece    When planning ABGs, the cleft surgeon should always  see the patient with the cleft orthodontist. In our unit, we  aimed to do this at 8 years of age and we reported our ABG  results in an audit of all cases carried out between 1996 and  2000 measuring the result of an oblique occlusal radio-  graph taken 6 months post-operatively (Table 69.1). The  scale used was after Bergland et al. in 1982 and modified    Type 1 86%  Type 2 8%  Type 3 2%  Failure 4%  Unilaterals results overall (n = 80)  Type 1 71 (88%)  Type 2 6 (8%)  Type 3 2 (3%)  Failure 1 (1%)  Bilaterals results overall (n = 30)  Type 1 24 (80%)  Type 2 3 (10%)  Type 3 Nil  Failure 3 (10%)  Unilaterals late and adults (n = 19)  Type 1 12 (63%)  Type 2 4 (21%)  Type 3 2 (11%)  Failure 1 (5%)  Unilaterals early cases only (n = 61)  Type 1 59 (97%)  Type 2 2 (3%)  Type 3 Nil  Failure Nil    Notes: Late = after the eruption of the maxillary permanent canine  tooth on the cleft side; Early = before the eruption of the maxillary  permanent canine tooth on the cleft side.    to measure against the adjacent permanent erupted tooth,  usually a central incisor, as the permanent canine of course  would not normally be erupted at this time in most cases.  In this way, only alveolar bone height measured as 75% of  normal or better (Types 1 and 2) with no other deficiencies  are regarded as good.    e Although the results of this audit showed generally  good results, we noted two negative findings. Patients  grafted late (after the eruption of the permanent canine  tooth) and those having bilateral ABGs generally did  less well. We also noted that late grafting was often  associated with delays caused by prolonged orthodon-  tic preparation or lack of compliance with orthodontic  preparation. As a result and for some years, we assess  these patients at 7 years of age and thus graft them  earlier. This has produced some different and generally  improved outcomes.   © The minimum pre-operative imaging required is an  OPT and an oblique occlusal radiograph. When the  presence or condition of both erupted and unerupted  teeth is not clear or when the presence of a relevant  alveolar defect is not clear, a cone beam CT is obtained.  By ‘relevant’ alveolar defect, we mean one which if not  grafted will prevent the normal eruption of permanent  teeth and/or subsequent orthodontic movement of  those teeth. Decisions about timing of surgery, about  the need for orthodontic expansion, for stabilization of  the premaxilla and for tooth extraction at the time of  ABG are made jointly.    @ The criteria required at the alveolar defect site are a  good blood supply, restoration of normal anatomy espe-  cially of the nasal floor at the correct height, elimination  of excess tissue (usually scar tissue) within the alveolar  defect and complete cover of the graft by soft tissue.   © For a good blood supply, the recipient site should ide-  ally be free of scars which situation only really exists  in a surgically unoperated cleft. Delayed closure of the  alveolar cleft after previous repair of the lip and/or the  hard palate certainly involves dissection in a scarred  area. The graft should have close contact to surrounding  tissues, which means to the alveolar processes as well as  to the soft-tissue cover. Dead space around the grafted  material will fill with haematoma, which through its  organization by connective tissue leads to a thicker scar  and so should be avoided.   © Complete coverage of the graft by soft tissue is an impor-  tant factor for achieving a good blood supply and is essen-  tial for the protection of the graft against infection. The  blood supply of mucoperiosteal flaps raised in children  below the age of 12 years appears to have very good via-  bility especially compared to that of adults. If infection  occurs post-operatively, it will tend to produce necrosis of  the flap, graft exposure and with it graft failure. The ideal    soft-tissue cover is that which corresponds completely to  the normal anatomy of this area. The nasal mucosa should  be horizontal (axial) without any transposed oral mucosa.  The palatal mucosa should be adjacent to the alveolus at  its palatal inclination, and the buccal mucosa should simi-  larly lie on the inclination of the buccal alveolus. Over the  alveolar crest, there should be fixed gingivae which are a  requirement for the unerupted teeth to erupt, with mobile  mucosa away from the crest.    e A wide variety of materials has been proposed for  alveolar grafting including homologous bone, alloge-  neic freeze-dried bone marrow, homologous cartilage  and various bone substitutes as well as bone morpho-  genic protein. More or less, satisfactory results with  these materials have been claimed. Similar encour-  aging reports have been made of the use of gingiva-  periosteoplasty although with some deleterious effect  on growth. There is widespread acceptance that autolo-  gous bone grafts have the lowest risk in primary heal-  ing and arguably give the best results. We will therefore  limit ourselves to considering them only.   © Different donor sites for autologous bone grafts have  been proposed and used including anterior and poste-  rior iliac crest, rib, mandible, calvarium, tibia, perios-  teal flaps and periosteal grafts. The decision in favour of  one or other of the different donor sites depends among  other things on the age of the patient at operation, i.e.  the quantity of cancellous bone available at the different  donor sites in different ages, as well as the convenience  for the surgeon and the patient of the various donor  sites. In an ideal recipient site, one can obtain good  results with every graft but the literature and our own  experience shows that autologous cancellous bone is the  most proven successful graft with which one can fill the  defect completely. It allows vessels to grow into the graft  from the recipient site and to transform the graft into  the locally adapted bone in the easiest and most rapid  way. Moreover, cancellous bone has the highest resis-  tance against infection.    In patients older than 2 years of age, cancellous bone can  be harvested from the iliac crest with the help of a tro-  car. The use of a trocar reduces the invasion of the donor  site procedure and also reduces the pain at the donor site.  However, the core graft obtained is compressed which can  be a disadvantage in contrast to cancellous bone chips  harvested openly from the iliac crest which can be packed  into every nook and cranny of the alveolar defect and  compressed into it. The iliac crest itself can be raised as an  osteoplastic flap and cancellous bone chips harvested from  inside the ilium and the lid replaced. The anterior crest is  our site of choice because it provides adequate cancellous  bone and can be harvested simultaneously to the cleft pro-  cedure. The keys to prevention of post-operative morbidity  at this site are the avoidance of any muscle stripping in    particular on the lateral aspect of the crest, as well as the  use of a cannula inserted into the wound at surgery after  the lid has been replaced and used to infuse long acting  local analgesia on a few occasions during the first 24 hours  after surgery.   Adequate stability of the premaxilla at and after ABG  surgery is important in bilateral alveolar clefts in order to  ensure good bony union between the fragments and across  the clefts. If necessary, this can be achieved by a reason-  ably strong labial arch wire and orthodontic brackets/  bands although when the premaxilla is reasonably stable  this is not required. When arch expansion has been car-  ried out before ABG, this can be retained during and after  surgery by a posteriorly placed Trans-Palatal Arch (TPA).  We have devised a removable TPA easily flicked out at the  start of surgery giving the surgeon full access to the whole  of the palate, and easily replaced at the end of the opera-  tion (Figure 69.1).   Rarely, the premaxilla is in a severely aberrant position  and cannot be moved into an ideal position by orthodon-  tics. In such cases, a premaxillary osteotomy can be car-  ried out and we generally prefer to do that in conjunction  with the bilateral ABG procedure.    The principal concerns about very early bone grafting have  been the potential harmful effects on maxillary growth.  However, a further concern is that while the early bone  graft will often produce a good repair of the alveolar cleft,  by the time the permanent dentition adjacent to the cleft  is erupting (especially the permanent maxillary canine  tooth) between 7 and 12 years of age +, commonly the  bone in the alveolar cleft is of insufficient volume to sup-  port those erupting teeth and a further ABG procedure  needs to be considered. The same criticism has been lev-  elled at early periosteoplasty.    Our approach to ABG in South Wales (Morriston Hospital,  Swansea and up to 1994, St Lawrence Hospital, Chepstow)  has been essentially unchanged since 1985. Grafting has  been carried out ideally in the mixed dentition shortly before  the eruption of the permanent maxillary canine teeth.   All children with an alveolar cleft (classified with ‘A’ or ‘a’  on LAHSHAL) are seen on a multidisciplinary cleft clinic at  least by the cleft surgeon and cleft orthodontist. This used  to be at the age of 8 years but following the carrying out of  an audit of all cleft ABGs carried out by the team between  1996 and 2000 (see Table 69.1), it was noted that the small  number of poor results or failures were almost always in  those children or young adults who were operated on a little  late, sometimes because the orthodontic preparation started  and finished too late. From this time, these children have  been assessed at 7 years of age. In all cases, an OPT and an  oblique occlusal radiograph of the alveolar cleft are taken  (two occlusals in bilateral cases). Occasionally, when the  position of ectopic teeth is difficult to determine or the size  of the alveolar cleft too difficult to visualize, a cone beam CT  scan is obtained. A decision is made on whether an ABG is  required, whether any orthodontic preparation is necessary,  when to proceed with the ABG, if any fistulae need to be  repaired at the same time and if any dental extractions are  required. It is rare to carry out other procedures simultane-  ously, except occasionally minor lip revision.   This approach also varies little from the method pro-  posed by Boyne and Sands and reported by Abyholm and  colleagues. When there has been any segment collapse  present, the maxillary dental arch has been expanded  orthodontically and in bilateral cases, the lateral segments  and the premaxilla have been aligned. Following align-  ment, the expansion has generally been retained with a  removable trans-palatal arch and lateral arms, and a labial  arch wire in bilateral cases (Figure 69.2). However, in the  last 10 years, the incidence of arch collapse has fallen quite    dramatically and as a result pre-ABG orthodontic arch  alignment has been required much less often.   Only autogenous cancellous bone harvested from the  anterior iliac crest has been used as the graft material and  with consistently good results (Figure 69.3).   During the early part of this period, a significant num-  ber of cleft patients presented who had, for various reasons,  missed the opportunity of receiving a graft into their alveo-  lar clefts during the mixed dentition phase. In most cases,  these have been managed with careful orthodontic prepara-  tion with fixed bands and tertiary ABG in the same sur-  gical manager as described above. This has applied equally  to those patients who have not required orthognathic sur-  gery, the graft not only facilitating closure of fistulae but  also giving support to dental restorations with or without  osseointegrated implants. Such tertiary grafting can be very  successful but in these older patients, the success rates are  not as high as those in the younger children (Table 69.2).   The ABG surgical procedure starts with inspection of the  hard and soft palate with a cleft gag in situ (the Dingman  is ideal for these older children). If anterior palatal fistulae  are present, these are generally repaired first in two layers  if possible (Figures 69.4 through 69.6). The repair of any  posterior palatal fistulae away from the alveolar cleft may  be considered at this time.   The entire alveolar cleft is identified by the raising of  labio-buccal muco-periosteal flaps after incising around  any labial fistula (Figure 69.7). These flaps critically include  keratinized gingivae. In unilateral cases, a flap is raised on  the lesser segment from the alveolar cleft to the anterior  aspect of the first molar tooth and a further smaller flap  raised on the greater segment up to just across the midline.  In bilateral cases, virtually no dissection is permitted on  the premaxilla to preserve its blood supply. The flaps are  raised separating oral from nasal mucosa.   The nasal layers are then identified and separated  sharply from the palatal mucosa. Scar tissue and any  excess nasal mucosa within the alveolar cleft are excised  and the nasal floor repaired. It is important that this  repair is carried out in such a way that the nasal floor  lies at the same height as the normal side. Occasionally, a  large inferior turbinate will obstruct an appropriately high    1) Inspection of the hard and soft palate and repair of any  palatal fistulae present   4) Excision of any labial sinus present along with scar tissue  and excess nasal mucosa within the alveolar cleft   6) Repair of nasal mucosa at level of normal nasal floor    repair and the turbinate can be trimmed with diathermy.  Sometimes, the lower end of the nasal septum may also  obstruct the repair and this can also be trimmed. Together  with excision of the scar tissue within the cleft, this nasal  floor repair redefines the complete alveolar deficit into  which is then packed the cancellous bone chips.    Figure 69.5 Large palatal fistula repair with two palatal  flaps in unilateral cleft.    In unilateral cases, the mucoperiosteum on the greater  segment is then sutured back into place with resorbable  sutures (in bilateral cases, the central mucoperiosteum  on the premaxilla should not have been raised) and the  lateral flap on the lesser segment is then advanced, aided  by appropriate horizontal sharp division of periosteum,    and closed with keratinized gingivae over the alveo-  lar crest to the palatal oral mucosa and medially to the  greater segment, all without tension. The posterior defi-  cits of mucoperiosteum over the alveolus buccally from  where the flap has been advanced is allowed to heal by  secondary epithelialization.    Figure 69.6 Large palatal fistula repair with two palatal  flaps and advancement in bilateral cleft.    In bilateral cases (Figure 69.8), the lateral segment  muco-periosteal flaps are similarly advanced after perios-  teal release and sutured over the bone graft to the premax-  illary mucosa and palate.    Figure 69.7 Unilateral alveolar bone grafting procedure.  (a) Incisions marked. (b) Flaps raised. (c) Scar tissue excised  from alveolar cleft. (d) Nasal floor repaired. (e) Bone graft being  inserted into the alveolar defect. (f) Alveolar defect filled and  lateral flap periosteum being divided. (g) Medial flap sutured,  lateral flap advanced and sutured. (Continued)    Figure 69.7 (Continued) Unilateral alveolar bone grafting procedure. (a) Incisions marked. (b) Flaps raised. (c) Scar tissue excised  from alveolar cleft. (d) Nasal floor repaired. (e) Bone graft being inserted into the alveolar defect. (f) Alveolar defect filled and lateral  flap periosteum being divided. (g) Medial flap sutured, lateral flap advanced and sutured.   In the preparation of patients with bilateral cleft lip and  palate (especially bilateral complete cleft lip and palate) for  ABG, it is common for the lateral segments and the pre-  maxilla to need to be aligned and sometimes expanded  orthodontically. Occasionally, it is difficult for a good posi-  tion of the premaxilla to be achieved. It is also necessary for  a freely mobile premaxilla to be stabilized for ABG surgery  as a moving premaxilla may prevent bony union across the  alveolar clefts.   In bilateral cleft lip and palate (BCLP), especially when  complete, the bone of the premaxilla is attached very nar-  rowly to the nasal septum. Its blood supply is derived  principally from the labial mucoperiosteum. Occasionally  that ‘narrow’ bony attachment to the nasal septum may  be rather broader and more robust, and this may be why  it sometimes proves resistant to orthodontic devices  trying to move it. Also occasionally, the premaxilla is    positioned inferiorly and is not amenable to being repo-  sitioned superiorly by non-surgical means. In those few  cases in which the premaxilla is aberrant and cannot be  repositioned orthodontically, a premaxillary osteotomy  may be required. The anatomy as described above needs  to be taken into consideration when designing the surgical  approach and osteotomy technique if the premaxilla is not  to lose its blood supply and become a free graft.   Only the differences between the bilateral and the  unilateral procedures are shown in these diagrams. The  premaxillary osteotomy is almost always carried out at  approximately the same age as ABG and we will usually  carry it out in conjunction with the bilateral ABG and,  if required, palatal fistula repair all at the same surgical  episode. It is possible to stage these procedures and we have  done so rarely.   The bony attachment of the premaxilla may be  approached from part of the incision used for the bone    grafting procedure. This is demonstrated in Figure 69.9c  and the only additional dissection required is a small  area subperiosteally over the bony attachment to the sep-  tum. The osteotomy itself is carried out gently using a  fine osteotome (Figure 69.9e). Sometimes bone has to be  removed with Rongeurs or forceps. The premaxilla may    then be moved digitally and placed in its new position  with the guidance of an occlusal wafer. Fixation is best  achieved with a preformed strong labial arch wire within  pre-existing fixed orthodontic bands (Figure 69.9g).   Once the premaxilla is repositioned and stabilized, any  palatal fistula is repaired and the bilateral alveolar bone    1) Model surgery to reposition the premaxilla and fabricate  an occlusal wafer    2) Note any need for the removal of erupted or buried teeth  and any part of the maxilla or premaxilla    3) Securing of orthodontic fixed bands and fabrication of a  strong arch wire which will support the premaxilla in its  new position    4) Surgery in which the premaxilla is approached through a  small lateral incision permitting both the removal (if  required) of some of the premaxilla and division with a  small osteotome of its bony attachment some of which  may also need to be removed to allow repositioning of the  premaxilla    5) Digital movement of the premaxilla into its new position,  temporary fixation into the preformed occlusal wafer and  stabilization with a strong arch wire. The wafer is then  removed.    6) Bilateral alveolar bone grafting with simultaneous repair of  palatal fistula.    grafting performed but this can be done at a later opera-  tion (Table 69.3).    e Planning should be undertaken by the multidisci-  plinary team including the orthodontist and restorative  dentist.   e The optimal age for alveolar bone grafting is just prior  to the eruption of the canine tooth.   e Tension-free closure of soft-tissue flaps is important for  good healing.    1. Boyne PJ and Sands N. Secondary bone grafting of  residual alveolar and palatal clefts. J. Oral Surg. 1972;  30: 87-92.   2. Abyholm FE, Bergland O and Semb G. Secondary  bone grafting of alveolar clefts. A surgical/  orthodontic treatment enabling a non-prosthodontic  rehabilitation in cleft lip and palate patients. Scand J  Plast Reconstr Surg. 1981; 15(2): 127-140.    Azzolini A, Riberti C and Bertani A. 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Br J Oral Surg. 1973; 11:  77-93.   Honigmann K and Prein J. Die Kieferosteoplastik als  Teil des operativen Gesamtkonzeptes zum LKG-  Spaltenverschluss. Fortschr Kiefer-Gesichts-Chir.  1993; 38: 69-70.   Honigmann K and Sugar AW. Reconstruction of cleft  lip amd palate osseous defects and deformities. In  Greenberg AM and Prein J (eds.), Craniomaxillofacial  Corrective Bone Surgery, Chapter 48. New York, NY:  Springer; 2002. pp. 562, 565.   Honigmann K. Combined palate- and cheiloplasty as a  new treatment concept in cleft surgery (German).  Zahn Mund Kieferheilkd Zentralbl. 1983; 71(6):  600-604.   Honigmann K. Die kombinierte Segel- und Lippenplastik  als neues Behandlungskonzept in der Spaltchirurgie.  Zahn- Mund- u. Kieferheilkd. 1983; 71: 600-604.    Honigmann K. One-stage closure of uni- and bilateral  cleft lip and palate. Bri J Oral Maxillofac Surg. 1996  Jun; 34(3): 214-219.   James DR and Brook K. Maxillary Hypoplasia in Patients  with cleft lip and palate. Deformity — the alternative  surgical approach. Eur J Orthod. 1985; 7: 231-247.   Jones ML and Sugar AW. The late management of cleft lip  and palate problems: A joint orthodontic/surgical  approach. J Royal Coll Surg Ed. 1990; 35: 376-386.   Kalaaji A, Lilja J and Friede H. Bone grafting at the stage  of mixed and permanent dentition in patients with  clefts of the lip and primary palate. Plast Reconstr  Surg. 1994; 93: 690-696.   Knox J, Hunt J, Sugar A, Extence H, and Hammond V.  The orthognathic management of cleft lip and pal-  ate skeletal discrepancy: CLP series Part 9 Ortho  Update. 2014; 7: 15-22.   Knox J. In Sugar AW, AOCMF Surgery Reference on  Congenital Deformities, Cleft Lip and Palate. www.  aocmf.org. 2012   Koch J. The closure of the bony part of the cleft lip and  palate malformation: The problem of primary osteo-  plasty. In Hjorting-Hansen E. (ed.), Proceedings  from the 8th International Conference on Oral and  Maxillofacial Surgery. Chicago, Berlin, London:  Quintessence Publishing Co; 1985.   Koole R, Bosker H and van der Dussen EN. Late secondary  autogenous bone grafting in cleft patients compar-  ing mandibular (Ectomesenchymal) and iliac crest  (Mesenchymal) grafts. J Cranio-Max-Fac. Surg. 1989;  17(Suppl 1): 28-30.   Llewelyn J and Sugar AW. Lag screws in sagittal split  osteotomies-should they be removed?. Br J Oral  Maxillofac Surg. 1992; 30: 83-86.   Maviglio P, De Santis P, Mavilio D and Fiume D. Cranial  bone graft in treatment of alveolar cleft. Riv Ital Chir  Plast. 1990; 22: 335-340.   Meazzini MC, Rossetti G, Garattini G, Semb G and  Brusati R. Early secondary gingivo-alveolo-plasty  in the treatment of unilateral cleft lip and palate  patients: 20 years experience. J Cranio-Maxillo-Faci  Surg. 2010 April; 38(3): 185-191.   Mueller AA, Zschokke I, Brand S, Hockenjos C, Zeilhofer  HF and Schwenzer-Zimmerer K. One-stage cleft  repair outcome at age 6- to 18-years—a comparison  to the Eurocleft study data. Br J Oral Maxillofac Surg.  2012 December; 50(8): 762-768.   Poole MD, Robinson PP and Nunn ME. Maxillary  advancement in cleft lip and palate patients. A modi-  fication of the Le Fort 1 osteotomy and preliminary  results. J Maxfac Surg. 1986; 14: 123-127.   Posnick JC and Tompson B. Modification of the maxillary  Le Fort 1 osteotomy in cleft-orthognathic surgery:  The unilateral cleft lip and palate deformity. J Oral  Maxfac Surg. 1992; 50: 666-675.    Rintala AE and Ranta R. Periosteal flaps and grafts in pri-  mary cleft repair: A follow-up study plast. Reconstr  Surg. 1989; 83: 17-22.   Samman N, Cheung LK and Tideman H. A comparison of  alveolar bone grafting with and without simultane-  ous maxillary osteotomies in cleft palate patients. Int  J Oral Maxillofac Surg. 1994; 23: 65-70.   Samuels R, Sugar AW, Jones ML and Newton C. Hard  and soft tissue changes of internally fixed cleft and  non-cleft Le Fort 1 osteotomies. Abstracts of the 12th  Congress of the European Association for Cranio-  Maxillo-Facial Surgery, The Hague, The Netherlands,  5-10 September 1994. J Craniomaxfac Surg. 1994; 22:  (Suppl.1), Abstract 127, 44.   Sindet-Pedersen S and Enmark H. Reconstruction of alve-  olar clefts with mandibular or iliac crest bone grafts.  J Oral Maxillofac Surg. 1990; 48: 554-558.   Skoog T. The use of periosteal flaps in the repair of  clefts of the primary palate. Cleft Palate J. 1965; 24:  332-339.   Smahel Z and Mullerova Z. Facial growth and develop-  ment in unilateral cleft lip and palate during the  period of puberty: Comparison of the development  after periosteoplasty and after primary bone graft-  ing. Cleft Palate Craniofac J. 1994; 31: 106-115.   Smith AT. The use of orthodontic chain elastic for tem-  porary intermaxillary fixation. Br J Oral Maxillofac  Surg. 1993; 31: 250-251.   Stricker M, Chancholle AR, Flot F, Malka G and Montoya  A. Periosteal grafting for the repair of complete pri-  mary cleft repair. Ann Chir Plast. 1977; 22: 117-125.   Sugar AW. Orthognathic Surgery. In Jones ML and Oliver  RG (eds.), Walther and Houston’s Orthodontic  Notes, Chapter 19. London: Wright (Butterworth-  Heinemann Ltd), ISBN 0 7236 1005 3; 1994.   Tideman H, Stoelinga P and Gallia L. Le Fort 1 advance-  ment with segmental palatal osteotomies in patients  with cleft palates. J Oral Surg. 1980; 38: 196-199.   Tideman H. Staged Le Fort 2/Le Fort 1 osteotomies in Cleft  Patients with Naso-Maxillary Hypoplasia Norman  Rowe Lecture Conference of British Association of Oral  and Maxillofacial Surgeons. Cardiff, Wales, April 1993.   Wake M. Paper read to the British Association of Oral  Surgeons. London: Royal College of Surgeons of  England; April 1976.   Wassmund M. Der Verschluss des Kieferspaltes und  Nasenbodens bei vollstandiger Spaltbildung -  Zeitpunkt und Methoden. Fortschr Kiefer-Gesichts-  Chir. 1955; 1: 27-36.   Wolfe SA and Berkowitz S. The use of cranial bone grafts  in the closure of alveolar and anterior palatal clefts.  Plast Reconstr Surg. 1983; 72: 659-671.   Wolff J. Das Gesetz der Transformation der Knochen.  Berlin: Hirschwald; 1892.    There are many types of facial clefting disorders reported  in the literature. The cleft lip and palate anomaly is the  most common of these, being reported in approximately  1:700 live births. In 75 per cent of cleft lip and palate cases,  the cleft runs through the alveolus.   Perhaps the most important development in the treat-  ment of cleft lip and palate patients followed the work  of Boyne and Sands and was the introduction of recon-  struction of the alveolar cleft with bone, at a time when  the growth of the maxilla is largely completed (secondary  alveolar bone grafting). Attempts at alveolar bone grafting  go back as far as 1901 when Von Eiselberg used a pedicled  bone graft to fill the defect. However, in 1908, Lexter was  the first to demonstrate the use of free bone grafts.    ® primary (0-3 years), often undertaken at the time of lip  repair and now of historical significance only;   ® early secondary (3-6 years), before the eruption of the  permanent incisor teeth;   ® secondary (6-13 years), before the eruption of the per-  manent canine teeth;   © late (after 13 years), after the eruption of the permanent  canine teeth.    Functional and aesthetic problems are associated with  cleft lip and palate. The severity of these will depend upon  the type of cleft (unilateral or bilateral).   @ inability to suck up a straw or blow up balloons;   © poor appearance of the incisor teeth, which traumatize  the upper lip;    The objectives of alveolar bone grafting are therefore  aimed at addressing the above complaints as follows:    complete closure of all oronasal fistulas with significant  improvement in speech;  ® restoration of the continuity of alveolar/dental arch  with bone;  ® providing stability to the premaxilla and dental arch;  allowing normal eruption of the permanent teeth in the  cleft area and providing sufficient bone for the place-  ment of dental implants, where needed;  @ allowing orthodontic alignment of the maxillary  dentition.  Additional benefits can also be achieved with reconstruc-  tion of the nasal floor and piriform aperture, as follows:    Primary bone grafting was adopted by many centres in  the 1950s and early 1960s; however, reports emerged  demonstrating a significant detrimental effect of this pro-  cedure on maxillary growth. Secondary bone grafting  was advocated by Boyne and Sands. This approach was  popularized by further work undertaken by Abyholm  et al. Where possible, alveolar bone grafting should be  undertaken between the ages of six and 13 years. Perhaps  the ideal age is eight years following the peak in maxillary  growth and before the unerupted canine tooth has started  to erupt from bone into the cleft. This is usually before the  canine root has developed two-thirds of its final length.  Waiting until maximal transverse growth of the max-  illa has been achieved may avoid the need for presurgical  maxillary expansion or at least minimize the presurgi-  cal orthodontic treatment required. Timing of surgery  is largely guided by dental age, although other factors  such as psychological development, speech and social cir-  cumstances should be taken into account in a multidisci-  plinary and child-friendly setting. Where the permanent  canine tooth has already erupted into the cleft area, this  will significantly compromise the graft and consideration  should be given to delaying the grafting procedure until  the canine is fully erupted and can be aligned by presurgi-  cal orthodontic therapy to optimize the surgical outcome.   Late alveolar bone grafting is known to be less suc-  cessful. This is due to a number of factors including poor  hygiene and tobacco smoking. This patient group, however,  should not be excluded from treatment and it is impor-  tant that alveolar bone grafting is offered to older patients  requesting facial reconstruction and dental rehabilitation.  Careful and comprehensive treatment planning is essen-  tial and most patients will require presurgical orthodontic  treatment. It is essential that alveolar bone grafting pre-  cedes facial osteotomy surgery and reconstructive rhino-  plasty for optimal results.    Patients should be assessed within a multidisciplinary  setting. A full history should focus on previous surgical  episodes and complications related to these. Examination  of the cleft area should note the presence of supplemental  and supernumerary teeth and the presence of dental caries  in the remaining dentition. Deciduous teeth which have  erupted into the cleft will compromise the available soft  tissue for flap reconstruction and should be removed prior  to definitive surgery.   Photographic and radiographic records (panoramic,  occlusal and periapical films) are essential for treatment  and audit. Fully coned three-dimensional computed  tomography (CT) scanning is becoming increasingly  important as this gives full visualization of the cleft defect  at a reasonable radiation dosage. When used post-opera-  tively, it is possible to accurately assess the volume of suc-  cessfully grafted bone and is a powerful audit tool.   Study models are obtained and, for the bilateral cleft  cases, an interocclusal acrylic wafer is constructed to the  predeter-mined agreed post-operative position of the  premaxilla.    Surgery is undertaken under general anaesthesia with  nasal intubation in both unilateral and bilateral cases.  Use of ilium is the author’s preferred option for harvesting  bone as this site reliably produces large volumes of donor  bone and allows a second team to harvest bone simulta-  neously. Infiltration of the oral cavity with local anaes-  thetic solution with vasoconstrictor helps intraoperative  haemostasis and dissection, and aids post-operative pain  control. The mouth is irrigated with a chlorhexidine solu-  tion and prophylactic antibiotic therapy instituted and  continued for 5 days. The primary objectives of the surgery  are to close all oronasal fistulas and therefore the whole  of the cleft area, including the hard palate, needs to be  widely exposed. Scar tissue lying within the cleft alveolus  and nasal floor area should be excised to create room for  grafted bone.    Through a small incision over the iliac crest, dissection  is taken to the perichondrium of the crest. The cartilagi-  nous cap is divided along its length with stop cuts at either  ends and the cartilage cap retracted medially to expose the  inner aspect of the ilium. A corticocancellous block is now  harvested with additional cancellous bone (Figure 69.10)  The cortical sheet is now separated from the cancellous  block and the cancellous portion morcellated. The wound  is closed primarily with insertion of an epidural catheter  into the wound to provide post-operative analgesia with a  local anaesthetic solution.    Incisions for flaps are made starting in the buccal suclus  posteriorly along the gingival margins from the upper  first molar tooth to the cleft margin on the lesser segment  (Figures 69.11 and 69.12)   A second flap is raised on the greater segment sufficient  to expose the piriform aperture on the noncleft side.   Dissection is taken into the cleft incising along the cleft  margins vertically and joining the incisions submucosally  as they meet in the buccal sulcus above the cleft. Separate  horizontal incisions are now made within the cleft on  either side approximately 5 mm below the level of the pala-  tal shelves and extending to the posterior extent of the cleft  (Figure 69.13).   Bilateral Veau palatal flaps are raised as far posteriorly  as possible to fully expose the cleft in the hard palate.  Where necessary, a backcut is made medial to the molar  teeth should advancement be required. The cleft is now  fully exposed.   The medial margins of the Veau flaps are trimmed  and approximated with a continuous suture (Figure 69.14).    The horizontal incision into the cleft to sep-  arate the nasal layer from the palatal tissues with Veau flaps  being elevated.    Where the inferior turbinate has hypertrophied and is  lying within the cleft alveolus, this is trimmed to above  the level of the palatal shelves as described by Iino  (Figures 69.15 and 69.16)   Following removal of any excess mucosa, the nasal layer  is approximated closing the fistula along its length. A thin  sheet of cortical bone is inserted at the level of the piriform  aperture reconstructing the nasal floor (Figure 69.17).  A biomembrane (Bio-Gide’; Geistlich Pharma, Wolhusen,  Switzerland) is placed above the cortical sheet which acts  as a barrier to ingress of infection and promotes guided  tissue regeneration.   Bio-Gide is also placed on the cleft surface of the  approximated Veau flaps (Figure 69.18) and the cancellous  bone chips are packed tightly into the cleft defect.   The buccal surface of the grafted cleft is then also  covered with Bio-Gide and the buccal flaps transposed to  cover the graft and sutured without tension (Figure 69.19).    Approximation of the Veau flaps following  wide exposure of the cleft area.    The hypertropy of the inferior turbinate  lying within the alveolus area of the cleft.    Inferior turbinectomy and reconstruction of  the nasal floor with a Bio-Gide biomembrane overlying a thin  sheet of cortical bone.    Formal reconstruction of the nasal floor at the  level of the piriform aperture with a thin sheet of cortical bone.    Reconstruction of the alveolus with cancel-  lous bone chips. Note the Bio-Gide biomembrane on the pala-  tal surface of the bone.    Rotation of these flaps ensures a satisfactory sulcus depth  in the cleft area.    Full exposure of the bilateral cleft is required for closure of  the nasal layer and to facilitate a reliable palatal flap repair.  The surgical technique therefore includes premaxillary  osteotomy which allows repositioning of the premaxillary  segment to an optimal position determined pre-operatively  following consultation with the left orthodontist. An acrylic  wafer is constructed on the study model to aid fixation of  the premaxilla post-operatively and the orthodontist is  asked to band and place brackets on the maxillary teeth.  Buccal mucoperiosteal flaps are raised as before;  however, special care is taken when performing the  vertical incision on the premaxillary side of the cleft  (Figure 69.20). The mucoperiosteum on the labial aspect  of the premaxilla has to remain attached on a wide base to    The graft covered with Bio-Gide and the  mucoperiosteal release flap rotated to cover the graft without  tension.    the premaxilla as this will form the vascular supply to the  premaxillary segment.   Horizontal incisions into the cleft on either side  re made at the level of the nasal floor and these are  extended to the midline and join on the palatal aspect  of the premaxilla and are designed in such a way as to  leave a generous cuff of mucosa attached to the premax-  illa. The posterior horizontal incisions inside the cleft  are then extended as one incision in the midline over  the caudal end of the hypertrophied vomerine/maxillary  suture freeing up the whole of the nasal mucosal layer  (Figure 69.21).   The vomerine/maxillary suture area is now osteoto-  mized with either a small osteotome or drill. The premax-  illa can now be reflected in a superior direction based on  the labial pedicle and the nasal layer is closed along the  length of the cleft (Figure 69.22).    Division of nasal and palatal tissues and ele-  vation of flaps. Note the generous cuff of mucosa on the pala-  tal aspect of the premaxilla.    The osteotomized premaxilla is retracted  anteriorly allowing excellent vision for accurate closure of the  nasal layers.    Finally, bilateral Veau flaps are raised, as described  previously, with backcuts if necessary to give additional  length. These are trimmed medially and approximated.  A cortical bone sheet, covered by Bio-Gide, is now placed  on both sides of the cleft and a further sheet placed to  bridge the palatal shelves to reconstruct the nasal floor.  The premaxilla is repositioned in the planned post-  operative position and the attached lingual cuff of mucosa  sutured to the Veau flaps across the width of the anterior  palate (Figure 69.23).   Bio-Gide is placed on the inside of the suture line and  cancellous bone is packed into the cleft defect from both  sides and covered with further Bio-Gide. Finally, the buccal  mucoperiosteal release flaps are rotated and advanced to    The premaxilla is repositioned and palatal  tissues approximated prior to final placement of the cancel-  lous graft.    Rigid fixation of the premaxilla into a locat-  ing wafer prior to final closure over the Bio-Gide biomembrane  covering the graft.    cover the grafted clefts and sutured into place (Figure 69.24).  The acrylic wafer is now wired into place securely.    Antibiotics and a chlorhexidine mouthwash are con-  tinued for 1 week and the patient is placed on a liquid-  ized diet and strict oral hygiene measures for 3 weeks.  Ambulation is encouraged on the first post-operative day.  Complications are rare with these procedures, although  minor wound dehiscence is not uncommon. Infection  of the graft is the most serious complication and where  dehiscence occurs, it is wise to extend the prophyactic  antibiotic cover.    e Planning of treatment is best undertaken in a  multidisciplinary team setting.   ¢ Optimum age for alveolar bone grafting is between  seven and nine years of age.   e Tlium isa reliable source of cortical bone sheets and  large volumes of cancellous bone.   e In the bilateral case, premaxillary osteotomy, com-  bined with guided tissue regeneration, followed by a  period of rigid fixation produces predictable results.   ¢ Computed tomography is a powerful audit tool as  bone volumes can be measured accurately.   ¢ It is essential that alveolar bone grafting precedes  facial osteotomy surgery and cleft rhinoplasty for  optimal results.    Abyholm FE, Bergland O, Semb G. Secondary bone graft-  ing of alveolar clefts. A surgical/orthodontic treat-  ment enabling a non-prosthodontic rehabilitation  in cleft lip and palate patients. Scandanavian J Plast  Reconstruc Surg. 1981; 15: 127-140.    Arctander K, Klobenstvedt A, Aalokken TM et al. Computer  tomography of alveolar bone grafts 20 years after repair  of the unilateral cleft lip and palate. Scandanavian J Plast  Reconstruc Surg. 2005; 39: 11-14.   Banks P. The surgical anatomy of secondary cleft lip and  palate deformity and its significance in reconstruc-  tion. Brit J Oral Surg. 1983; 21: 78.   Boyne PJ, Sands NR. Secondary bone grafting of residual  alveolar and palatal clefts. J Oral Surg. 1972; 30: 87-92.   Bureau S, Penko M, McFadden L. Speech outcome after  closure of oronasal fistulas with bone grafts. J Oral  Maxillofac Surg. 2001; 59: 1408-13.   Iino M, Kondoh T, Fukuda M et al. Partial inferior turbi-  nectomy during secondary alveolar bone grafting. Int  J Oral Maxillofac Surg. 2002; 31: 489-94.   Kazemi A, Stearns JW, Fonseca RJ. Secondary grafting  in the alveolar cleft patient. Oral and Maxillofacial  Surgery Clinics of North America 2002; 14: 477-90.   Posnick J. The staging of cleft lip and palate reconstruc-  tion: Infancy through adolescence. In: Rose R  and Ross A (eds). Craniofacial and Maxillofacial  Surgery in Children and Young Adults. Philadelphia:  WB Saunders, 2000: 785-815.   Scott JK, Webb RM, Flood TR. Premaxillary osteotomy and  guided tissue regeneration in secondary bone graft-  ing in children with bilateral cleft lip and palate. Cleft  Palate-Cran J. 2007; 44: 469-75.   Introduction 7al  Rhinoplasty procedures at the time of the primary cleft lip surgery 722  Cleft rhinoplasty during the pre-school years 724  Cleft rhinoplasty once growth has stopped 726  Definitive rhinoplasty 728  Suggested readings 732  INTRODUCTION e Disturbed junction between the upper and lower    Despite all the improvements in primary cleft surgery,  cleft nasal deformity still remains a functional and aes-  thetic dilemma for patients and surgeons.   There is inherent composite tissue abnormality or  hypoplasia. The developmental problems therefore can  be divided into the following three categories: the cover-  ing, the framework (bone and cartilage) and the lining.  The questions are: what are the deformities and what is the  optimal time for correction?   There is adequate information in the literature that early  limited correction of the lower lateral cartilage provides  no subsequent growth disturbance, allows better nasal  growth and reduces the psychological trauma to the child.  Developmentally, the explanation falls into two distinct  factors, which are responsible for the cleft nasal deformity.  First, there is agenesis of tissue due to the lack of meso-  dermal and ectodermal quantity. Second, there is associ-  ated deformation as a result of mechanical stresses located  within the cleft margins.    © Septum  e Perpendicular plate deviating to the cleft side  e Quadrangular septal cartilage deviating caudally  towards the non-cleft side  e Nasal spine deviating to the non-cleft side  ® Dorsum  - Bony pyramid deviating to the non-cleft side  e Asymmetry of the nasal bone and flattened at the  cleft side  e Asymmetry of the upper lateral cartilage on the  cleft side    lateral cartilages on the cleft side  e Downwards displacement of the lower lateral carti-  lage on the cleft side  e Tendency to bifidity  e Buckling of the lateral crura on the cleft side  e Reduced height of the medial crura on the cleft side  © Columella  e Deviation at the top to the cleft side and at the base  to the non-cleft side  @ Alar base  e Lateral displacement resulting in a horizontal rota-  tion of the nostril at the cleft side    © Septum  e No specific deviation  e Disturbed caudoventral outgrowth  ® Dorsum  e Lack of projection and flattening of the osseo-  cartilaginous vault  e Disturbed junction between the upper and lower  lateral cartilages  e Tip  »  Bifidity  e Downwards of the lateral crura on both sides  © Columella  e Very short  @ Alar base  e Lateral displacement resulting in horizontal rota-  tion of both nostrils    Alveolar cleft, hypoplasia and retroposition of the maxilla  compound the nasal deformity.    We divide our approach to the cleft rhinoplasty into  four stages. They are as follows:    1. Rhinoplasty procedures at the time of primary cleft lip  surgery    Pre-operative assessment is the most important step.  The family’s and patient’s impression of the deformity and  their expectations should be discussed in detail. The aim is  always improvement and not perfection. There is an over-  lap between the third and fourth steps repairing and the  patients need towards other corrective procedures.    RHINOPLASTY PROCEDURES AT THE TIME  OF THE PRIMARY CLEFT LIP SURGERY    We describe two different approaches. One is based on  McComb’s technique where patients undergo pre-surgical  orthopaedics and the other is based on Ahuja’s technique,  where no pre-surgical orthopaedics is carried out.    At the time of the lip repair, the skin of the nose on the cleft  side is freed from the underlying bony and cartilaginous  skeleton. Sharp pointed scissors are passed up through the  incision in the upper buccal sulcus on the side of the cleft,  extending the dissection over the cleft half of the nose. The  same scissor is also used to free the dome of the alar carti-  lage and medial crura. The dissection is carried out in this  same plane up to the nasion.   Now the affected lower cartilage can be easily lifted  upwards with the attached nasal lining.   The alar lift is maintained by two mattress sutures  (Figure 70.1). A straight needle with 3-0 nylon suture is  started at the nasion, just cranial to the dissection boundary.    The needle is passed through the intracrural angle into the  nostril. A bolster is passed through the needle, and then  the needle is passed through the nasal lining and lateral  crura and then passed subcutaneously to the exit point at  the nasion. Here, another bolster is applied and the two  ends of the suture are held in a clip and the needle is cut off.  A similar second suture is placed, if necessary, towards the  lower third of the lateral crura (Figure 70.2). Alar lift is car-  ried out to the desired contour, compared to the non-cleft  side and both sutures held in a clip until the primary lip  repair is completed. The final knotting is completed once  a desirable height is contoured. The mattress sutures are  removed at 5-7 post-operative days.    The procedures are carried out exactly the same as in  the unilateral procedures; however, there is no landmark  to position the alar lift. The upper lateral cartilages  should normally be at the same height as the lower  lateral cartilage. Therefore, the aim of lifting should be  to the height of the upper lateral cartilage and to reduce  the nostril size equally (Figures 70.3 and 70.4).   This is based on Ahuja’s ‘limited open’ approach, where  elevation, medial rotation and suture fixation of the lateral  crura, reconstruction of the nostril sill, alar base position-  ing and correction of the vestibular webbing is carried out  along with lip repair.   The nasal tip and lower half of the dorsum are exposed  and an inverted U incision on the cleft side and a marginal  incision on the non-cleft side are made (Figure 70.5).   The inverted U incision on the cleft side is joined with the  buccal sulcus incision. The upper half of the medial crura,  the dome and the lateral crura of both alar cartilages are  dissected from the dorsal nasal skin. The base of the lateral  crura on the cleft side is released from the pyriform margin.   A single horizontal mattress suture of undyed 5-0  Prolene on a round-bodied needle approximates the two  domes to elevate the lower lateral crura on the cleft side  (Figure 70.6).    Figure 70.2 Second mattress suture placed towards the  lower third of the lateral crura.    Rhinoplasty procedures at the time of the primary cleft lip surgery 723    Figure 70.5 Inverted U incision on the cleft side and the  marginal incision of the non-cleft side.    Figure 70.6 Horizontal mattress suture from the cleft side  to the non-cleft side.    Figure 70.7 Second horizontal mattress from the lateral  crura on the cleft side to the lower end of ipsilateral upper  lateral cartilage.    A second suture of the same material is used to fix  the lateral crura on the cleft side to the lower end of the  ipsilateral upper lateral cartilage (Figure 70.7). This mat-  tress suture is placed in a differential manner at both ends  depending upon the adjustment required. On the cleft  side from the lip repair, the part of the advanced mucosa  is fed into the vestibular incision to compensate for the  shortage of the lining that can lead to the vestibular web  or fold.   The cleft lip is repaired in the usual way, together with  reconstruction of the nostril sill and floor.   A suitable nasal splint is placed and maintained as long  as possible (Figure 70.8). Ahuja recommends a vaseline  gauze for 5-7 days. The authors prefer a nasal splint.   Bilateral inverted U incisions are used. Dissections of  the upper half of the medial crura on both side as well as  the dome and lateral crura from the overlying skin are  performed. The bases of the lateral crura on both sides are  dissected from the pyriform margins.   The desired alar height in relation to the height of the  upper lateral cartilage is established and the sutures placed  accordingly. The advanced mucosa from both sides of the  lip repair is fed into the vestibular incisions (Figure 70.9).    The bilateral cleft is repaired in the usual way together with  reconstruction of the nasal sill and floor. Suitable nostril  splints are placed and maintained as long as possible.    A mid-columella transverse incision is made across the  columella. It is extended superiorly on the inner edge of  the columella to the dome, continuing as an infracartilagi-  nous incision down to the pyriform aperture. The lower  lateral cartilage and upper lateral cartilages are exposed  (Figure 70.10). The fibrous attachment of the lower lat-  eral cartilage to the upper lateral cartilage and the rim of  the maxilla are freed by sharp dissection. The interdomal  attachments between both lower lateral crura are also  freed. This should allow the lower lateral cartilage to be  completely free and mobile, allowing it to be evaluated for  mucosal tethering on the lateral end.    Figure 70.10 A mild columella transverse incision with  bilateral infracartilaginous incision.    Figure 70.11 The required mobilization on the cleft side is  assessed by placing a skin hook.    The deficiency of the cleft side mucosa is evalu-  ated by placing a hook in the intermediate crural mar-  gin and advancing the freed lower lateral cartilage with  attached mucosa to match the height of the non-cleft side  (Figure 70.11). If there is tethering of the lower lateral car-  tilage, re-evaluation of the previous release of the lower  lateral cartilage from the upper lateral cartilage and the  rim of the maxilla is made to ensure that only the mucosal  attachment remains (Figure 70.12a and b). If the mucosa  is still tight and limits elevation of the lower lateral carti-  lage, an inferior turbinate mucosal flap is raised, which is  attached to the lower lateral cartilage and the mucosa and  this flap is completely elevated into the pyriform fossa.    Figure 70.12 (a) Frontal view of lateral mucosa dissection  towards the inferior turbinate. (b) Lateral view showing the  inferior turbinate mucosal flap.    After release of the lower lateral cartilage and  correction of the mucosal deficiency, the chondro-  mucosal unit is advanced into its correct position and  held in two places. First, it is fixed to the apex of the  medial crura, which is fixed to the opposite side medial  crura on the non-cleft side (Figure 70.13). Second, the  lateral third of the lower lateral crura on the cleft side  is fixed to the lower part of the upper lateral crura. No  sutures are placed into the septal cartilage.   The skin is redraped and closed over with 6-0 Prolene  sutures. Additional support can be provided with alar  transfixation sutures to the skin at the alar crease. The  number can vary from one to three (Figure 70.14). The  advantages are that it reconstitutes the alar crease, supports  the nasal tip projection and prevents vestibular webbing.   A suitable nostril splint is applied and maintained as  long as possible. The sutures are removed in the seventh  post-operative day.    A mid-columellar transverse incision is made across the  columella (Figure 70.15) similar to the unilateral approach;  here a bilateral approach is made along the columella and  along the infracartilaginous area. The whole of the lower  half of the nose is exposed after blunt and sharp dissection.  Bilateral inferior turbinate flaps are raised to ensure that  there is no mucosal tethering (Figure 70.16). The chondro-  mucosal unit is advanced to an acceptable height and held  by two sutures as before.   The skin is redraped and closed with 6-0 Prolene  sutures. Additional sutures can be provided with alar  transfixion sutures bilaterally.   When redraping the columella skin, if there is a defi-  ciency along the columella, a composite earlobe graft can  be used in the defect. A word of caution here, if the bed  vascularity is not adequate, the graft may not take.    Figure 70.13 Two mattress sutures placed at the apex  of the middle crura and the lateral crura to the upper lateral  cartilage.    Figure 70.14 Alar transfixation to the skin at the alar  crease.    Figure 70.15 Mild columellar incision and bilateral infra-  cartilaginous incision extending towards the inferior turbinate.    Figure 70.16 Bilateral inferior turbinate chondro-mucosal  flaps and placement of three sutures as before.    The approach is twofold. First is a dorsal approach once  the nasal lobule is degloved via columellar and infracatila-  gionous incisions. The second is hemi-transfixion incision  in any septoplasty procedure.   In the former, the medial crura and fibrous attachments  are separated and a mucoperichondrial flap is raised to the  base of the nasal floor from above.   The anterior nasal spine is inspected and if it is dis-  placed, a 3-mm osteotome is used to mobilize it from the  maxillary bone to correct the midline. Once the midline  position is stabilized, the soft tissues are attached with a  4-0 polydioxanone (PDS) round-bodied suture.   The lower one-third of the septal cartilage is resected  and a septal straightening is carried out in the usual way  (Figure 70.17).    If the approach is carried out via a hemi-transfixion  incision, a mucoperichondrial and mucoperiosteal dis-  section is carried out in order to expose both sides of the  cartilaginous and bony part of the nasal septum. Then the  lower third of the nasal cartilage together with the vomer-  ine bone, if required, is removed. This would aid in cen-  tralizing the nasal septum.   The cartilage, which has been removed, is used as graft  material.    The lower lateral cartilage from the cleft side is dissected  from the nasal skin and the lining. Sharp curved dissect-  ing scissors are very valuable in this procedure.   The required amount on cephalic excision is carried  out to create an alar crease (Figure 70.18). This is car-  ried out bilaterally. Due to the cleft-side hypoplasia, the  amount of cephalic excision would be less than the non-  cleft side.   The removed septal cartilage, or separately harvested  conchal cartilage, is used to support the lower lateral car-  tilage in a tailor-made fashion (Figure 70.19). The septal  cartilage can be trimmed to form an intercrural graft.  Conchal cartilage can be used as an onlay graft to the lat-  eral crura or as an extension from an intercrural graft to  the lower lateral cartilage contour.   The intercrural graft sits on the anterior nasal spine and  is stabilized to the desired height with two or three 4-0 PDS  round-bodied mattress sutures, holding the medial crura  (Figure 70.20). In the past, the non-cleft side lower left car-  tilage was dissected in its entirety and it was found that it  was not necessary to do so unless there is gross second-  ary deformity. In spite of mobilization and stabilization,  the dome height may not be equal. Next, an onlay graft  should be placed over the intermediate crura and sutured  with 4-0 PDS sutures. It is preferable to place the knot on  the dorsal surface.    Figure 70.19 Intercrural graft with extension into the  dome of the cleft side and stabilized with mattress sutures.    Figure 70.20 Intercrural graft stabilized with mattress  sutures and only graft along the dome of the cleft site.    If there is gross hypoplasia of the lower lateral cartilage,  a conchal cartilage can be used as an intercrural graft and  onlay graft to provide support and height.   Once the symmetry of the nasal lobule is achieved, a  horizontal mattress suture is placed from the lower end  of the upper lateral cartilage to the upper end of the lower  lateral cartilage, along the lateral third of the affected side  (Figure 70.21).    Figure 70.21 Horizontal mattress suture from the lateral  crura to the ipsilateral upper lateral cartilage.    If there is lining deficiency in spite of good mobilization  of the fibrous attachment to the maxilla, a finger extension  to the inferior surface of the inferior turbinate is obtained.   The benefit of mobilizing the nasal lining on its own is  the freedom to overcome any webbing deformity and in  turn provide a symmetrical nostril shape. The disadvan-  tage, however, is introducing further scarring on the ven-  tral surface of the lower lateral cartilage.    A dorsal hump reduction is carried out by resecting the  cartilaginous hump with a blade. Following that, the  bony hump is osteotomized with a Rubin osteotome and  removed. When hump reduction is performed, medial  osteotomies are not necessary for nasal infracture. If  a hump reduction is not needed, a midline osteotomy of  the nasal bone is carried out using a 5-mm osteotome or  straight guarded osteotome.   A midline osteotomy of the nasal bone is carried out  using a 5-mm osteotome. Depending upon the size of the  nose, between two and five stab incisions are made along the  lateral border of the nose and the bridge. Transcutaneous  osteotomies are made using a 2-mm osteotome. Infracture  is carried out like any other rhinoplasty procedure. If there  is gross hypoplasia of the nasal bone, the infracture would  not provide the necessary height in which case an onlay  calvarial or costal cartilage graft is required.    The skin is redraped; examination is carried out for resid-  ual asymmetry and irregularity. Crushed cartilage is used  to overcome these problems.    The nasal lining is repaired with 5-0 Vicryl suture and the  columella skin with 6-0 Prolene sutures.    Support tape is applied to minimize any chance of haema-  toma, following which a suitable thermoplastic nasal splint  is applied. These procedures are exactly similar to any stan-  dard rhinoplasty operation. The difference here is place-  ment of a suitable nostril splint, which should remain for  a period of 3-6 months. This is a social embarrassment to  some patients, but it must be used at night, at the very least.    The main difference is the columella shortening, bifid  blunt nasal lobule and broad nasal bridge. The columella  incision is designed to maximize the columella skin  height (various modifications are shown in Figure 70.22a  through d). The dissection is carried out as before, bilat-  eral lower lateral cartilage mobilization is carried out as  before, following which septal centralization is achieved.  An intercrural graft is placed and stabilized with the  medial crura to the desired height. Onlay conchal carti-  lage is placed and sutured as before (Figure 70.23).   Hump reduction is a rare event in the bilateral cleft.  However, if needed, medial and lateral osteotomy is car-  ried out with infracture. A spreader graft has a role to play  in providing stability to the nasal septum and the nasal  bridge. An onlay cartilaginous graft is placed if necessary  and upper and lower lateral cartilages are sutured as before.   Nasal lining is extended to the inferior turbinate. The  skin is repositioned and irregularities checked and cor-  rected with crushed cartilage. The skin is repaired with  6-0 Prolene and the lining repaired with 5-0 Vicryl and  the dressing is as before.    Figure 70.22 Various modifications of the columella  incision designed to maximize the columella skin height.    Figure 70.23 Intercrural graft held by mattress sutures.  Onlay graft of the dome held by mattress sutures.    This is the final procedure in the journey of cleft patients.    The unilateral cleft lip nose is considered more difficult  to treat than the bilateral cleft lip nose due to a lack of  symmetry.    @ Nasal tip asymmetry with the dome at the cleft side  lower than the non-cleft side.   @ The lower lateral crura at the cleft side is often crimped,  deformed or hypoplastic.   © The nasal tip may be wide as the lower lateral cartilages  are spaced further apart.   e Asymmetry at the naso-alar groove, with depression at  the cleft side.   © The alar rim at the cleft side is often lower than the non-  cleft side.   © Soft tissue deficiency at cleft side with depressed nasal  bony floor at the previous alveolar bone graft (ABG) site.   The facial skeleton as the framework for the face should  be treated first in any craniofacial deformity before cleft  rhinoplasty is performed. This holds true for both cleft  and non-cleft patients. Patients who require maxillary  advancement due to maxillary hypoplasia should ideally  have the osteotomy first before rhinoplasty. Alternatively,  the cleft lip rhinoplasty can be done simultaneously with  the osteotomy. Bony depression at the previous alveolar  bone graft side can be augmented with alloplastic material  or autogenous material.    A block of contoured corticocancellous bone can be  harvested from the mandible, calvarium or hip as required  and secured to the pyriform rim defect as an onlay graft via  an intra-oral circumvestibular incision. Two microscrews  are used to secure the bone to the underlying bony base.   Ifanon-resorbable material is preferred, Medpor (porous  polyethylene implants) can be fashioned and shaped to  fit the defect as an augmentation material. The method  of surgical access and means of securing the implant is  the same as for bone grafts. To reduce the incidence of  infected implant, the Medpor is soaked and impregnated  with Gentamycin solution before final placement.    Incision and skeletonization  In cleft rhinoplasty, open rhinoplasty is preferred as it  allows unparalleled access to the underlying aberrant nasal  tip anatomy and dorsum. An inverted V-transcolumellar  incision is used with bilateral marginal incisions. The  nasal tip is carefully degloved and skeletonized. Very  often, one will appreciate the difference in size and mor-  phology between the lower lateral cartilage at the cleft side  and the non-cleft side.   Dissection should be in a subperichondral plane along  the upper lateral cartilage, followed by subperiosteal plane  along the nasal bones.   The septum can be reached via a tip split technique. The  fibrous attachment between the bilateral lower lateral car-  tilages is dissected to reach the septum. Subperichondal  dissection is carried out and a piece of septal cartilage graft  is dissected out leaving at least 10-12 mm of caudal and  dorsal strut (Figure 70.24). To facilitate a wider exposure,    Figure 70.24 Septal graft is harvested from the septum,  leaving 10-12 mm of dorsal and caudal strut.    part of the upper lateral cartilage can be separated from  the nasal septum at the dorsal region.   For patients with dorsal humps, these can be removed as  in any rhinoplasty. A cartilaginous hump can be excised  with a blade while the bony hump is osteotomized and  removed with a Rubin osteotome. The remaining rough  edges can be smoothed out by rasping or by using a dia-  mond bur (Figures 70.25 and 70.26).    Nasal bone infracture  Nasal infracture via endonasal or percutaneous osteoto-  mies can be done to close the open roof defect and realign  the nose if it is deviated.   For the deviated nose, the bony septum should also be  mobilized and straightened.    There are a few tip grafting techniques that are useful in  cleft lip rhinoplasty. They are as follows:    1. Extended septal graft (Figure 70.27)  2. Columellar strut (Figure 70.27)    An extremely useful method in acquiring additional  nasal projection is the extended septal graft technique.  The septal cartilage graft is sutured to the caudal end of  the septum with 5-0 PDS sutures, projecting in a caudal  direction beyond the nasal septum. This allows correc-  tion of the nasolabial angle from an obtuse angle to 90°.    Figure 70.26 Hump reduction with columellar strut and  onlay grafts (post-operative).    Figure 70.27 Extended septal graft is fashioned from the  harvested septal graft. It is sutured to the caudal end of the  septum. It can be further reinforced by a columellar strut.    For increased strength and height, the nasal tip is further  ‘propped up’ with a columellar strut. The columellar strut  should be sutured to the extended septal graft. The dome at  the cleft side can be lifted to the same height as the dome of  the non-cleft side and sutured to the extended septal graft  and columellar strut. Onlay grafts can be sutured on top  of this to increase the nasal tip height. This helps to mask    Figure 70.28 The nasal projection is directed in a caudal,  anterior direction by the extended septal graft and columellar  strut. Placement of an onlay graft at the nasal tip will further  increase nasal projection, mask some asymmetry of the nasal  tip and form a more defined nasal tip.    Figure 70.29 Illustration showing extended septal graft  sutured to the caudal end of the septum, columellar strut, left-  sided Batten graft and an onlay graft.    some of the asymmetry in the nasal tip. Residual asymme-  try due to the hypoplastic nature of the lower lateral car-  tilage at the cleft side can be camouflaged with alar batten  graft. The best sources of cartilage grafts are either septal  or conchal cartilages. Rib cartilage grafts are useful when  strong projections are needed and are used for extended  septal grafts and columellar struts.    Various suturing techniques are employed to reduce the  nasal tip width. These include transdomal sutures, inter-  domal sutures and intercolumellar sutures.   This is a main problem among the oriental population.  This can be augmented with either alloplastic material or  autogenous cartilage graft.   Gore-Tex (expanded polytetrafluoroethylene) is a com-  monly used material. This can be fashioned into a dorsal  graft and placed in the subperichondral and subperiosteal  pocket to augment the nasal bridge. Sheets of Gore-Tex of  2-mm thickness can be stacked to the required height and  secured with 5-0 PDS sutures. To reduce the incidence of  infected implants, the Gore-Tex is soaked in Gentamycin  solution before final placement. The graft has to be further  shaped to ensure smooth continuity between the implant  and the radix and bridge of the nose.    A source of autogenous cartilage graft is the costochondral  cartilage. The fifth, sixth or seventh rib can be harvested  via an inframammary incision. The obtained rib graft  can then be fashioned to a dorsal graft of the appropriate  height and length. This can be placed in the subperichon-  dral and subperiosteal pocket (Figures 70.30 and 70.31).    Figure 70.31 Post-dorsal augmentation with rib cartilage,  extended septal graft and columellar strut.   Alar base reduction can be done together with percutane-  ous alar cinch with 3-0 non-resorbable sutures. Differential  reduction may need to be done, as the alar width at the  cleft side may be wider than the non-cleft side.    Excess vestibular mucosa at the cleft side can be trimmed  selectively to restore a semblance of nostril symmetry.    Skin closure by 6-0 Prolene and mucosal closure with 5-0  Vicryl sutures.    The problems list for bilateral cleft lip nose includes the  following:    One does not have to deal with the asymmetry of the uni-  lateral cleft lip nasal deformity in bilateral cleft lip rhi-  noplasty. The aim of the surgery is to achieve increased  nasal tip projection, narrow the nasal bridge, the nasal  tip and the alar base. Incision and skeletonization    techniques are the same as that for the unilateral cleft lip  nasal deformity.    Although hump reduction is rare, infracture of the nasal  bone is still carried out as it allows narrowing of the  nasal bridge. This can be performed with medial and lat-  eral nasal osteotomies and results in sharper nasofacial  angles. Augmentation of the dorsum with alloplastic  implants such as Gore-Tex or rib grafts helps in two  ways. It augments the dorsum of the shallow bridge and  simultaneously creates the illusion of a narrow nasal  bridge.    The bilateral cleft lip nasal deformity presents with a short-  ened columella. Nasal tip projection can be increased with  a columellar strut and this can be further reinforced with  extended septal graft if needed. Instead of conchal and  septal grafts, rib grafts may be needed to form the strong  underlying architecture. The wide nasal tip can be nar-  rowed with transdomal sutures and interdomal sutures  using 5-0 resorbable sutures on a round bodied needle.    Further definition and projection of the nasal tip can be  achieved with onlay grafts.    Alar base reduction can be done together with percutane-  ous alar cinch.  Closure is as described in unilateral cleft rhinoplasty.  Competency should be obtained in the standard aes-  thetic rhinoplasty prior to engaging in cleft rhinoplasty  procedures.    Ahuja R. Primary rhinoplasty in unilateral cleft patients:  The ‘limited oper’ approach and other technical con-  sideration. Cleft Palate J. 2006; 43: 492-498.   Godin MS, Waldman SR and Johnson CM Jr. Nasal  augmentation using Gore-Tex: A 10-year experience.  Arch Facial Plast Surg. 1999; 1(2): 118-121.   Malek R. Nasal deformities and their treatment in second-  ary repair of cleft lip patients. A clinical study of 175  cases. Scand J Plast Reconstr Surg. 1974; 8: 131-141.   McComb H. Primary correction of unilateral cleft lip.  Nasal deformity: A 10 year review. J Plast Reconstr  Surg. 1985; 75: 791-797.    The need for segmental surgery, with the intention to align  the dentoalveolar arches, has greatly been reduced, since it  is now widely accepted that orthodontic treatment should be  part of the treatment plan in patients with dentofacial defor-  mities. Alignment of teeth and elimination of dentoalveolar  compensation is usually achieved by orthodontic treatment  alone, yet there still are indications for segmental surgery and  they will be discussed for each separate osteotomy. In gen-  eral, however, segmental osteotomies carried out in the den-  tate area require enough available space for these osteotomies  to be performed safely without damage to the periodontal  apparatus. This implies that when segmental surgery is con-  templated, this aspect should be carefully considered in the  treatment plan so that spaces are created in the dental arches.   This advice is particularly relevant for mandibular segmen-  tal surgery because the mandibular bone is usually more dense  when compared to the maxilla and, therefore, less abundantly  vascularized. In general, a diastema of 5 mm, allowing for  approximately 2 mm of septal bone to be attached to the root  of the tooth next to the osteotomy, is considered to be safe.    The first account of an anterior maxillary segmental  osteotomy (AMSO) was probably from Cohn-Stock in    1921,' but a single stage set-back osteotomy through a  vestibular approach was first described by Wassmund  in 1926.2 In 1962, Wunderer presented an important  improvement of Wassmund's technique in that he recom-  mended a predominantly palatal approach, which simpli-  fied the procedure. In 1980, Bell introduced the concept  of the ‘down-fracturing’ in which the anterior segment is  approached through a horizontal vestibular incision.*    The main consideration for the AMSO is to reposition and  fix the fragment in the desired position without jeopar-  dizing the vascular pedicle. The vascular pedicle is either  predominantly buccal or palatal. In either situation, care  should be taken not to impair the blood supply by inad-  vertent cutting of the important vessels or by stretching or  folding of the mucoperiosteal flap that contains the vascu-  lar pedicle.   The anterior fragment may be moved upwards, down-  wards, rotated and set back. An additional mid-line  osteotomy allows for expansion or elimination of a cen-  tral diastema. Most importantly, however, this allows for  correct positioning of the canines by the rotation of both  anterior fragments slightly by pulling the canines down.  At present, this osteotomy is mainly carried out to cor-  rect an extremely reversed curve of Spee by intruding  the anterior segment, i.e. in Class II division 2 anom-  alies. For this reason, the Wunderer approach is to be  preferred.   Two vertical, vestibular incisions are made with a distal  slant, to provide a maximum buccal, soft-tissue pedicle  (Figure 71.1). The mucoperiosteum is gently elevated to  reach the nasal aperture. A periosteal elevator or small  Langenbeck retractor is used to retract the mucoperi-  osteal flap, but care should be taken not to strip off the  gingival attachments around the anterior teeth. With  a short Lindemann burr, a bone cut is made from the  nasal aperture slightly curved towards the alveolar crest  (Figure 71.2). Care should be taken not to damage the peri-  apical area of the canines. It is recommended that a5 mm    Figure 71.1. Incision is curved backwards to allow a broad,  buccal pedicle.    Figure 71.2 Curved bone cut running from the nasal aper-  ture to the alveolar crest. A 5-mm margin is left with regards to  the apex of the canine tooth.    margin above the apices of these teeth be left in order to  avoid permanent neurovascular damage. The cut through  the alveolar portion may be completed at this stage.  Attention is then directed towards the palate and an ante-  riorly curved incision is made through the palatal mucosa  (Figure 71.3). The mucoperiosteum is elevated posteriorly  and the palatal cut is made connecting both alveolar cuts  (Figure 71.4). At this stage, attention should be paid to the  position of the nasal tube and cuff as they can easily be  damaged during this procedure. After completion of the  bone cuts, the anterior segment can be rotated upwards,  thereby dislocating the cartilaginous nasal septum from  the nasal crest. A chisel may then be used to cut the nasal    Figure 71.3 Anteriorly curved incision made in the palate.  Posterior of the line of the supposed osteotomy, the cut may  be made in the gingiva to allow reflection of the flap.    septum in a more controlled fashion once the fragment is  beginning to rotate.   The fragment may be rotated all the way up, just pedicled  to the vestibular mucoperiosteum (Figure 71.5). In this  way, excellent access is obtained for trimming the bony  interferences that exist when the fragment is to be set back  or intruded. A well-irrigated acrylic burr is ideal to reduce  the bony margins, particularly on the palatal side and the  paranasal buccal bone plates. The nasal spine should be  reduced, ifnecessary, for which a bone rongeur may be used.   A mid-line osteotomy is often necessary. This allows  for widening of the fragment and better positioning of the  canines in the dental arch. A thin Lindemann burr is best  used to start approximately 5 mm away from the palatal  gingival margin and continue all the way through the    Figure 71.6 After a groove is made with a thin Lindemann  burr, an osteotome is used to ‘fracture’ the buccal cortical plate    segment towards the palatal cut. Separation is achieved by  gently wiggling with an osteotome; this causes fracturing  of the interdental septum and buccal plate (Figure 71.6).  This way, the least possible damage is inflicted to the peri-  odontal apparatus. If elimination of a central diastema is  required, the interdental bone should be reduced from a  palatal approach with a short Lindemann burr.    The Wassmund approach also begins with two vertical ves-  tibular incisions that may be curved anteriorly to expose  the nasal aperture. The bone cuts are made as described for  the Wunderer technique. On the palatal side, bilateral mar-  ginal gingiva incisions are made from the lateral incisor to  the second premolar, after which the palatal mucosa is ele-  vated from the bone in a tunnelled fashion (Figure 71.7).  The palatal bone cut is made through the buccal cuts with  a long Lindemann burr. This procedure is essentially car-  ried out blindly. The separation from the nasal septum is  achieved through a small vertical mid-line incision in the  buccal vestibule. The nasal spine is exposed and the sep-  tum cut from the nasal crest with a forked chisel.   It is the appropriate reduction of bone on the palatal  side that makes this procedure a less attractive alternative.  This, again, is to be carried out blindly with the obvious  risk of taking away too much bone. Mid-line splitting,  if necessary, should be done from the buccal side with a  thin fissure burr and thin osteotome. For this reason, a  small vertical incision is made over the nasal spine in the  vestibule. The spine is exposed by limited subperiosteal  dissection.    For the down-fracturing technique, a horizontal vestibular  incision is made extending at least one tooth distal to the  proposed osteotomy on both sides. The mucoperiosteum is  reflected to expose the nasal aperture, whilst the alveolar  crest at the side of the osteotomy is also carefully exposed.    Figure 71.7 The palatal bone cut is made with a long  Lindemann burr after the palatal mucosa, which is still attached  to the anterior fragment, has been lifted.    The bone cuts are made as in the Wassmund technique  but the vertical cuts are used to gain access to the palatal  bone. The palatal cut is completed with a thin tapered fis-  sure burr or 4mm osteotome. During this manoeuvre, the  palatal mucosa should not be damaged since this will be  the sole vascular pedicle once the fragment is down frac-  tured. When the anterior fragment is down fractured, the  bone can be trimmed to fit the new position.    If no posterior segmental osteotomies are carried out,  fixation is relatively simple. A prefabricated acrylic splint,  reinforced with a steel wire with which loops are made, is  used to stabilize the fragments. The anterior fragment is  manoeuvred into place, after which the splint is first fixed  to the posterior teeth using pull wires, that are fed through  the loops in the wafer (Figure 71.8). Once this is done,  pull wires should be used to first pull the canines into the  splint, and if necessary, followed by the central incisions.  Since a tendency exists for the fragment to be slightly  rotated upwards when pushed backwards, the canines  tend to be in supraposition. This undesirable effect can be  counteracted by a mid-line split and the use of canine pull  wires. To secure the position of the anterior segment(s),  two four-hole miniplates can be used to fix the fragment  (Figure 71.9).   The acrylic splint may be removed in a few days if the  patient still has orthodontic brackets. A rigid arch wire  will then usually suffice to keep the teeth in the proper  position. Intermaxillary fixation is never necessary and  is not to be recommended. In case, the anterior segmen-  tal osteotomy is combined with posterior segmental  osteotomies, the posterior fragments should be stabilized  first with an acrylic splint, temporary IMF and miniplates.  Once secured, the anterior fragment can be stabilized  with a four hole microplate. The incisions are closed using  3/0 sutures.    Figure 71.8 Acrylic splint secured to the posterior teeth  first using pull wires. Pull wires are also used to fix the ante-  rior fragment in the splint. These wires are twisted around the  canines and then tightened to the splint.    Figure 71.9 Four-hole microplate securing anterior frag-  ment to the posterior maxilla, above the level of the apices.    Apart from some swelling apparent for a few days, hardly  any complications can be expected. However, when  intrusion is the main purpose of the procedure and the  palatal mucosaisleftintact (Wassmund or down-fracturing  technique), it is recommended that the colour of the buccal  gingiva is carefully checked. A bone step at the site of the  palatal osteotomy may cut off the blood supply and, thus,  endanger the viability of the anterior segment.    The posterior maxillary segmental osteotomy (PMSO)  was introduced in 1954 by Schuchardt as a two-staged  procedure to correct anterior open bite.* In 1960, Kufner  described a one-stage modification.’ Several modifications  of the PMSO have been described with either horizontal or  vertical buccal incisions, a direct or transantral approach  to the palate and varying degrees of exposure of the palatal  bone before osteotomy. In 1972, West and Epker provided  an extensive review, emphasizing the versatility of this  procedure.®    As in the AMSO, special attention should be paid during  the whole procedure to the buccal gingiva to maintain ade-  quate blood supply to the fragment. Inadvertent tearing of  the buccal or palatal mucoperiosteal flap may jeopardize  the vitality of the segment.   Typical indications include anterior skeletal open bite  treated by bilateral PMSOs with intrusion of the segments.    Although at currently this deformity is often treated by  a one-piece Le Fort I tilting and intrusion osteotomy,  the indication is still valid, particularly in patients with  a steep sella-nasion-A (SNA) angle, because tilting of the  whole tooth-bearing maxilla tends to cause an obtuse  nasolabial angle.   Extrusion, widening and narrowing of the posterior  arch are also possible with this technique and vertical  movements are often combined with transverse move-  ments. One of the best applications is advancement and  rotation of the lesser segment in unilateral cleft lip and  palate (CLP) patients or the posterior segments in bilateral  CLP patients. The PMSO allows for reconstruction of an  uninterrupted arch form in many of these patients, simul-  taneously with grafting of the alveolar cleft.   In general, elimination of edentulous spaces in the arch  can be achieved by advancing the posterior segment.    A vertical incision is made in the buccal mucoperiosteum  of the interdental area (Figure 71.10) and carried over to  the palatal side. With the alveolus exposed by reflection  of the mucoperiosteum, the bone cut is made with a fine  tapering fissure burr (short Lindemann). Bucally, submu-  coperiosteal tunnelling is carried posteriorly towards the  tuberosity. A flat, malleable retractor is placed under the  buccal pedicle with care taken not to tear off the attached  gingiva. The lateral, horizontal bone cut is made with a  long Lindemann burr in an ‘inside to outside fashion’. It  is first placed into the antrum at the uppermost point of  the vertical osteotomy, approximately 5 mm above the  apices of the posterior teeth (Figure 71.11). This distance    Figure 71.10 Position of buccal and palatal incisions for  posterior segmental osteotomy.    is considered to be safe with regards to the neurovascular  regeneration of the pulp of the teeth involved. The cut can  be completed almost to the tuberosity, the last millimetres  finished with a 4 mm osteotome.   The palatal osteotomy can be performed with a fine  tapering fissure burr or osteotome directly through the pos-  terior palatal mucoperiosteum, without direct exposure of  the bone. The aim is to place the bone cut at the junction of  the alveolus with the horizontal palatal process, above the  root apices and lateral to the greater palatine artery. With a  4mm osteotome angled at 45° to the vertical plane, a series  of punctures into the antrum can be made, after which the  cut is completed with a 10 mm Teflon-handled osteotome.  This way the palatal mucoperiosteum still maintains a  pedicle to the soft palate, which contributes to the blood  supply to the segment (Figure 71.12). The final step is the  posterior osteotomy through the tuberosity region which  is the same as described for the Le Fort I osteotomy.   Mobilization is achieved by rotating the osteotome in  the palatal osteotomy and by forward mobilization with a  curved osteotome in the tuberosity region (Figure 71.13).    Figure 71.11 Bone cut made in a tunnelled fashion  approximately 5 mm above the level of the apices.    Figure 71.12 Palatal bone cut made at the junction of the  alveolar process and the palate. The cut should be made lateral  to the greater palatal foramen. The mucosa in the posterior  palate can be left intact by guiding the osteotome under the  mucosa and completing the bone cut in a tunnelled fashion.    The segment(s) are moved into the desired position and  fixed with the aid of an acrylic, prefabricated splint and  pull wires much the same as described for the AMSO.  Once in position and fixed, a mini- or microplate can be  used to provide additional stabilization (Figure 71.14).  Due to the limited access, usually only one plate on each  side can be placed. The acrylic splint should therefore be  maintained for a period of 6 weeks, but IMF is not neces-  sary. The incisions are closed with 3/0 sutures.    The same considerations are applicable as for the Le Fort I  osteotomy with regards to swelling and possible post-  operative bleeding. There are no special aspects to be con-  sidered apart from occlusal factors.    Figure 71.13 A curved osteotome is used in the tuber-  osity area to mobilize the segment and also to manoeuvre it  forwards.    Figure 71.14 Mini- or microplate can be used to fix the  posterior segment to the remaining maxilla.    The PMSO is extremely suitable for advancing and  rotating the lesser fragment in unilateral CLP patients  or for repositioning both posterior fragments in bilateral  CLP patients. This can be done whilst the cleft is simul-  taneously grafted. For this purpose, an incision is made  around the cleft extended upwards (Figure 71.15). The  soft tissue in the cleft is mobilized and pushed upwards  to form the nasal layer. The vertical incision is used to  reflect the buccal mucoperiosteum, just as described for  the PMSO. The palatal osteotomy is made lateral to the  scar tissue that is usually present in the palatal cleft. After  the tuberosity split, the fragment is mobilized as for a  non-cleft case.   At this stage, the nasal layer is closed after appropri-  ate trimming of the redundant scar tissue. The segment  is then advanced and rotated or brought downwards  as required, and fixed with the use of an acrylic splint  and one four-hole miniplate (Figure 71.16). Once stabi-  lized the narrowed alveolopalatal cleft is grafted with  autogenous corticocancellous bone, and the palatal and  buccal mucosa can be closed with 3/0 sutures because  the advancement has approximated the soft tissues.  This technique usually corrects the paranasal depres-  sion often seen in cleft palate patients and consider-  ably improves the existing asymmetry of the alar base  (Figure 71.17). Long-term follow-up studies have shown  that the technique provides predictable and_ stable  results.    Figure 71.15 Segmental osteotomy of the lesser fragment  in patients with unilateral cleft lip and palate. The major frag-  ment can be mobilized using the Le Fort | technique.    (a) Lesser fragment advanced and fixed in the splint with wires. (b) Alveolopalatal cleft is grafted with particulate  autogenous bone.    Pre-operative (a and c) and post-operative (b and d) situation in patient with left-sided unilateral complete cleft.  Note elimination of edentulous space and alignment of segment. Symmetry of the alar base has been achieved by advancing the  lesser fragment (c and d).    The first description of an anterior subapical mandibular  osteotomy was by Hullihen in 1849.7 However, in 1942,  Hofer made this procedure popular by recommending its  use for dentoalveolar set-back as well as advancement.® In  1959, Kar advocated this osteotomy to treat anterior skel-  etal open bite by interposition of a bone graft taken from  the lower border of the mandibular symphysis.’   Vertical bone cuts are made in the areas designated and  they are connected by a horizontal bone cut. These bone  cuts are made with a tapered fissure burr and, if possible,  carried just through the lingual cortex. The horizontal  bone cut should be at least 5 mm away from the apices  of the roots of the anterior teeth (Figure 71.18). A 4 mm  osteotome may be used to finish the osteotomy. If the  segment is to be brought down, a strip of bone should be  removed so as to allow the segment to fit the new position.  A prefabricated acrylic splint helps to position the segment  correctly in the desired position.    The anterior segment, once manoeuvred into place, is ide-  ally fixed with miniplates. The four-hole plates are bent  to fit the contour and placed in the corners of the box. If  necessary, an additional plate may be placed in the middle  of the horizontal bone cut. If orthodontic treatment is car-  ried out, the wafer does not need to be fixed. Instead, a  rigid orthodontic arch wire should be inserted which will  be sufficient to maintain the position of the front teeth. In  cases where no orthodontic treatment is planned, an arch  bar or acrylic splint fixed to the teeth will be necessary to  maintain the position.    The anterior subapical mandibular osteotomy is, at present,  mainly used to level an extruded anterior dentoalveolar  part. In principle, however, movements in all directions  are possible, including forwards and backwards and even  upwards if the gap is grafted. It is also possible to correct  asymmetries.   Its vascularization is completely dependent on the lin-  gual mucoperiosteum-—muscle pedicle and therefore atten-  tion should be paid during the whole surgery not to tear  this pedicle. This is particularly relevant when relatively  large movements are planned.    Vertical incisions are made in the mucoperiosteum of the  interdental area and these are joined up by a vestibular  incision that is carried out into the buccal vestibule  (Figure 71.19). After subperiosteal dissection, the whole  buccal side of the chin is exposed and the flap pulled down-  wards with a chin retractor as described for the genioplasty.  Vertical bone cuts are made in the areas designated and  they are connected by a horizontal bone cut. These bone  cuts are made with a tapered fissure burr and, if possible,  carried just through the lingual cortex. The horizontal bone  cut should be at least 5 mm away from the apices of the roots  of the anterior teeth. A 4 mm osteotome may be used to fin-  ish the osteotomy. If the segment is to be brought down, a  strip of bone should be removed so as to allow the segment  to fit the new position. A prefabricated acrylic splint helps to  position the segment correctly in the desired position.   The anterior segment, once manoeuvred into place, is  ideally fixed with miniplates. The four-hole plates are  bent to fit the contour and placed in the corners of the    Figure 71.18 Incision in the interdental areas carried out  in the vestibule to approach the anterior subapical area and  bone cuts for the subapical anterior mandibular osteotomy.    Figure 71.19 Fixation of the anterior segment with two  four-hole miniplates.    box (Figure 71.19). If necessary, an additional plate may  be placed in the middle of the horizontal bone cut. If  orthodontic treatment is carried out, the wafer does not  need to be fixed. Instead, a rigid orthodontic arch wire  should be inserted which will be sufficient to maintain the  position of the front teeth. In case no orthodontic treatment  is planned, an arch bar or acrylic splint fixed to the teeth  will be necessary to maintain the position.    In 1959, Kole recommended the use of this osteotomy to  close an anterior open bite whilst the gap was grafted with  bone taken from the lower border. This author advises  strongly against this method because this will most likely  change the contour of the chin in an unacceptable man-  ner. Detachment of the periosteum and muscles and resec-  tion of the rounded inferior fragment will create a square  ‘fleshy chin’ that is aesthetically not pleasing. If this tech-  nique is selected, the interpositional graft should be har-  vested from another location.    This osteotomy does not usually create unforeseeable prob-  lems although, as in genioplasties, severe haemorrhage in  the floor of the mouth may be encountered. This is due  to damage to the vessels located in the genioglossal mus-  cle. Ice packs and positioning of the patient in an upright  position are supportive measures to be taken. Apart from  occlusal factors, no other aspects need be considered.   e It is important to avoid any damage to the periodontal  ligaments of the teeth adjacent to the osteotomy cuts.   e Avery fine osteotome rather than a bur should be used  to complete the bone cuts.    1. Cohn-Stock. Chirurgische immediatregulierung der  Kiefer. V Schr Zahnheilk. 1921 (cited by Wassmund,  1926).   2. Wassmund M. From: Lehrbuch der Praktische  Chirurgie des Mundes und der Kiefer (1939), Vol 1.  Leipzig: Joh Ambrosius Barth; 1926. p. 277.   3. Bell WH, Profit WE and White RP (eds). Surgical  Correction of Dentofacial Deformities, Vol 1.  Philadelphia, PA: WB Saunders; 1980.    4. Schuchardt K. Chirurgie fiir offenen Bisses. In  Bier A, Braun A, Kimmel H (eds.), Chirurgische  Operationslehre, 7. Leipzig: Aufl, band 2; 1954.   6. West RA and Epker BN. Posterior maxillary surgery:  Its place in the treatment of dentofacial deformities.  J Oral Surg. 1972; 30: 562-563.   7. Hullihen SP. Case of elongation of the underjaw and  distortion of the face and neck, caused by burn, suc-  cessfully treated. Am J Dent Sci. 1849; 9: 157.   8. Hofer O. Die operative behandlung der alveo-  lare retraktiones unterkiefers und ihre anwend-  ungsmoglichkeit fir prognathie und mikrogenie.  Zahn-, Mund- u Kieferheilk. 1942; 9: 121-132.   9. Kéle H. Formen des offenen Bisses und ihre chirur-  gische Behandlung. Deutsche Stomatologie. 1959;  9:°753.    Bell WH and Levy BM. Revascularisation and bone healing  after posterior maxillary osteotomy. J Oral Surg. 1971;  29: 313-320.   Erbe M, Stoelinga PJW and Leenen RJ. Long-term results  of segmental repositioning of the maxilla in cleft pal-  ate patients without previously grafted alveolo-palatal  clefts. J Cranio-Maxillofac Surg. 1996; 24: 109-117.   Moloney FB, Stoelinga PJW, Tideman H. The posterior  segmental maxillary osteotomy. Recent application.  Journal of Oral and Maxillofacial Surgery. 1984; 42:  771-781.   Stoelinga PJW, Van de Vyver HRM, Leenen RJ, Blijdorp  PA and Schoenaers JH. The prevention of relapse  after maxillary osteotomies in cleft palate patients.  J Cranio-Maxillofac Surg. 1987; 15: 226-331.   Stoelinga PJW and Hinderks F. The concept of segmental  repositioning of the alveolar arches and simultane-  ous grafting in CLP patients. J Craniomaxillofac Surg.  1992; 21(Suppl. I): 70.   Tideman H, Stoelinga PJW, Gallia L and Le Fort I.  Advancement with segmental palatal osteotomies  in patients with cleft palates. J Oral Surg. 1980; 38:  196-199.    Orthognathic mandibular surgical techniques are used  mainly to correct mandibular prognathism and retrogna-  thia. In addition, lower facial asymmetries, anterior open  bites and post-traumatic malocclusions can be rectified.  They can be used alone as single-jaw procedures or in combi-  nation with midface procedures as a bimaxillary procedure.   They are widely used for the correction of dentofacial  deformities and indications include malocclusions caus-  ing masticatory difficulties, temporomandibular dysfunc-  tion, sleep apnoea and unaesthetic appearance with its  attendant psychosocial effects.   Orthodontic preparation for surgery is usually required  to align, decompensate and coordinate the dental arches.  Ideally, treatment planning should be performed jointly  between the surgeon and orthodontist to clearly identify  treatment goals. Orthodontic preparation time varies but  usually requires approximately one year of fixed appliance  therapy. Post-surgical orthodontic detailing normally  takes about 6 months.   The most frequently used mandibular techniques are  the bilateral sagittal split osteotomy (BSSO) and the hori-  zontal genioplasty. Other techniques, such as the vertical  subsigmoid, inverted-L and C-osteotomies, although they  still have some adherents, are infrequently indicated and  relatively rarely performed.    The BSSO was first described in 1957 by Trauner and  Obwegeser and subsequently modified by DalPont,  Hunsuck and Epker.'*    Its main advantage is its versatility. Mandibular  advancement, setback and rotation can all be achieved.  An anterior open bite can be corrected by anticlockwise  rotation. It is carried out by an intraoral approach avoid-  ing external scarring. Direct fixation of the osteotomy  sites by miniplate or bicortical screw osteosynthesis is eas-  ily achieved, thereby negating the need for post-operative  intermaxillary fixation with its associated safety and  patient comfort implications.   Major complications are rare. Excessive haemorrhage  is uncommon, although the facial vessels are at risk when  making the buccal bone cut unless adequately protected  by a retractor. There is a risk of distraction of the condyle  when advancement of the mandible is carried out with  consequent incorrect occlusion which may only be rec-  ognized post-operatively, necessitating an early return to  the operating theatre for revision. The most frequent com-  plication and major risk of the BSSO, however, is damage  to the inferior dental nerve. Reported incidences vary,  but it is common in the immediate post-operative period.  Permanent anaesthesia is rare, however, with recovery usu-  ally occurring over a period of weeks or months. Finally,  unfavourable fracture at the osteotomy site can result in  a ‘bad split’. This is largely technique dependent. Ideally,  lower third molars should be removed at least 6 months  before surgery to minimize the risk of this occurring.    The incision is made down the external oblique ridge  down the lateral mandibular ridge and deepened down    to bone using cutting diathermy (Figures 72.1 and 72.2).  Subperiosteal dissection is carried out on the buccal sur-  face of the mandible inferiorly to the antegonial notch. It is  not necessary to raise the periosteum over the angle of the  mandible. The lingual surface of the ramus of the mandible  is then approached by elevating periosteum over the ante-  rior surface of the ramus towards the coronoid process for  approximately 2 cm above the occlusal plane. Retraction  of mucosa is achieved using either a forked retractor or by  clamping the anterior surface of the coronoid process by  using a curved Kochers clamp. The lingual surface of the  ramus is now exposed by introducing a periosteal elevator  above the level of the mandibular foramen and progress-  ing inferiorly (Figure 72.3). Usually, the lingula can be eas-  ily identified and the periosteal elevator can be positioned  immediately above the lingula and used as a retractor pro-  tecting the inferior dental nerve.    The lingual cut is made using a Lindeman bur as far  posteriorly as the lingula and deepened into cancellous  bone (Figure 72.4). Care must be taken to ensure that it is    Figure 72.3 Periosteal elevator being used to expose the  lingual aspect of the ramus.    sufficiently deep posteriorly. The Kocher and lingual retrac-  tor are then removed and a buccal channel retractor inserted.   The buccal bone cut is again carried out using a  Lindeman bur and extends from the lower border of the  mandible to the lateral mandibular ridge. It extends into  cancellous bone. Care must be taken to ensure that the cut  extends through the lower border of the mandible as far  lingually as possible (Figure 72.5).   The Kocher and lingual retractors are then again  inserted, and the joining cut linking the lingual and buc-  cal cuts is performed at the junction between the buccal  cortical plate and cancellous bone (Figure 72.6).    The split  A controlled split is carried out. This is commenced  using a curved osteotome placed at the junction of the  lingual and connecting cuts and tapped through poste-  riorly so that the superior end of the split line is initiated  in a downwards direction from above the lingual  (Figure 72.7).   An osteotome is then inserted at the junction of the buc-  cal and connecting cuts and the buccal plate is gradually    Figure 72.5 Buccal cut being extended down to the lower  border of the mandible.    Figure 72.7 The lingual split is being developed using a  curved osteotome.    Figure 72.8 The buccal plate is being prized laterally with  an osteotome.    prised laterally (Figure 72.8). The same osteotome can be  used to separate the buccal cortical plate from the cancel-  lous bone. Once the lower border of the mandible can be  seen, the osteotomy line can be propagated posteriorly  using an osteotome and Smith’s spreader to join the lin-  gual cut and complete the split.   The inferior dental nerve is usually easily identified dur-  ing the split and can be protected (Figure 72.9). However,  it can remain completely contained within the distal frag-  ment in which case it is not visualized. If it crosses from  the lingual to the buccal side, it may be partly or com-  pletely within the bone of the proximal segment. In this  circumstance, it must be carefully freed from the sur-  rounding bone using a fine osteotome.    After completion of the BSSO, the patient is placed into  intermaxillary fixation. Usually, a prefabricated splint is  used to locate the correct occlusion.    Fixation of the osteotomy sites can be achieved using  either a single buccal miniplate or bicortical screws placed  transbuccally (Figure 72.10). Control of the proximal frag-  ment is crucial. The mandibular condyle must be seated  in the glenoid fossa and not distracted downwards or for-  wards. This is largely a matter of feel. The proximal seg-  ment is pushed posteriorly and upwards using a curved  osteotome (Figure 72.11).    The intermaxillary fixation is released, the splintremoved  and occlusion checked (Figure 72.12). The intraoral  incisions are sutured and the cheek incisions are Steri-  stripped.    The osteotomy sites can be fixed with either plates or  bicortical screws (Figure 72.13). These can be either tita-  nium or resorbable. In the event of a ‘bad split’, i.e. lingual  (Figure 72.14) or buccal (Figure 72.15) cortical plate frac-  ture, a combination can be used.    This was first described in 1958 by Obwegeser.°  Horizontal osteotomy of the anterior mandible allows    Figure 72.12 The intermaxillary fixation has been released  in order to check the occlusion.    Figure 72.10 The osteotomy has been immobilized with  three bicortical screws.    Figure 72.11 Whilst the transbuccal holes are being  drilled, the proximal segment is pushed posteriorly with a  curved osteotome.    Figure 72.13 The ideal position of the holes when bicorti-  cal screws are used for immobilization.    Figure 72.16 A sulcus incision is used to expose the  anterior surface of the mandible.    the chin to be repositioned in three dimensions. It can  be advanced or set back to correct retro- or progenia. The  lower face height can be either decreased or increased by  excising bone or downgrafting the chin. Finally, rota-  tional osteotomy can be performed to correct a lower  facial asymmetry.    If combined with a sagittal split osteotomy, the genioplasty  is performed after the BSSO. It is easier if the patient is left in  intermaxillary fixation whilst the genioplasty is carried out.    Using cutting diathermy, an incision is made in the lower  lip approximately 5 mm above the reflection of the lower  labial sulcus and deepened to the anterior surface of the  mandible (Figure 72.16). The mentalis muscles are tran-  sected in the process. Subperiosteal dissection is carried  out towards the chin prominence. However, it is not nec-  essary to deglove the chin. Extending laterally, the mental  nerve is identified (Figure 72.17).    A reference cut is first made in the line of the mandibular  symphysis to mark the midline (Figure 72.18).   An Aufricht retractor is introduced into the lateral  extent of the subperiosteal pocket on first one side and then  the other below the mental foramen whilst the horizon-  tal osteotomy is performed. The mental nerve is directly  visualized and protected. The osteotomy can be completed  laterally using an osteotome (Figure 72.19). Having com-  pleted the bone cut on the first side, the saw is reversed and  the cut extended on the contralateral side to complete the  osteotomy (Figure 72.20).    The chin is mobilized into the planned position and fixed  using either plates or screws. The author uses screws when  possible (Figures 72.20 through 72.22). When the chin is  advanced, it is held in the planned position using a Kocher  clamp. It is often easier to use plates to fix the osteotomy in  this situation, particularly when the symphysis thickness  is narrow.    Figure 72.18 A small bone screw is used to mark the  midline.    Figure 72.19 The horizontal osteotomy is being done  with a reciprocating saw.    Figure 72.22 A bone plate may be used to immobilize  the segment if there is not good bone contact.    repaired. The mucosa is closed using resorbable, continu-  ous sutures. A pressure dressing is applied.    Ensure optimal operating conditions. Use a headlight  and ask for hypotensive anaesthesia.   Keep it simple. Avoid difficult and unusual procedures.  The sagittal split osteotomy is uniquely versatile and,  once mastered, is easy to perform and predictable. It is  easily combined with a genioplasty.   Perform a controlled split from anterior to posterior.  Visualize the inferior dental nerve early and protect it.  Use rigid fixation with either bicortical screws or a plate  fixation.    Figure 72.21 The mobilized segment is being held with  a Kocher clamp whilst a screw is being inserted to immobilize  the osteotomy.    Trauner R and Obwegeser H. The surgical correction  of mandibular prognathism with consideration of  genioplasty 1 and 11. Oral Surg. 1957; 10: 677-689,  787-792.    Le Fort I osteotomy  Osteotomies above the Le Fort I level  Suggested readings    One of the cornerstones of planning for a maxillary  osteotomy is to understand the position of the  upper central incisors as they relate to the upper lip  and the face. For this evaluation to be dependable,  the central incisors must have the correct location  and inclination inside the alveolar process. If at the  time of evaluation the incisors are in an abnormal  position, appropriate adjustments must be incorpo-  rated in the assessment.    Assess relationship between the upper central  incisors to the upper lip. The incisor show is about  2-3 mm in repose; it is normal to show 1-2 mm  above the gingivocervical margin when smiling.  Since this measurement depends on a normal  upper lip length, variation in the length and shape  of the upper lip may have significant impact on    this measurement. For instance, if the upper lip is  abnormally short (males normal values 22 + 2 mm,  females 20 + 2 mm) the upper incisors should not  be moved to accommodate an abnormally short lip.  Failure to take that into consideration may lead to  imbalance of the facial structures (Figure 73.1).  Assess facial thirds which are equal when measured  from hairline to glabella, glabella to subnasale and  subnasale to soft-tissue menton (Figure 73.2).   Observe the midpoint of the facial surface of the  clinical crown of the central incisor as it relates to  the forehead in profile, while smiling as described  by Andrews. In a well-balanced face, this point does  not project beyond glabella. The relationship is uni-  versal and is consistent across age, gender and racial  groups (Figure 73.3).   Sella-nasion-A (SNA) point angle (82°). For this  angle to be useful, the inclination of the SN to the  Frankfort horizontal should be adjusted to about 7°  (Figure 73.4).    © Midline position of the maxilla: The midline between the  maxillary central incisors should relate to the lower cen-  tral incisors, the philtrum, the chin, the nose and the  forehead. Photographs, pencilled in line, a string applied  to the face all help determine ifan asymmetry is present.   © Maxillary Cant: Measure the distance between the  medial canthal ligament, to the incisive edge of the  central and lateral incisors, and canine on one side and  compare it to the other side (Figure 73.6).    752 Orthognathic surgery - maxilla (Le Fort |, Il and III)    © Occlusal plane inclination: The inclination of the occlu-  sal plane has an impact on the aesthetics of the smile,  the position of the chin, and the airways. Utilizing  the cephalometric measurements, the occlusal plane  is typically close to 8° from Frankfort Horizontal  (Figure 73.7).    Traditionally, in planning for orthognathic surgery, we  depended on clinical examination which may not have  always portrayed the true facial deformity of the patient.  The ability to obtain three-dimensional (3D) reconstructed  data from computerized tomography of the facial skeleton    Figure 73.3 Anterior-posterior position of maxilla using  relationship of upper central incisor to forehead.    and merge it with the occlusal anatomy of the teeth from  dental casts has created a new paradigm shift in the way  we plan for orthognathic surgery. This computer-assisted  surgical simulation is useful in improving the determina-  tion of the midline, the maxillary cant and the inclination  of the occlusal plane. It is particularly relevant in recogniz-  ing and correcting yaw deformities which would not have  been otherwise recognized clinically.    @ Anaesthesia is accomplished with a nasotracheal tube  well secured to the forehead.   @ About 10 mL of 0.5% Lidocaine with vasoconstrictor is  injected in the buccal vestibule for haemostasis.   e Hypotensive anaesthesia, particularly at the time  of down-fracture, reduces oozing and improves  visibility.   e A non-threaded Kirschner wire is placed in the bridge  of the nose to be used as an external reference marker.  Distances from the wire to the central incisors are  recorded (Figure 73.8).    @ Place a circumvestibular incision, using a blade or elec-  trocautery, in the buccal vestibule from molar to molar  (Figure 73.9). The use of the electrocautery should be lim-  ited; orthodontic forces sometimes bring the apices of the  teeth close to the surface outside the bone putting them  at risk of thermal injury. Additionally, the use of electro-  cautery in the anterior region risks the formation of wide  scar band and possible shortening of the upper lip.   e Expose the piriform aperture, the infraorbital nerves  and the zygomatic buttresses.   e Expose the posterior maxilla by subperiosteal tunnel-  ling to the junction of the maxillary tuberosity with  pterygoid plates (Figure 73.8).    754 Orthognathic surgery — maxilla (Le Fort I, Il and III)    © Reflect mucoperiosteum of the floor of the nose, start-  ing with a small Molt curette and then with an angled  Freer elevator. Bothersome oozing can be minimized  with the use of strips of ribbon gauze impregnated with  a vasoconstrictor.   The lateral bony osteotomy is done in a straight line  or in the form of a step. The straight line runs from  the pterygomaxillary suture posteriorly to the lat-  eral nasal aperture anteriorly. The osteotomy should  be placed below the zygomatic buttress and 4-5 mm  above the apices of the maxillary teeth. When a step  design is selected the anterior limb of the step is kept  horizontal. The step, 4-5 mm in length, is placed in  the zygomatic buttress region. The benefit of the step  is in reducing the risk of shortening the face as the    maxilla is advanced horizontally forwards rather than  on aramp. The osteotomy can be performed with burs  or reciprocating saw. Visibility is improved by start-  ing the osteotomy posteriorly and moving forwards  (Figure 73.10).   Score the posterior wall of the maxillary antrum, with-  out going through it, with a thin spatula osteotome  introduced through the lateral osteotomy and directed  in a downwards direction.   Separate the nasal septum with the double beaded  osteotome directed downwards and_ backwards  (Figure 73.11).   Separate the maxilla from the pterygoid plates with a  small curved osteotome placed at, or just behind, the  tuberosity, as perpendicular as possible, and driven in  a downward and medial direction. The operator's index  finger is placed inside the mouth on the palatal side of  the tuberosity to verify the position and direction of the  osteotome (Figure 73.12).    Figure 73.9 Soft tissue incision in buccal vestibule about  1 cm above the junction of mobile and fixed mucosa. The inci-  sion is curved slightly cranially in the posterior region.    Figure 73.11 Septal osteotome is used to separate the  nasal septum from the maxilla. Note the blunt end of this  instrument which avoids tearing the nasal mucosa.    Figure 73.10 Outline of Le Fort 1 osteotomy. through the tuberosity in a downward and medial direction.    ® While protecting the nasal mucosa with a periosteal  elevator, cut the lateral nasal wall with a thin spatula  osteotome placed anteriorly in the nasal aperture and  directed in a posterior and downward direction to  about 30 mm without reaching the descending pala-  tine vessels. This step is repeated with increasingly  thicker osteotomes, slowly wedging the maxilla down  (Figure 73.13).   Down-fracture the maxilla with light digital pressure, if  resistance is encountered, repeat use of the osteotome.  Down-fractured maxillas that have pterygoid plates  attached to the tuberosity have markedly restricted move-  ments. The descending palatine vessels can be safely coag-  ulated. If indicated, impacted maxillary third molars can  be removed at this stage. With the maxilla in the down-  fractured position, the third molar can be elevated after    removing the thin buccal bony cover with an osteotome  or a Coupland chisel. Erupted third molars should be  removed prior to the down-fracture of the maxilla or pref-  erably 4 weeks prior to surgery (Figure 73.14).   Mobilize the maxilla with spreaders, Seldon elevators,  curved osteotomes and Tessier mobilizers in addition  to digital manipulation. The use of Rowe's disimpac-  tion forceps may damage the palatal mucosa and its use  should be limited. Once the desired mobility is accom-  plished, the maxillary and mandibular teeth are wired  together with or without a wafer splint. With the max-  illa and mandible attached together and the condyles  properly seated in the glenoid fossas, the complex is  passively closed to the desired vertical dimension using  the external reference point (Figure 73.15).   Reduce the nasal septum enough to prevent buckling.  Deep bony structures are trimmed to allow free move-  ments without interferences. To avoid excessive bone  trimming, the lateral wall of the maxilla is reduced  under direct vision, trimming only the bony spots that  are preventing the planned movement.   When posterior maxillary expansion is needed,  paramedian osteotomies on the nasal side of the hard  palate are done while the maxilla is in the down-  fractured position. The osteotomies are placed about  6-7 mm from either side of the midline and extend for-  wards to meet just behind the opening of the incisive  canal. From this point, the bony osteotomy is extended  forwards in the midline of the maxilla and advanced  between the roots of upper central incisors. The papilla  between the incisors is kept mostly undisturbed but the  soft tissues above it are gently freed from the bone to  finish the osteotomy cut between the teeth. Once all  the cuts are done, the segments are gently mobilized by  an osteotome and slowly stretched to reach the desired  movement. The osteotomy can be accomplished with a  fine bur, a slim saw, or a piezoelectric cutting instru-    Figure 73.13 The lateral nasal wall is cut with an ostotome ment. It is very important to avoid the perforation of    with a blunt end so as not to damage the nasal mucosa.    Figure 73.14 Down-fractured maxilla. vator are used to mobilize the maxilla and move it forward.    756 Orthognathic surgery - maxilla (Le Fort |, Il and Ill)    the palatal mucosa and the damage to the buccal papilla  (Figure 73.16).   ®@ When the maxilla needs to be separated into three  pieces, similar cuts are performed in the back of the  hard palate and then, in addition to connecting to oste-  otomies across the midline of the hard palate, the cuts  are extended laterally to finish, most often, between  the upper canines and the lateral incisors on each side.  To avoid damage to the teeth adjacent to the planned  osteotomies, it is necessary to have the roots orthodon-  tically diverged prior to surgery. It is not necessary to  have a diastema between the crowns.   ® Patients undergoing maxillary impaction may require  the removal of bone from the floor of the nose equivalent  to the desired impaction of the maxilla. Additionally,  patients undergoing maxillary impaction may require  the removal of the inferior turbinates to provide needed  space and to reduce nasal airway obstruction. With the  maxilla in the down-fracture position, the nasal mucosa  is incised lengthwise on both sides and the inferior tur-  binates are resected with scissors and electrocautery.  The nasal mucosa is then closed with 4-0 chromic gut  sutures.   ® Fixation of the maxilla is ideally done with two plates  and screws on each side - one in the piriform rim area  and a second one in the malar buttress region. The  maxilla, still attached to the mandible, is brought pas-  sively and without any interferences to its final position  using the mandibular condyle as a guide. It is critical to  have the condyle properly seated in the glenoid fossa.  This step begins prior to surgery, by understanding  the patient's specific occlusion and centric relation. If  interim splints are used they must be accurate, other-  wise a cant or side to side movements of the maxilla may  occur. The anterior plates are placed first; constantly  referring to the external reference point to avoid inad-  vertent shortening or lengthening the midface. Plate    Figure 73.16 For small maxillary expansion, osteotomes  are used for opening the midline sutures to expand the maxilla  posteriorly.   ® Verify accuracy of the fixation. This can be done by  manually maintaining the mandible in occlusion while  the IMF wires are removed. Observing any shift of  occlusion while the teeth are slowly released is helpful  in recognizing an error in fixation. Malocclusion that is  secondary to inaccurate plating needs to be addressed  at this stage.   @ Alar cinch suture is often needed to prevent alar flare  that occurs as the result of the maxillary surgery. Evert  the lip and grasp the fibrous tissue located immediately  below the alar cartilage. Pass a 0 Vicryl or similar suture  through the tissue and visualize the pulling effect on  the alar region to assure proper placement of the suture.  Repeat this step on the opposite side. The suture is tied  to the desired tension in the midline (Figure 73.18).    Figure 73.17 Two small plates, in the piriform rim and  zygomatic buttress, are used to fix the maxilla.    e V-Y closure of the anterior wound can affect the protru-  sion of the upper lip and preserve its length. The rest  of the maxillary incision is closed in one layer, which  should include mucosa and muscle, with running 3-0  Vicryl suture (Figure 73.19).   © Light elastics may be applied between the maxillary and  mandibular teeth.    © Obtain cephalometric radiographs to verify the planned  movement and to monitor any future relapse.   @ Check the occlusion; minor occlusal interdigitation  problems are corrected with light elastics. More signifi-  cant midline or AP discrepancies may require a return  to the operating room for correction.   ® Orthodontic tooth movement can be started as early as  4-6 weeks post-surgery.    Also known as quadrangular Le Fort I. It is similar to the  standard Le Fort I except that it extends higher on the  anterior wall of the maxilla and the body of the zygoma.   ©@ Identical to Le Fort I approach except for the osteotomy  on the lateral wall of the maxilla (Figure 73.20).   © Start bony cuts low at the lateral wall of the nose.   © Continue laterally, below the infraorbital rim, skirting  around the infraorbital foramen, to the zygomatic body.   © Down-fracture the maxilla with attention not to break  the thin lateral maxillary wall.   @ Fixation with miniplates and screws and bone graft as  needed.    Adult patients with nasomaxillary hypoplasia to  accomplish mostly advancement and some downward  movements.    Operation  ® Intraoral circumvestibular incision from molar to molar  © Bilateral oblique paranasal skin incisions or coronal flap  © Bony outline  e Horizontal line across the nasofrontal and naso-  maxillary sutures.  e Extend vertically downwards through the lacrimal  bone, keeping the canthal ligaments intact.  e Continue posterior to the lacrimal apparatus to  cross the medial aspect of the infraorbital rim.  e Continue from the intraoral side, in a downward  and lateral direction to finish in the pterygomaxil-  lary fissure (Figure 73.21).  e Separate the nasal septum from the base of the skull  with an osteotome starting at the level of the bridge    758 Orthognathic surgery - maxilla (Le Fort |, Il and III)    of nose and sloping in a posterior and inferior  direction. Pre-operative computed tomography  (CT) scan can help assess the midline structures  and their proximity to the proposed septal osteot-  omy (Figure 73.22).    © Fixation is with miniplates and screws with bone grafts  placed primarily in the bridge of the nose and other  areas as needed.   Follows similar outline to the high Le Fort I osteotomy  with the exception of including the infraorbital rims. The  infraorbital nerve is overly manipulated in this osteotomy  increasing the risk of long-term injury (Figure 73.23).   Maxillary and zygomatic deficiencies in patients that have  scleral show and normal nasal projection. The movements  are mostly advancement. Often, aesthetic and functional  movements needed at the tooth level differ from what is  needed at the infraorbital rim level.    ® The entire osteotomy can be accomplished from an  intraoral circumvestibular incision; the orbital floor  is cut with osteotomes introduced from either side of  the osteotomized infraorbital rims. If unfeasible, addi-  tional skin or transconjunctival access is performed.    Le Fort Ill osteotomies, transcranial  frontofacial osteotomies, monobloc or  sagittal bipartition    Correction of concurrent nasal, orbital, zygomatic  and maxillary deficiencies in mostly syndromic or    post-traumatic patients. Abnormalities in the shape of the  forehead will affect the selection between a transcranial  approach and a subcranial Le Fort III osteotomy.   Timing of surgery is selected ona case-by-case basis with  early intervention often influenced by severe proptosis,  sleep apnoea, and need to improve the child's appearance  around school age. It is important to take into account that  early intervention will result in restrictive growth on the  facial skeleton, and even with overcorrection, repeat sur-  gery, once the growth is completed, may be indicated.   ® Coronal flaps; additional access to the orbital floor may  require lower cutaneous eyelid incision or a transcon-  junctival approach.   e Extends to the floor of the orbit and the infraorbital  fissure.   e Continues behind the nasolachrymal apparatus  onto the medial wall of the orbit to the bridge of  the nose.   e ‘The nasal septum is separated from the base of skull  as described for Le Fort II osteotomy.   e The pterygoid plates are separated from the  tuberosity with an osteotome introduced either  from the coronal flap approach or through a small  intraoral incision in the tuberosity region.   e Concurrent midfacial and supraorbital rim defi-  ciencies require a transcranial approach whereby  the supraorbital rims and the midface are advanced  as a single unit ‘monobloc’. The outline for this oste-  otomy differs from that of the Le Fort III procedure  in that the superior cuts run across the anterior cra-  nial fossa to include the entire orbital rim.   e Patients with associated hypertelorism and palatal  constriction can, in addition, have ‘facial biparti-  tion’. The face is divided in the central area down to  the hard palate and a predetermined column of bone  is removed. As the two halves are brought together,  the hypertelorism, as well as the palatal constriction  are corrected and the face is advanced as single unit.   e Mobilize with spreaders, Rowe's disimpaction  forceps and Tessier mobilizers, avoiding unplanned  fractures which are common in the infraorbital rim  and the palate.   e Preserve medial canthal attachment whenever pos-  sible. Should there be need to detach it, appropriate  canthopexy is done at the conclusion of surgery.   e Mobilize the face to the planed position and tempo-  rarily wire together the maxillary and mandibular  teeth.    e Blocks of autogenous bone graft, calvarial, rib or  iliac crest, are placed primarily in the areas of the  zygomatic arch, lateral orbit wall and nasal bridge.   e Use miniplates and screws to stabilize the osteot-  omy and the grafted bone. Concerns of migration  of metal plates and restriction of growth make a  strong case for the use of biodegradable plates and  screws in children.   e Decision to release of the intermaxillary fixation  depends on the stability of the osteotomy.   e Dental arch discrepancies may require an addi-  tional Le Fort I osteotomy. Although this proce-  dure can be done concurrently with the midface  advancement, it is preferable to do it separately at  a later date.    e Meticulous planning entails placing the upper central  incisors in an ideal vertical and AP position, in addition  to having the occlusal plane levelled in the proper  inclination.   e External reference point is essential in placing the  maxilla in the desired position.   e Proper seating of the condyles in the fossa while fixing  the maxilla.   e Plate bending should be accurate; minor imperfections  lead to malocclusion.    Frost DE. Orthognathic surgical techniques. In Ward  Booth P, Schendel SA and Hausamen JE (eds.),  Maxillofacial Surgery. St. Louis, MO: Churchill  Livingstone Elsevier; 2007. pp. 1224-1246.   Perciaccante VJ and Bays RA. Maxillary orthognathic  surgery. In Miloro M (ed.), Peterson's Principles of  Oral and Maxillofacial Surgery. Hamilton, London:  BC Decker; 2004. pp. 1179-1204.   Posnick JC and MuhlingJ. Surgical treatment of craniofacial  dysostosis syndrome and single-suture craniosynos-  tosis. In Ward Booth P. Schendel SA and Hausamen JE  (eds.), Maxillofacial Surgery. St. Louis, MO: Churchill  Livingstone Elsevier; 2007, pp. 876-900.   Schlosser JB, Preston CB, and Lampasso J. The effect of  computer aided anteroposterior maxillary incisor  movement on ratings of facial attractiveness. Am J of  Orthod Dentofacial Orthop. 2005; 127: 17-24.   Wolford LM and Fields RT, Jr. Diagnosis and treatment  planning for orthognathic surgery. In Betts NJ and  Turvey RA (eds.), Fonseca, Oral and Maxillofacial  Surgery, Orthognathic Surgery, Vol. 2. Philadelphia,  PA: W.B. Saunders; 2000. pp. 24-55.   Operative technique for intraoral distraction device placement  Operative technique for extraoral distraction device placement  Post-operative care    Distraction osteogenesis (DO) is a powerful technique  utilized to gradually lengthen the mandible significant  distances. DO creates new bone without the need for bone  grafting and donor site morbidly. The distraction tech-  nique requires proper understanding and application of  the biologic principles of DO that are age appropriate and  anatomically sound. DO has a wide range of applications  (Table 74.1) and requires selection of an appropriate intra-  oral or extraoral distraction device.    A thorough history and clinical examination is appro-  priate with utilization of diagnostic imaging; including  panoramic, posterior-anterior and lateral cephalomet-  ric radiographs. Computed tomography (CT) scans with  three-dimensional (3D) reconstructions of the man-  dible and temporomandibular joint are helpful. Dental  study models mounted on a semi-adjustable articulator  with prediction model surgery are of benefit. In selected  instances, stereo lithographic models may aid in treat-  ment planning. Standardized 3D cephalometric predic-  tion tracings are appropriate. All clinical and diagnostic   2. Craniofacial syndromes: Hemifacial micosomia, Treacher  Collins syndrome, Nager syndrome, Pierre Robin  sequence   7. Mandibular retrognathia with temporomandibular joint  disease or juvenile rheumatoid arthritis    tools are utilized to plan out the proper 3D distraction  vector selection.   DO device selection is based on available bone stock,  ease of application, distance of DO and ability to adjust the  distraction vector post device placement. It is the author’s  preference to utilize an intraoral device (Tables 74.2 and  74.3) although extraoral devices, in selected instances,  have advantages (Tables 74.4 and 74.5).    Standard pre-operative medical evaluation, diagnos-  tic tests and anaesthesia consultation regarding the  patient’s airway are appropriate. Many of the patients  undergoing mandibular lengthening by DO have severe    1. Allows bidirectional and tridirectional mandibular  lengthening of 10-30 mm and avoids intermaxillary  fixation   2. Avoids external skin scars of distraction, pin loosening or  pin tract infection   3. Allows longer consolidation times with minimal to no  skeletal relapse after extreme mandibular lengthening   4. Can be applied to neonates, infants, paediatric and adult  patients   5. Avoids more invasive bone grafting procedures and  potential donor site morbidity   8. Decreased length of hospital stay and cost compared  with bone grafting with less chance of blood transfusion    1. Applicable to small mandibles in infants and small  children due to less available bone stock   2. Extraoral device results in less disruption to periosteum  and blood supply   4. Offers the potential for three-dimensional vector  adjustments after device placement. Adjustments can be  made in the horizontal vertical and transverse planes    mandibular retrognathia with significantly compro-  mised airways. Pre-operative polysomnography is a  strong consideration in patients with suspected obstruc-  tive sleep apnoea. An awake fibre-optic nasoendo-  tracheal intubation of the trachea may frequently be  required. Distraction procedures for lengthening of the  mandible are more commonly carried out under general  anaesthesia although in selected cases sedation and local  anaesthesia has been used.    The patient is placed in a supine position with appropriate  head support and is prepped and draped in the normal  fashion for an oral and maxillofacial surgical procedure.  The author prefers appropriate intravenous antibiotic  prophylaxis. After establishing general anaesthesia, pref-  erably by nasoendotracheal methods, local anaesthesia  (typically 2% lidocaine with 1/1,00,000 epinephrine or  0.5% bupivacaine with 1/2,00,000 epinephrine) is infil-  trated throughout the planned area of incisions. Care is  taken to avoid toxic local anaesthetic dosages, particu-  larly in infants and children. A bite block is placed on  the contralateral side to open the mandible and bring the  ramus forwards. An incision is made over the external  oblique ridge a distance of 2-3 cm. The length of incision  is based on the length of osteotomy and degree of surgical  access. A sharp dissection is carried out through buccina-  tor muscle down to the external oblique ridge. The sub-  periosteal dissection is carried out exposing the anterior  aspect of the ramus of the mandible to the level of the  insertion of the temporalis muscle and a notched ramus  retractor is used to retract tissues. The subperiosteal dis-  section is carried out down to the angle of the mandible  and the antegonial notch region, stripping off the mas-  seter muscle. The dissection is carried out anteriorly to  an extent that is required for placement of the distraction  device. Care is taken to identify the mental nerve, partic-  ularly in infants and children. A careful superior medial  subperiosteal dissection is carried out at the body ramus  junction in preparation for the osteotomy cut and to pro-  tect the lingual nerve.   The planned osteotomy is a linear osteotomy at the  body ramus junction, distal to the second molar and is  placed in an oblique angle (it is helpful to remove the  third molar if present some 3-6 months predistraction).  The superior and inferior aspect of the osteotomy is  located and marked with a 701 burr. The lateral cortex  osteotomy is completed with the 701 burr or reciprocat-  ing saw. Appropriate pre-operative diagnostic imaging  will help to identify the position of the inferior alveolar  neurovascular bundle. The inferior border osteotomy is  made in a through-and-through fashion to the medial  aspect of the mandible with a channel retractor in place  to avoid the facial artery and vein. Care is taken to  ensure that this cut does not encroach upon the inferior    alveolar neurovascular bundle. The superior aspect of  the osteotomy cut is not completed at this time.   Prior to placing the sterile distraction device  (Figure 74.1), it is important to open and close the device  to ensure all components are functional and then the  device is typically placed at the zero position. The intra-  oral distraction device is contoured with plate bending  pliers to lie passively on the lateral aspect of the man-  dible. It is particularly important to ensure the correct  distraction vector in three planes of space, which is more  frequently parallel to the occlusal and sagittal planes  rather than parallel to the inferior border of the mandi-  ble (Figure 74.2a-e). It is helpful during this stage of the  operation to have the mouth closed by a surgical assistant.  Screw holes are drilled, one anteriorly and one posteri-  orly, and screws (preferably 2.0 mm) are utilized to secure  the device. If access is difficult posteriorly, a 5 mm percu-  taneous stab incision can be utilized for introduction of a  trocar through which drilling and screw placement can  occur. It is advisable to place three to four screws per bony  segment a minimum of 5 mm away from the edge of the  osteotomy. The length of screws is dependent on the posi-  tion of important structures such as the inferior alveolar  neurovascular bundle, teeth roots and developing tooth  buds in infants and children. The DO device is typically  secured with a combination of monocortical and bicorti-  cal screws.   After the distraction device is secured, and with ade-  quate soft-tissue retraction with a seldin retractor on the  medial aspect of the mandible, the superior aspect of the  body ramus osteotomy is now completed utilizing a 701  burr and reciprocating saw leaving a small area of bone  around the lingual aspect of the inferior neurovascular  bundle. Initially, a wedging osteotome is tapped into place  superiorly above the inferior alveolar nerve, and utilizing a  torquing motion a fracture is created through the remain-  ing portion of the mandible. At this stage, it is important  to open the distraction device and see that the bony seg-  ments move freely and also to inspect the inferior alveolar  neurovascular bundle. If there is difficulty in separating    Figure 74.1 Left and right bidirectional telescopic man-  dibular distractor (Innova Life Sciences Corporation, Toronto,  Canada).    the bony segments, the distraction device may be removed,  the osteotomy completed and device reapplied.   Placement of the distraction activation arms is under-  taken prior to closure. The activation arm can emerge    Figure 74.2 (a) An incision is made through mucosa down  through buccinator muscle over the external oblique ridge.  The distance is 2-3 cm based on planned surgical access and  distraction device size. (b) The bidirectional telescopic mandibular  distractor is contoured and secured on the lateral aspect of the  mandible after partial completion of the osteotomy at the body  ramus junction. (c) The bidirectional telescopic mandibular  distractor distracter has been secured with monocortical and  bicortical screws and the osteotomy is completed. (Continued)    Figure 74.2. (Continued) (d) The activation arm can be placed such as it emerges transmucosally or percutaneously depending on  the size of the mandible and surgical access. (e) The distraction device is activated to ensure complete movement of both segments of  the mandible and the inspection of the inferior alveolar neurovascular vascular bundle.    transmucosally or percutaneously depending on the size of  the mandible or surgical access. If it is elected to have the  activation arm exit percutaneously, a small incision is made  in the symphysis region of the mandible approximately to  the level of the inferior border. It is important that there  is no soft-tissue drag on the exiting area of the activation  arm. Copious irrigation is carried out and after haemosta-  sis is achieved, the mucosa is closed with a combination  of horizontal mattress sutures with 3/0 or 4/0 Vicryl, and  a running 4/0 chromic gut for water-tight closure. Most  cases require bilateral application of distraction devices.  Occasionally, unilateral distraction may be undertaken in  younger patients.    The external distraction device can be placed through an  external percutaneous submandibular approach or by a  combination of intraoral and extraoral approaches.    Anintraoralapproachas described previously is undertaken  and the osteotomy is partially completed. Percutaneous  incisions (1-1.5 cm) are placed in the submandibular area  close to the planned area of pin placement. The pins are  best placed approximately 6-8 mm away from the distrac-  tion osteotomy site and should be 4 mm apart depending  on the distraction device (Figure 74.3a-d). Pinhole sites  will determine the initial vector of distraction and should  be placed in locations based on pre-operative diagnostic  studies. In a four-pin device, the skin or soft tissue is    pinched between the two pairs of pins to reduce the length  of resulting scar. Fifty millimetre half pins are inserted  through a trocar through the external incisions. The exter-  nal distraction device is attached to the pins. The comple-  tion of the osteotomy is then accomplished in the superior  border as described previously. The devices are opened to  allow direct visualization of the distraction osteotomy site  and then backed down to zero position.    The osteotomy and device placement can also be under-  taken through a totally extraoral approach to the man-  dible, in which case a bolster underneath the shoulders  and neck with the head extended somewhat improves  access to the submandibular region. The classic Risdon or  submandibular approach is utilized with the skin incision  being slightly higher, close to the inferior border. The skin  and subcutaneous tissues are incised, the platysma mus-  cle is divided with care being taken to ensure identifica-  tion and preservation of the marginal mandibular branch  of the facial nerve. A blunt dissection is carried out down  the inferior border of the mandible and angle region.  In order to provide adequate surgical access, the facial  artery and vein frequently require dissection, clamping,  transection and ligation. A subperiosteal dissection is  carried out stripping off the masseter muscle and anteri-  orly to visualize areas of pin placement. Depending on the  position of the incision the distraction pins can emerge  through the incision or in separate percutaneous inci-  sions. Osteotomy completion and pin placement are as  described in the section ‘Combined intraoral and extra-  oral approach’. Tissues are closed in layers, muscle peri-  osteum and platysma 3/0 Vicryl, subcutaneous tissue 4/0  Vicryl and skin with 5/0 monofilament nylon. The device    Figure 74.3 (a) External distraction device holes are drilled at least 6 mm away from the distraction osteotomy site and are  placed 4 mm apart. The hole location determines the vector of distraction. (b) Fifty millimetre half pins are secured, two on either  side of the osteotomy site. (c) The through-and-through osteotomy is created in the body ramus junction with care being taken to  spare the inferior alveolar neurovascular bundle. (d) The application of the multiple planar distraction device (Howemedica Stryker  Leibinger, Portage, Michigan).    activation is similar as described for intraoral devices.  The distraction device removal should be accomplished  with the same criteria as established for intraoral devices  with adequate osseous fill of the distraction gap visual-  ized on radiographs, CT scan and/or ultrasound. The  device removal is usually carried out under local anaes-  thesia after the appropriate time of bony consolidation.  This may range from 2 months in very young children to  5 months in adult patients.    If the patient has significant airway compromise with  obstructive sleep apnoea, patient admission to the inten-  sive care unit (ICU) with endotracheal intubation over-  night or until ready for extubation is a consideration.  Alternatively, extubation could be achieved if the patient  is awake and alert and able to protect their own airway.  Requirements for discharge from hospital are adequate  pain control and PO intake, and otherwise stable recov-  ery from anaesthesia and surgery. A ‘minimal chew’ soft  diet is recommended for 6-8 weeks. In older children  and adults, chlorhexidine 0.12% mouth rinse is a con-  sideration during distraction device activation. Use of  post-operative oral antibiotics requires judgement and  is based on patient wound healing and clinical progress.  Skin sutures, if used, are usually removed 7-10 days post-  operatively (or longer) depending on wound tension dur-  ing distraction.    Activation of the distraction device is typically started  on post-operative day 5, although earlier distraction may  be commenced in younger patients. The distraction rate  is typically 1 mm a day divided in two or three activa-  tions. It is important that responsible adults or patients  activate the devices properly. In patients from the age  of birth to 2 years a distraction rate of 1.5-2 mm a day  may be appropriate based on rapid ability to create new  bone and concern with premature bony consolidation.  Monitoring of distraction with periodic radiographs  and visual inspection is appropriate one to two times  per week. Frequent assessment during distraction allows  recognition of complications or aberrant distraction  vectors and is necessary to determine the completion  of distraction. 3D vector adjustments can be made dur-  ing distraction with selected multivector intraoral and  extraoral DO devices (Figures 74.4 through 74.6). These  are best done after approximately 10 mm of lengthen-  ing has occurred due to compression and stretching of  the distraction regenerate. Vector alterations may be  accomplished in sequential activations depending on  the degree of distraction regenerate and the desired 3D  changes.   Activation arms are typically removed under local  anaesthesia and conscious sedation after the completion    Figure 74.4 Bidirectional telescopic mandibular distractor  with opportunity to distract longitudinally and mediolaterally.    of the distraction activation. Device retention is based  on the radiographic appearance of adequate ossification  of the distraction regenerate which can range from 2 to  5 months. Alternately, ultra sound can be used to assess  the distraction regenerate. Intraoral devices are better  tolerated by the patient during the consolidation period.  Intraoral or extraoral distraction device removal is  accomplished under local anaesthesia with sedation as a  separate procedure or under general anaesthesia particu-  larly if a Le Fort I osteotomy and/or other surgical pro-  cedures are to be performed. Orthodontic intervention is  frequently helpful in distraction cases to optimize occlu-  sal outcomes.    Routine surgical problems can be addressed with appropri-  ate post-surgical care including management of bleeding,  haematoma, infection and wound dehiscence. Distraction  device complications may include the following: loosening  of the device secondary to inadequate stability which can  result in fibrous union; failure of the device to activate due  to device malfunction or premature bony consolidation;  paraesthesia of the inferior alveolar, mental neurovascular  bundle or lingual nerve which is usually temporary but on  occasions can be permanent. Temporary cranial nerve VII  palsy can occur with extraoral approaches but is rarely per-  manent. Skeletal relapse is uncommon if adequate distrac-  tion rates and consolidation times are utilized. Relapse may  occur at the temporomandibular joint or the distraction  osteotomy site.    Figu re 74.5 (a) Multiple axis intraoral distraction device (MDO-M distractor, Orthognathics GmbH, Zurich, Switzerland).  (b) Schematic diagram showing distraction in a longitudinal direction. (c) Distraction vector adjustments in a superior/inferior plane.  (d) Rotational movement of the distal segment with the distraction device.    Figure 74.6 Multi-Guide II external distraction device shown on the paediatric mandible. Device can activate longitudinally,  mediolaterally and superiorly/inferiorly (Stryker Leibinger, Portage, Michigan).    This chapter has focused on the surgical technique of  osteotomy and distraction device placement by intraoral  and extraoral approaches for mandibular lengthening by  DO. DO research and techniques are constantly evolving.  This work is designed to supplement the reader’s surgical  knowledge of DO, but it would be expected that a respon-  sible practicing surgeon would attend appropriate con-  tinuing education courses and lectures and have reviewed  textbooks and important articles to provide the knowl-  edge base to appropriately apply distraction techniques.  In order to successfully apply distraction techniques, the  practitioner should have a very good understanding of the  biologic basis and principles of distraction as treatment  modifications and adjustments are frequently required.  DO is a powerful surgical technique and, when applied  appropriately, distraction can be very rewarding to the  patient and the practitioner.    e DO techniques require proper understanding and  application of the biologic principles of DO that are  anatomically sound and age appropriate.   e DO device selection is based on available bone stock,  ease of application, distance of DO and ability to adjust  the distraction vector post-device placement.   e When performing the lateral cortex, inferior border and  superior border osteotomies care is taken to ensure  that these cuts do not encroach upon the inferior alve-  olar neurovascular bundle, facial artery and vein or the  lingual nerve.   e When the platysma muscle is divided, care is taken to  ensure identification and preservation of the marginal  mandibular branch of the facial nerve.   e When securing the distraction device to the mandible,  it is important to ensure the correct 3D distraction  vector.   e The length of the mono and bicortical distraction  device screws is dependent on the position of the infe-  rior alveolar neurovascular bundle, teeth roots and  developing tooth buds in infants and children.   e After completion of the osteotomy cuts, a wedging  osteotome is tapped into place superiorly above the  inferior alveolar nerve, and utilizing a torquing a motion  a fracture is created through the remaining portion of  the mandible.   e Distraction rates can range from 1 to 2 mm per day,  divided in two to three activations per day, depending  on the age of the patient.   e 3D vector adjustments can be made during distraction  with selected multivector intraoral and extraoral DO  devices and are best done after approximately 10 mm  of lengthening has occurred.    Ilizarov GA. Transosseous Osteosythesis: Theoretical and  Clinical Aspects of the Regeneration Growth of Tissues.  Berlin, Germany: Springer-Verlag; 1992. pp. 287-328.   McCarthy J, Grayson B, Williams J and Turk A. Distraction  of the mandible: The New York University experience.  In McCarthy J (ed.), Distraction of the Craniofacial  Skeleton. New York, NY: Springer-Verlag; 1999.  pp. 80-203.   Samchukov M, Cope J and Cherkasin A. Biological basis of  new bone formation under the influence of tension  stress. In Samchukov M, Cope J and Cherkasin A  (eds.), Craniofacial Distraction Osteogenesis. St. Louis,  MO: Mosby; 2001. pp. 21-36.   Triaca A, Minoretti R, Dimai W and Merz B. Multiaxis intra-  oral distraction of the mandible. In Samchukov M,  Cope J and Cherkasin A (eds.), Craniofacial  Distraction Osteogenesis. St. Louis, MO: Mosby; 2001.  pp. 323-333.   Walker D. Buried bidirectional telescopic mandibular dis-  traction. In Samchukov M, Cope J and Cherkasin A  (eds.), Craniofacial Distraction Osteogenesis. St. Louis,  MO: Mosby; 2001. pp. 313-322.   Walker DA. Management of severe mandibular retrogna-  thia in the adult patient using distraction osteogen-  esis. J Oral Maxillofac Surg. 2002; 60: 1341-1346.   Walker D. Mandibular lengthening by distraction osteo-  genesis. In Bell W, Guerrero C (eds.), Distraction  Osteogenesis of the Facial Skeleton. Hamilton, Ontario:  BC Decker; 2007. pp. 327-340.    Distraction osteogenesis (DO) of the maxilla is a technique  utilized to gradually lengthen the maxilla (predomi-  nantly the cleft maxilla) extensive distances. DO creates  new bone without the need for bone grafting and donor  site morbidity. Maxillary DO has many significant differ-  ences from mandibular DO. Anatomically, the maxilla is  comprised of thin-walled membranous bone and distrac-  tion vectors are predominantly in a tangential vector from  the osteotomy site as opposed to a perpendicular vector  from the osteotomy site in the mandible. It is important  to have a sound understanding of the biologic principles  of DO and maxillary osteotomies when applying dis-  traction techniques. There are a multitude of distraction    devices including bone-borne, tooth-borne and intra-oral  and extra-oral devices. The indications, advantages and  disadvantages for maxillary DO are listed in Tables 75.1  through 75.3.    A thorough history and clinical examination is appro-  priate with utilization of diagnostic imaging, including  panoramic, posterior anterior and lateral cephalomet-  ric radiographs. Computed tomography (CT) scans with  three-dimensional (3D) reconstructions of the maxilla are  helpful. Dental study models mounted on a semi-adjust-  able articulator with prediction model surgery are of ben-  efit. In selected instances, stereolithographic models may  aid in treatment planning, osteotomy location and device  contouring. Standardized 3D cephalometric prediction  tracings are appropriate. In cleft maxilla patients, pre-  operative speech assessment with nasopharyngeal airflow  studies and/or fibre-optic nasopharygoscopy is important  to identify borderline or frank velopharyngeal incompe-  tence which may worsen with distraction. All clinical and  diagnostic tools are utilized to plan out the proper 3D dis-  traction vector selection and distance of distraction.   Maxillary DO device selection is based on available  bone stock, ease of application, distance of DO and abil-  ity to adjust the distraction vector post-device placement.  Intra-oral bone-borne devices have many advantages  including good device stability and longer consolidation  times, although extra-oral devices with cranial stabiliza-  tion, in selected instances, have advantages such as longer  distraction distances and ability to adjust distraction vec-  tor, but typically have shorter consolidation times.    Cleft palate patients with previous pharyngeal flap sur-  gery require extra care and attention for nasal endotra-  cheal intubation which may best be performed through  fibre-optic approaches. Some craniofacial syndromes have  choanal atresia and pre-operative CT scans and anaes-  thesia consultation would be appropriate. An anaesthesia  approach can be either from an oral or naso-endotracheal  approach. Occasionally, patients with severe maxillary  retrognathism with sleep apnoea have tracheostomy tubes  which can be utilized for inhalational anaesthesia.    The operative technique is similar to the classic Le Fort I  osteotomy with some important modifications. After  establishing general anaesthesia and administering appro-  priate antibiotic prophylaxis, attention is directed to the  maxillary vestibule where local anaesthetic 2% lidocaine  1/100,000 epinephrine is infiltrated in the planned area of  incision. Toxic dosages should be avoided, particularly in  paediatric patients or those patients with cardiac anoma-  lies. After allowing suitable time for haemostasis, a ves-  tibular incision is made a minimum of 5 mm above the  attached gingiva from zygoma to zygomaa. It is desirable  to leave significant labial attached gingiva pedicled to the    maxilla. Adjustments in the incision location can be made  in areas of cleft alveolus. The subperiosteal dissection is  carried out exposing the piriform rim, the infraorbital  nerve, the zygoma and a subperiosteal tunnel is carried  out posteriorly back to the pterygomaxillary junction  (Figure 75.1).   Osteotomy location is based on the need for adequate  bone above and below the osteotomy site for application of  the bone-borne distraction devices. At this point, the level  of the osteotomy is marked with a 701 tapered fissure bur  or with a reciprocating saw. All bone cuts or osteotomies  are made with adequate soft-tissue retraction and copious  saline irrigation. It is advisable at this time to contour and  secure the left and right bone-borne distraction devices  with two screws above and below the osteotomy site. It  is important to have the vector of the distraction device  close to the sagittal plane and not convergent. The distrac-  tion devices are now removed and stored in a safe sterile  location. Typically, it is desirable to have approximately  5 mm of bone height above the apices of the dentition.  The osteotomy location may have to be higher in younger  patients where the developing canine teeth are unerupted.  It is advantageous to have a step osteotomy in the zygoma  region. The angle of the osteotomy will also control the  vector of distraction and this can be adjusted to either  inferiorly or superiorly depending on available bone stock  (Figure 75.2a and b). External maxillary devices utilize a  tooth-borne component which allows greater flexibility  of osteotomy location. A Frier elevator is used to strip the  nasal mucosa from the inferior and lateral aspect of the  lateral nasal wall to the posterior extent of the nasal wall.  A periosteal retractor is placed along the lateral nasal wall  to prevent tearing of the tissues. An osteotomy is made  with the reciprocating saw from the zygoma to the piriform    Figure 75.1 The subperiosteal dissection is carried out  exposing the piriform rim, the infraorbital nerve, the zygoma  and a subperiosteal tunnel is carried out posteriorly back to  the pterygomaxillary junction.    Figure 75.2 (a) The angle of the osteotomy is in the horizontal plane with a step at the zygoma for bone-borne distraction  device. (b) The angle of the osteotomy will also control the vector of distraction and this is placed in a superior to inferior position  allowing vertical lengthening of the maxilla during distraction, depending on available bone stock.    rim at the appropriate level. With the Langenback toe out  retractor placed to the pterygomaxillary junction, the oste-  otomy is carried out posteriorly and inferiorly back to the  pterygomaxillary junction (Figure 75.3a). The osteotomy  is performed on the contralateral side of the maxilla care  being taken to ensure it is symmetric. Next, the anterior  nasal spine is dissected free and initial area of the attach-  ment of the nasal septal cartilage to the maxilla is freed up.  The nasal mucosa is stripped from the floor of the nasal  cavity and the inferior aspect of septal cartilage. With ade-  quate tissue retraction and a finger placed at the posterior  nasal spine (oral side), the nasal septal osteotome is tapped  with a mallet separating cartilaginous septum and vomer  from the maxilla (Figure 75.3b). With a periosteal elevator  in place protecting lateral nasal mucosa, a spatula osteo-  tome is gently tapped along the lateral nasal wall until an  increase in resistance is felt, ensuring the descending pala-  tine neurovascular bundle is not transected (Figure 75.3c).   At this point, it is the author’s preference to use the  curved pterygoid osteotome to separate the maxilla  from the pterygoid plates just prior to down fracturing  the maxilla. It is important to place the osteotome near  the inferior aspect of the pterygomaxillary junction and  angled inferiorly in order to avoid the internal maxillary  artery (Figure 75.3d). The operating surgeon controls  the pterygoid osteotome and places a finger on the pala-  tal aspect of the pterygomaxillary junction, while the  surgical assistant strikes the osteotome with the mallet.  Subsequently, the maxilla is digitally down fractured with  pressure on the anterior maxilla and midface. Extensive    mobilization is not required, just enough to free up the  maxilla (Figure 75.3e). If difficulty is experienced in mobi-  lizing the maxilla, recheck all osteotomy cuts, and if nec-  essary, the Rowe disimpaction forceps can be placed on  the nasal floor below nasal mucosa and on the hard pal-  ate to free up the maxilla. Care is taken to avoid damage  to the incisors.   It is advisable to remove the sinus mucosa from the infe-  rior aspect of the maxillary sinus and to remove any bony  irregularities along the Le Fort I cut that may impede dis-  traction movement (Figure 75.3f). Next, the bone-borne  distraction devices can be placed and secured with 1.5-2.0  mm self-tapping screws of appropriate length. The devices  should be activated a few millimetres to ensure maxillary  movement then backed down to zero (Figures 75.4a and b  and 75.5a and b). When using external distractors, there  is no bone-borne stabilization and if there is significant  mobility of the maxilla, a transosseous 3/0 gut suture can  be placed in the piriform area. If there is concern with  respect to alar base flaring, an alar base suture with 2/0  vicryl can be placed. Copious saline irrigation is carried  out, haemostasis is obtained and tissues are closed in a  two-layer fashion with 3/0 vicryl interrupted horizon-  tal mattress sutures in the muscle periosteum layer. The  mucosal incision is closed with 4/0 monofilament nylon  horizontal mattress sutures for wound eversion then 4/0  chromic gut running suture for watertight closure. The  incision may have considerable tension on it during long  distraction distances. It is typical to have the device acti-  vation arm exit through the incision line or through a    Figure 75.3 (a) A periosteal retractor is placed along the lateral nasal wall to prevent tearing of the tissues. An osteotomy is made  with the reciprocating saw from the zygoma to the piriform rim at the appropriate level. With the Langenback toe out retractor  placed to the pterygomaxillary junction, the osteotomy is carried out posteriorly and inferiorly back to the pterygomaxillary junction.  (b) With adequate tissue retraction and a finger placed at the posterior nasal spine (oral side), the nasal septal osteotome is tapped  with a mallet separating cartilaginous septum and vomer from the maxilla. (c) With a periosteal elevator in place protecting lateral  nasal mucosa, a spatula osteotome is gently tapped along the lateral nasal wall until an increase in resistance is felt ensuring the  descending palatine neurovascular bundle is not transacted. (d) It is important to place the osteotome near the inferior aspect of the  pterygomaxillary junction and angled inferiorly in order to avoid the internal maxillary artery and have a finger palpating the ptery-  gomaxillary junction from the oral side. (e) The maxilla is digitally down fractured with pressure on the anterior maxilla and midface.  Extensive mobilization is not required, just enough to free up the maxilla. (f) It is advisable to remove the sinus mucosa from the infe-  rior aspect of the maxillary sinus and to remove any bony irregularities along the Le Fort | cut that may impede distraction movement.    Figure 75.4 (aand b) Bone-borne distractor after osteotomy and placement, and after the completion of distraction. (Courtesy    Figure 75.5 (aand b) Bone-borne distractor in paediatric patient after osteotomy and placement, and after the completion of  distraction. (Courtesy of Zurich Pediatric Maxillary Distractor, KLS Martin Jacksonville, FL.)   External maxillary distraction devices have a tooth-  borne component which is usually placed by the ortho-  dontist pre-operatively or intra-operatively and are  attached to the external distraction framework con-  nected to the halo frame (Figures 75.6 and 75.7a and b).  Alternatively, bone plates can be attached to the maxilla  and attached via stainless steel wire to the external verti-  cal bar (Figure 75.8). Placement of the halo frame should  be based on bone quantity and quality measured on pre-  operative CT scan. The halo frame should be parallel to  Frankfort horizontal plane and should be sized to fit not  more than approximately 2 cm from the patient’s head  and be placed far enough anterior to allow the maxillary    distance of distraction. The screws should penetrate the  scalp and calvarium into the outer cortex only. Three to  four screws per side is desirable, 2-4 cm above the helix  of the ear, avoiding the thin bone of the temporal fossa.  The vertical component of the external system should be  in the midline parallel to the facial plane and is attached  to the orthodontic intra-oral device (Figures 75.7a and b  and 75.8).    If the patient has significant pre-operative airway com-  promise, patient admission to the ICU with endotracheal  intubation overnight, or until ready for extubation, is a    Figure 75.6 Orthodontic device to be cemented on to  molars with external arms to be connected to external distrac-  tion device.    Figure 75.7 (a and b) Rigid external distraction (RED)  device with attachment to orthodontic devices. (Courtesy of  KLS Martin, Jacksonville, FL.)    Figure 75.8 Halo frame external distractor with bone  plate attachments on the maxilla and midface. (Courtesy of  BLUE Device Multi-Vector Distraction, Biomet Microfixation,  Jacksonville, FL.)    consideration. Alternatively, extubation could be achieved  if the patient is awake and alert and able to protect their  own airway. Periodic nasal clearing of significant blood  clots with a Q tip and hydrogen peroxide may be appropri-  ate. Topical or systemic sinus decongestants can be used  depending on patient age and clinical need. Requirements  for discharge from hospital are adequate pain control and  p.o. intake, and otherwise stable recovery from anaesthesia  and surgery. A ‘minimal chew’ soft diet is recommended  for 6-8 weeks. In older children and adults, chlorhexidine  0.12% mouth rinse is a consideration during distraction  device activation. Use of post-operative oral antibiotics  requires judgement and is based on patient wound healing  and clinical progress. No specific care is required for halo  screws.    Activation of the distraction device is typically started  on post-operative day 5-7, although earlier distraction  may be commenced in younger patients. The distraction  rate is typically 1 mm per day divided in two or three  activations. It is important to have responsible adults or  patients to activate the devices appropriately. Monitoring  of distraction with periodic radiographs and visual  inspection is appropriate one to two times per week.  Frequent assessment during distraction allows recognition  of complications or aberrant distraction vectors and is  necessary to determine the completion of distraction.  3D vector adjustments can be made during distrac-  tion with selected extra-oral DO devices. Vertical vector  alterations may be accomplished in sequential activations  depending on the degree of distraction regenerate and  the desired 3D changes. If orthodontic appliances are in  place, class III and/or vertical elastics may aid in occlusal  correction.    Activation arms are typically removed under local  anaesthesia and conscious sedation after the completion of  the distraction activation. In devices with non-removable  activation arms, tissues are monitored periodically. Device  removal is accomplished under local anaesthetic and  sedation and is based on the radiographic appearance of  adequate ossification of the distraction regenerate which  can range from 6 weeks to 5 months. Intra-oral devices  are better tolerated by the patient during the consolida-  tion period. If external devices are removed after shorter  consolidation times, an orthodontic facemask appliance  should be worn at night time for an additional 2-3 months  to minimize relapse. Orthodontic intervention is fre-  quently helpful in distraction cases to optimize occlusal  outcomes.    Routine surgical problems can be addressed with appropri-  ate post-surgical care including management of bleeding,  haematoma, infection and wound dehiscence. Distraction  device complications may include the following: loosen-  ing of the device secondary to inadequate stability and  failure of the device to activate (breakage, activation gear  malfunction). Surgical intervention with replacement or  restabilization of the DO device would be appropriate.  Aberrant distraction vectors can produce occlusal prob-  lems which can be remedied with orthodontic treatment  with elastic traction or on occasion with mandibular  surgery. Premature bony consolidation is rare, but occa-  sionally fibrous union can occur and may be treated with  application of bone plate fixation and or autologous bone  grafting. Paraesthesia of the infraorbital nerve is usually  temporary but on occasion can be permanent. Skeletal  relapse at the distraction osteotomy site is uncommon if  adequate distraction rates and consolidation times are  utilized. Velopharyngeal incompetence is documented  in cleft maxilla after long distraction distances and may  require a pharyngeal flap to correct speech problems.  Intracranial pin migration with halo frame (particularly  with craniofacial syndromes or previous cranial vault sur-  geries) has been reported.    e Maxillary distraction techniques require proper under-  standing and application of the biologic principles of  DO that are anatomically sound and age appropriate.   e Anatomically, the maxilla is comprised of thin-walled  membranous bone and distraction vectors are pre-  dominantly in a tangential vector from the osteotomy  site as opposed to a perpendicular vector from the  osteotomy site in the mandible.   e Maxillary DO internal or external device selection is  based on available bone stock, ease of application,    distance of DO, osteotomy location and ability to adjust  the distraction vector post-device placement.   e In cleft maxilla patients, pre-operative speech assess-  ment with nasopharyngeal airflow studies and or  fibre-optic nasopharygoscopy is important to iden-  tify borderline or frank velopharyngeal incompetence  which may worsen with distraction.   e Cleft palate patients with previous pharyngeal flap sur-  gery require extra care and attention for nasal endo-  tracheal intubation which may best be done through  fibre-optic approaches.   e¢ Maxillary osteotomy location is based on the need  for adequate bone above and below the osteotomy  site for application of internal bone-borne distraction  devices and can be placed in a higher position with  external DO devices.   e When securing the internal distraction devices to the  maxilla, it is important to ensure the correct 3D distrac-  tion device vector close to the sagittal plane and not  convergent.   e The external distractor halo frame should be paral-  lel to Frankfort horizontal plane, should be sized to fit  and not be more than approximately 2 cm from the  patient’s head and should be placed far enough ante-  rior to allow the maxillary distance of distraction.   e When securing the halo frame with screws, avoid the  thin bone of the temporal region and select CT scan-  guided screw position in craniofacial syndromes or  those patients with previous cranial surgery.   e Distraction rates can range from 1 to 2 mm per day,  divided into two to three activations per day, depend-  ing on the age of the patient.   e 3D vector adjustments can be made during maxillary  distraction with selected multivector extra-oral DO  devices.    Altuna G, Walker D and Freeman E. Surgically assisted  rapid orthodontic lengthening of the maxilla in  primates—A pilot study. Am J Orthod. 1995; 107:  531-536.   Bell WH. Le Fort I osteotomy for correction of maxillary  deformities. J Oral Surg. 1975; 33: 412-426.   Bell WH, Fonseca RJ, Kennedy JW and Levy BM. Bone  healing and revascularization after total maxillary  osteotomy. J Oral Surg. 1975; 33: 253-260.   Bell W, Pinto L, Chu S, Buschang P, and Guerrero C.  Simultaneous correction of three-dimensional max-  illary deformity by the Le Fort I osteotomy and dis-  traction osteogenesis technique. In Bell W and  Guerrero C (eds.), Distraction Osteogenesis of the  Facial Skeleton. Hamilton, Ontario: BC Decker;  2007. pp. 327-340.   Figueroa AA, Polley JW and Ko E. Distraction osteogen-  esis for treatment of severs cleft maxillary deficiency  with the RED technique. In Samchukov M, Cope J  and Cherkasin A (eds.), Craniofacial Distraction  Osteogenesis. St. Louis, MO: Mosby; 2001. pp. 85-93.    Guerrero C. (eds.). Distraction Osteogenesis of the Facial Rachmiel A. Regenerate bone formation during maxillary  Skeleton. Hamilton, Ontario: BC Decker; 2007. and midface distraction. In Samchukov M, Cope J  pp. 327-340. and Cherkasin A (eds.), Craniofacial Distraction   Guyette TW, Polley JW, Figueroa AA and Smith BE. Osteogenesis. St. Louis, MO: Mosby; 2001.  Changes in speech following maxillary distrac- pp. 477-484.  tion osteogenesis. Cleft Palate Craniofac J. 2001; 38: Samchukov M, Cope J and Cherkasin A. Biological basis  199-205. of new bone formation under the influence of tension   Polley JW and Figueroa AA. Rigid external distraction: stress. In Samchukov M, Cope J and Cherkasin A  Its application in cleft maxillary deformities. Plast (eds.), Craniofacial Distraction Osteogenesis. St. Louis,    Craniosynostosis is a term first coined by Virchow to  describe the premature fusion of one or more cranial  sutures resulting in an abnormal head shape. Because of  this stenosis, growth perpendicular to the suture line is  restricted with compensatory overgrowth at the remain-  ing patent suture lines. Most forms of craniosynostosis are  random and non-syndromic, occurring as isolated inci-  dences and are not associated with any other conditions or  deformities. In the United States, non-syndromic cranio-  synostosis occurs in approximately 1 in 1000 live births.  Diagnosis is based on both clinical and radiographic eval-  uations. The clinical evaluation involves the palpation of  the skull for any movement, ridging and absence or pres-  ence of the anterior and posterior fontanelles. Quantitative  measurements of the superior orbital rims, relative to the  most anterior aspect of the cornea, are also useful in treat-  ment planning of superior orbital rim advancements. The  radiographic evaluation of craniosynostosis is used to  quantitatively define aberrant anatomy, plan surgical pro-  cedures and provide a means to demonstrate to parents  the difference between stenosed and nonstenosed sutures.  Computed tomography provides the craniofacial team  with a baseline record, a means of surgical planning and  a modality to document surgical changes in vivo thereby  allowing longitudinal comparisons.    ® Inhibition of brain growth: Although the neurodevelop-  mental morbidity of non-syndromic craniosynostosis is  not fully understood, children manifesting non-syndromic  synostosis exhibit significant speech, behavioural and cog-  nitive abnormalities compared with the general population.   ® Intracranial hypertension: Varying degrees of intracra-  nial hypertension, decreased cerebral perfusion pressure  and episodic respiratory obstruction are documented  complications associated with complex craniosynosto-  sis. Intracranial hypertension of greater than 15 mm Hg  develops in 13% of single suture synostosis and 42% of  multisuture synostosis patients. Multisuture stenosis is  accompanied by hydrocephalus in 10% of cases. Acute  intracranial hypertension manifests as papilloedema,  headache and nausea/vomiting; chronic signs are optic  and cerebral atrophy.   © Neuromotor development: In a series of scaphocephalic  patients, auditory short-term memory and language  developmental impairment persisted following cra-  nial vault corrective surgery. Neuromotor develop-  ment improves with surgery. Functional studies suggest  regional cerebral circulation improvement following cor-  rective surgery for unilateral or simple craniosynostosis.    © Visual/auditory impairment: Glucose metabolism and  brain function relative to visual development and spatial  coordination significantly improve following corrective  surgery for single-suture synostosis. Although poste-  rior plagiocephaly comprises less than 3% of all isolated  synostosis cases, diagnosis is critical because of its rela-  tionship to significant hemifield visual asymmetry. The  degree of visual field impairment does not correlate to  the degree of deformation or the laterality of the defect.    ® Correction of the deformity provides a more normal  contour to the naso-orbital region, supraorbital unit  and cranial vault. Children who fail to undergo timely  repair of craniosynostotic deformities often represent  due to social hardships and parental concerns for their  child’s successful integration into society.    ® Sagittal synostosis (Figure 76.1)  e Scaphocephaly  e Transverse skull narrowing  e Anteroposterior skull elongation    Premature sagittal fusion  Represents 50% of synostosis cases in the United  States   Differential diagnosis includes infant positioning,  moulding, congenital torticollis and lambdoid  synostosis    Brain volume in the normally developing child nearly  triples in the first year of life growing from 350 to 950 g;  at 24 months, the brain reaches 1250 g with the adult brain  weighing 1350 g. Rapid brain growth requires that the  cranial vault achieve 80% of the adult size by birth and  readily expands until 3 years of age. A good indication  of cranial growth can be ascertained by skull circumfer-  ence measurements. Low figure measurements for any age  group may be a sign of craniosynostosis or microcephaly.  The cephalic ratio is defined as the relationship between  the bitemporal width and the anteroposterior length. The  normal length to width ratio is 2:3. A lower ratio may  be suggestive of sagittal synostosis. In craniosynostosis,  premature suture fusion is combined with continued  brain growth. Precise timing remains controversial and  individualized. We prefer surgical repair between 4 and 8  months of age, whereas other centres have reported good    results when treatment is completed between 2.5 and 3  years of age. Timely surgical intervention allows for rapid  frontal lobe growth which supports the forehead and  supraorbital ridge. Additionally, at this age the cranium is  highly malleable and therefore easier to contour. Children  over | year of age have thicker bone which is more difficult  to modify. Although some patients may require multiple  staged surgical procedures, early intervention may have a  positive effect on facial growth and result in a lessening of  the facial deformity as the child grows.    The pre-operative assessment should include a complete  blood count and a basic metabolic panel. It is imperative  that the child be cross-matched for at least two units of  packed red blood cells, fresh frozen plasma and platelets  before surgery. The blood must be available in the oper-  ating theatre before incision. Central venous catheteriza-  tion and large-bore peripheral venous access greatly assist  the anaesthesia team in monitoring and resuscitation  associated with significant blood loss and fluid shifts that  may occur during the operation. In addition to routine    electrocardiography, peripheral oxygen saturation and  capnography monitoring, arterial line placement and pre-  coridal Doppler monitoring are useful adjuncts in patient  monitoring. All fluids and blood products are warmed. It  is critical that the operating theatre should be kept warm  during induction, patient preparation and draping to  ensure the maintenance of normal body temperature.    © The patient is positioned supine with the head secured  on a Mayfield headrest. Via a coronal incision, a  subperiosteal anterior scalp flap is elevated along with  the temporalis muscle bilaterally. Pre- or postauricular  extensions may be utilized if needed (Figure 76.5a and b).   © Bilateral subperiosteal reflection extends to the peri-  orbital and zygomaticotemporal regions anteriorly  whilst maintaining the attachment of the medial can-  thal tendons. Posteriorly, the scalp flap is reflected  midway between the coronal and lambdoid sutures  (Figure 76.6). Markings for the bifrontal craniotomy and  fronto-orbital bar/bandeau are indicated (Figure 76.7).    ® Bifrontal craniotomy using the Midas Rex drill  (Medtronic, Minneapolis, MN) developing a 1.5 cm  bandeau (Figure 76.8).   ® Retraction of the frontal and temporal lobes of the brain  facilitates superior orbital and temporal osteotomies.  Bilateral tongue-in-groove (tenon) extensions developed  via a reciprocating saw to the level of pterion (Figure 76.9).   ® Intracranial retraction of frontal lobes (Figure 76.10)  as well as intraorbital retraction of the periorbita  (Figure 76.11) is necessary to achieve the anterior skull  base osteotomy. One may tailor the level of the lateral  orbital rim osteotomy based on aesthetic needs.   © The removed bandeau is adjusted bilaterally via the  removal of wedges from the recessed side and scoring of  the over-projected side (Figure 76.12a). The bandeau is  recontoured by bending the recessed side and straight-  ening the over-projected side (Figure 76.12b).   @ Barrel-staving osteotomies are placed in the parietal  and/or temporal bones as needed for reshaping  (Figure 76.13).   © Resorbable plates and screws are utilized for stabiliza-  tion of the bandeau and forehead (Figure 76.14a and b).    Figure 76.6 Superior view demonstrating extent of  subperiosteal reflection, as well as degree of right-sided  anterior plagiocephaly.    Figure 76.7 Bur holes in preparation for bifrontal  craniotomy at the level of the supraorbital region.    Figure 76.11 Combined intracranial and_intraorbital  retraction to complete the anterior cranial base osteotomy  along the orbital roof.    Figure 76.12 Removed bandeau (a) before and (b) after  wedge and scoring osteotomies.    ® Surgical positioning, approach and osteotomy design  is similar to that already described for plagiocephaly  repair. Sites of osteotomies bilaterally as indicated  (Figure 76.15).   © Following osteotomies, reshaping and fixation of the Figure 76.13 Barrel-staving osteotomies achieved via  bandeau and forehead are undertaken (Figure 76.16). Midas Rex or reciprocating saw to impart plasticity to the bone.    Figure 76.14 (a) Oblique and (b) superior views following  resorbable plate fixation.    Figure 76.17 Proposed osteotomy markings from  (a) frontal and (b) lateral views.    Figure 76.15 Lateral view of proposed osteotomy design  for repair of bicoronal synostosis.    © The surgical positioning, approach and initial osteot-  omy design is similar to that already described. The site  of osteotomies of the anterior cranial vault and supe-  rior orbital rims from frontal (Figure 76.17a) and lateral (b)  (Figure 76.17b) views.   ® Superior view of bandeau before (Figure 76.18a) and Figure 76.18 Bandeau (a) before and (b) after reshaping  after (Figure 76.18b) reshaping. and resorbable plate fixation.    © The bandeau is sometimes vertically split at the midline  and an autogenous cranial bone graft placed to correct  true hypotelorism (Figures 76.19 and 76.20).   ® Assessment of the gap between the bandeau and  anterior cranial base assists in determining symmetric  correction and bitemporal expansion (Figure 76.21).   ® Barrel staving is often needed to widen the temporal  region before final anterior cranial vault reshaping and  fixation (Figure 76.22a and b).    sagittal suture requires formal total reshaping of the cra-  nial vault, with or without superior orbital rim shaping.  When the entire sagittal suture is fused, a combination    of both anterior and posterior approaches may be nec-  essary. For children over 12 months of age or children  with the need for upper orbital reconstruction, we pre-  fer the supine position at one operative setting, or rarely,  in two stages with posterior reconstruction preceding  anterior treatment by 4-6 months.   The forehead is tilted posteriorly, and the occiput is  tilted anteriorly thereby reducing the anterior—posterior  dimension; resorbable fixation is used to secure the  segments. Barrel staving as well as interchanging of  the temporal segments helps widen the transverse  dimension (Figure 76.23).   The patient must be prone when the posterior half of the  sagittal suture is involved with protection of the airway  and globes. Unless a significant concomitant supraorbital  deformity exists, we prefer to treat full sagittal suture ste-    nosis via total cranial vault reshaping at one operative set-  ting with the patient in the prone position (Figure 76.24).   @ Intraoperative (Figure 76.25a) and _— schematic  (Figure 76.25b) pre-operative superior views of the pro-  posed osteotomy sites for total cranial vault reshaping  without orbital osteotomies.    Figure 76.20 Internal resorbable plating of the bandeau  at the midline with autogenous bone grafting.    Figure 76.22 (a) Barrel-staving bone cuts are manipulated  via bone benders and (b) final fixation achieved via resorbable    Figure 76.23 Total cranial vault reshaping and resorbable  plate fixation to correct sagittal synostosis.    Figure 76.26 (a) Superior intraoperative and (b) schematic views following total cranial vault reshaping and fixation.    Figure 76.27 Lateral intraoperative views (a) before and (b) after total cranial vault reshaping.    @ Intraoperative (Figure 76.26a) and _ schematic  (Figure 76.26b) superior views after total cranial vault  reshaping to increase the biparietal width and reduce  the frontal and occipital projection.   © Intraoperative left lateral view before reshaping  (Figure 76.27a) and after reshaping and fixation  (Figure 76.27b).    e Elevation of a coronal flap should be in the subperi-  osteal plane with inclusion of the temporalis muscles  maintaining attachment to the flap.   ¢ Development of a supraorbital bandeau with a  minimum height of 1.5 cm.   e Liberal placement of barrel-staving osteotomies to  facilitate intraoperative three-dimensional changes  and post-operative moulding if necessary.   e Use of resorbable plate fixation thereby avoiding the  need for plate and screw removal or migration.    Becker DB, Petersen JD, Kane AA, Cradock MM, Pilgram  TK and Marsh JL. Speech, cognitive, and behavioral  outcomes in nonsyndromic craniosynostosis. Plast  Reconstr Surg. 2005; 116(2): 400-407.   Burrows AM, Mooney MP, Smith TD, Losken HW and  Siegel MI. Growth of the cranial vault in rabbits with  congenital coronal suture synostosis. Cleft Palate  Craniofac J. 1995; 32: 235-246.   David LR, Genecov DG, Camastra AA, Wilson JA and  Argenta LC. Positron emission tomography stud-  ies confirm the need for early surgical intervention  in patients with single-suture craniosynostosis.  J Craniofac Surg. 1999; 10(1): 38-42.   Ghali GE and Sinn DP. Nonsyndromic craniosynostosis. In  Milero M, Ghali GE, Larsen PE and Waite PD (eds.),  Petersonte PD (edsE, LarsOral and Maxillofacial  Surgery. 2 ed. Hamilton, Ontario: BC Decker; 2004.  pp. 887-900.   Ghali GE, Sinn DP and Tantipasawasin S$. Management  of nonsyndromic craniosynostosis. In Haug RH and  Steinberg B (eds.), Atlas of the Oral and Maxillofacial  Surgery Clinics of North America. Philadelphia, PA:  W.B. Saunders; 2002. pp. 1-41.    Hayward R and Gonsalez S. How low can you go?  Intracranial pressure, cerebral perfusion pressure  and respiratory obstruction in children with complex  craniosynostosis. J Neurosurg. 2005; 102(Suppl 1):  16-22.   Marchac D and Renier D. Treatment of craniosyonostosis  in infancy. Clin Plast Surg. 1987; 14: 61-72.   Ozgur BM, Aryan HE, Ibrahim D, Soliman MA,  Meltzer HS, Cohen SR et al. Emotional and    psychological impact of delayed craniosynostosis  repair. Childs Nerv Syst. 2006; 22(12): 1619-1623.   Siatkowski RM, Fortney AC, Nazir SA, Cannon SL,  Panchal J, Francel P et al. Visual field defects in  deformational posterior plagiocephaly. J AAPOS.  Jun 2005; 9(3): 274-278.   Virtanen R, Korhonen T, Fagerholm J and Viljanto J.  Neurocognitive sequelae of — scaphocephaly.  Pediatrics. 1999; 103(4 Pt 1): 791-795.   Revision rate for orbital hypertelorism surgery 76%  Primary reasons for failure/relapse    Orbital hypertelorism is defined as an increased distance  between both the medial and lateral sides of the orbits  and should not be confused with telecanthus.!* It is  a physical finding associated with a number of con-  genital midline anomalies: craniofrontonasal dysplasia,  frontonasal dysplasia, encephalocele, midline dermoid  cyst, syndromes characteristic of midface retrusion and  craniosynostosis (e.g. Apert and Crouzon syndromes),  and atypical midline cleft anomalies. Though all patients  with hypertelorism exhibit some telecanthus, not all  patients with telecanthus are hyperteloric (Figures 77.1  and 77.2, Table 77.1).24-© These anomalies characteristi-  cally cause widening of the upper craniofacial segment  and orbital hypertelorism.”* Generally, these are non-  progressive entities and best addressed once the cranio-  orbital units are near skeletal maturity (5-8 years of  age).”° The extent and location of facial widening dictates  which procedure is performed: box osteotomies versus  facial bipartition.    ® Contrast computed tomography (CT) with three-  dimensional (3D) reconstruction with 1-mm cuts  e Contrast is helpful in enhancing brain parenchyma  and intervening soft tissues.    ® Construction of a 3D model  e In asymmetric cases, the use of virtual surgical  planning is helpful.!  e Determine surgical plan from using 3D model  (Figures 77.3 and 77.4).  @ Ancillary assessment"!  e Ophthalmology  — Pre-operative and post-operative assessments.  ® This population pre-operatively may exhibit epiblepha-  ron, astigmatism and exotropia.  e Genetics  e Orthodontic  ® Decision for box osteotomies versus facial bipartition    Figure 77.1 Some definitions pertaining to orbital measure-  ments. ICD, inner canthal distance; IPD, inter pupillary distance;  OCD, outer canthal distance; PFL, palpebral fissure length.    Figure 77.2. Graphic representation of various measurements as seen in normal orbit (upper row), in orbital telecanthus or  pseudo-hypertelorism (middle row) and in orbital hypertelorism (lower row). ICD, inner canthal distance; IPD, inter pupillary dis-    Sources: Songur E et al., J Craniofac Surg, 1997; 8(1): 29-31; Whitaker LA  and Vander Kolk C, Otolaryngol Clin North Am, 1988; 21(1):  199-214; Hansman CF, Radiology, 1966; 86(1): 87-96.   @ Narrow the nasal dorsum and reconstruct to create a  nose with adequate projection.    Figure 77.4 Bird's-eye view after frontal craniotomy and  superior orbital roof osteotomies.    e Tarsorrhaphy sutures of 5.0 silk from grey line to  grey line just lateral to the pupil of each eye.   e The coronal flap is outlined approximately 3 cm  posterior to the hairline and is extended preauricu-  larly as needed for exposure.   e ‘The patient is draped with full exposure of the head  and neck down to the clavicles.   - Subgaleal dissection ensues with an incision  through the periosteum about 2 cm above the  superior orbital rim. Once lateral to the tem-  poral ridge, an incision down to the temporalis  muscle is made through the superficial and deep  layers of the temporalis fascia. The dissection is  continued anteriorly and inferiorly in this layer  to best preserve the facial nerve and superficial  temporal fat pad. An incision along the back of  the zygomatic arch through the layers may be  performed for better access to the zygoma.   — Extensive exposure of the nasal bones cen-  trally with release of the supraorbital nerves,  exposure of the lateral orbital rim and malar  area, circumferential intra-orbital dissection  to the posterior and middle third of the orbit  (approximately 2 cm deep) and obliteration of  the anterior and posterior ethmoidal arteries  using bipolar electrocautery.   - Alarge pericranial flap is harvested extending 2 cm  posterior to the coronal incision and pedicled ante-  riorly and laterally.   - Medial canthus: As long as anatomically  feasible, the medial canthi should be left intact  to better enable the moving of the soft tissues  of the orbit.    - Lateral canthus is usually dissected off from  Whitnall’s tubercle and reattached at the end of  the surgery.   - Standard Le Fort I maxillary vestibular incision  made from premolar to premolar with extensive  superior subperiosteal dissection to the inferior  orbital rims bilaterally.   - A frontal bone flap is designed to leave 20 mm  superior to the superior orbital rim - this will  allow room for a bandeau and the supraorbital  osteotomy.   ® Craniotomy is then performed, and the dura is carefully  dissected from the osteotomized bone.    Figure 77.5 Markings for the orbital box osteotomy on a  skull model. The frontal craniotomy and the various markings  for the cuts in the orbital walls and roof are shown in upper  row and the left picture in lower row. The picture on right in  lower row shows the moved orbits after removal of central  excess tissue and completion of box osteotomy cuts. (Courtesy  of Dr Mukund Jagannathan.)    Careful epidural dissection is performed around the  anterior cranial fossa over the lateral aspects of the crib-  riform plate.  Nasal mucosa is dissected under the nasal bones before  the nasal osteotomy.    Zygomatic arch is divided at the junction of the  malar eminence.    Lateral orbital osteotomy.  The entire lateral segment osteotomy is performed  at least 2 cm posterior to the orbital rim - it is started  at the inferior orbital fissure and carried superiorly.  Superior osteotomies (Figure 77.8)   10 mm below and parallel to the inferior por-  tion of the frontal craniotomy along the supra-  orbital rim - making sure to leave at least 6 mm  of plateable bone intact at the supraorbital rim  (frontal bar).    Superior orbital roof osteotomy  The cut is made through the orbital roof staying at  least 2 cm from the supraorbital margin; the oste-  otomy should stop short of the cribriform plate to   - Abnormally shaped nasal dorsum  » Generally, a V- or U-shaped flap is usually   performed.  » Midline resection of the nasal septal com-  plex with preservation of the mucosa.   - 6mm of bone is preserved around the orbit in  all directions to enable appropriate fixation to  be placed.   Using a thin chisel, identify and preserve the naso-  lacrimal duct system with a nerve hook. The oste-  otomy is carried posterior to the lacrimal crest in  order to adequately protect the nasolacrimal duct  system. This osteotomy is then connected to the  inferior orbital fissure.    e Double action rongeurs are used to remove hyper-  plastic ethmoidal air cells. Preservation of the crib-  riform plate with bilateral removal of the ethmoids  along the length of the medial orbital roof osteot-  omy!» (Figure 77.11).   e Separation of the bony nasal septum from cranial  base (not necessary if midline is purposely being  preserved).   e Performed using a thin straight chisel just anterior  to the crista galli and aiming at the posterior por-  tion of the hard palate (Figure 77.12).   e Infra-orbital osteotomy (Figure 77.13) May be  placed above or below the infraorbital nerve, atten-  tion should be paid to the anatomic position of  unerupted tooth buds. (May be performed through  the coronal flap or through a maxillary vestibular  incision.)   e Via the coronal flap connecting the medial intra-  orbital osteotomy to the inferior orbital fissure  using a thin osteotome.   e Only a minimal step-off at the medial orbital wall is  tolerated - if significant, the posterior medial por-  tion of the orbit should be impacted.    Figure 77.11 (a) Resection of a median segment from  the anterior wall of the interorbital space. The ethmoid cells  are exenterated. (b) Osteotomies of the anterior cranial vault  with preservation of the cribriform plate. (c) Bone is resected  anteriorly to the cribriform plate and also along each side  to permit translocation without impinging on the olfactory  nerves. (d) The shape of the segments of bone resected from  the anterior cranial fossae varies, depending on the type of  translocation of the orbits required to correct the deformity.  (From Converse JG, Reconstructive Plastic Surgery, Saunders,  Philadelphia, PA, 1977.)    The decision to use resorbable versus titanium  hardware is based on the age and bony development  of the patient.   Hardware placed in glabellar area to secure the two  segments to each other.   Advancement at the zygoma is measured with cal-  liper to ensure symmetry and fixation is placed.   - If medial excision of bone is performed - the  dorsum should be reconstructed with a parietal  cranial bone graft.   - When a bifid tip is present an open rhinoplasty  approach is used to access the tip and approxi-  mate the lower lateral cartilages over the cranial  bone graft.   - Cranial bone grafts are also placed at the lateral  osteotomy sites in order to stabilize the medial-  ization of the orbital boxes.   - A 24-gauge stainless steel wire secured to drill  holes is placed in the contralateral nasofrontal  junction.   - A 24-gauge stainless steel wire is secured to  two holes that are placed at the new frontozy-  gomatic suture.   - Occasionally needed in the extradural space  created by the obliteration of the ethmoids/  nasal septum. Helps to inhibit ascending infec-  tion and eliminate dead space.   - Ifthe frontal sinus has formed (usually by the  age of 7), a proper frontonasal duct obliteration  and sinus cranialization is performed.   - Excess soft tissue may be stented using fibrin  glue, augmented with transnasal stiches and a  bolster (Figure 77.18).   - V-Y advancement or a Z-plasty may be used to  lengthen the nose when indicated."    e Place Jackson-Pratt Suction drains bilaterally and  secure externally with 2.0 silk suture.   © Placement of nasal trumpets for 3-5 days  - Limits pressure gradient at anterior cranial base  - Allows re-epithelialization of nasal mucosa    ® Conditions which result in transverse dental arch nar-  rowing/restriction with medial upward cant in addition  to hypertelorism (Figure 77.20).  e Craniofacial dysostosis syndromes such as Apert  and Crouzon.  e Also indicated for some craniofrontonasal dyspla-  sia and atypical midline cleft anomalies.    ® Medialize the two orbits to a normal position and later-  alize the dentition.   © Narrow the nasal dorsum, and reconstruct to create a  nose with adequate projection.    Figure 77.19 Facial bipartition surgical technique. (Left)  Osteotomy sites of the hemifacial segments to be rotated with  the medial bony triangle to be excised. (Center) Direction of  the rotation of the hemifacial segments towards the midline.  (Right) Final result after shifting the hemifacial segment and  osteofixation. Cranial bone graft to the nose can be performed  at the same surgical procedure.    e@ Airway management  - An oral RAE tube is placed and secured simi-  lar to that described in section ‘Box Osteotomies:  Technique’.  e Prepping.  e Basic prep as in box osteotomy technique with the  following additions:  - A throat pack is placed and a 2-minute peridex  rinse is performed.  -  Ericharch bars are placed on the maxillary teeth.  © Incision and dissection  e Coronal incision and dissection similar to that  described in section ‘Box Osteotomies: Technique’.  e Maxillary vestibular incision (Figure 77.23a).    Figure 77.21 Markings for the facial bipartition. On a skull  model. The upper row shows that the frontal craniotomy has  been performed and the cuts in the orbital roof, lateral wall  and the floor have been made. The zygomatic arch has been  divided and the pterygomaxillary cut has also been com-  pleted. Upper row left shows markings for the removal of the  central bony excess. The picture in upper row right and lower  row left shows the markings for splitting the palate in midline.  The picture in lower row on right shows completion of cuts and  medializing the two halves of the facial bipartition. (Courtesy  of Dr Mukund Jagannathan.)    © Osteotomies (Figure 77.22)  - Bifrontal craniotomy  - Incontrast to that in section ‘Box Osteotomies’,  no frontal bar is preserved in order to allow  unfettered rotation of the hemifacial segments.  = Craniotomy and epidural dissection is then  performed similar to that described in sec-  tion ‘Box Osteotomies: Technique’.  e Lateral osteotomies  - Similar to that described in section “Box  Osteotomies: Technique’ with the only varia-  tion being the extension of the lateral orbital  osteotomy into the lateral Tenon extension.  e Superior osteotomies  - Superior orbital roof osteotomy is similar to  that described in section ‘Box Osteotomies:  Technique’.  e Medial resection  - The medial resection and medial orbital oste-  otomy is identical to that described in section  ‘Box Osteotomies’.  e Pterygomaxillary osteotomy (intraoral or coronal  approach)  - Intraoral approach   » Using pterygoid osteotomes separate the  maxilla from the pterygoid plates.   » Pass an osteotome from the inferior orbital  fissure down through the pterygomaxil-  lary junction.   » One hand is placed intraorally while the  other holding onto the osteotome - a mallet  is then used to advance the osteotome.   e Rowe forceps and Seldins are simultaneously used  to achieve a controlled disimpaction of the two  halves of the face, which are then rotated to the  midline.   e Due to rotation after mobilization, triangular-  shaped wedges are removed from the lateral  orbital rims for a more appropriate fit against the  frontal bone.   - Standard maxillary vestibular incision made  from canine to canine with complete subperi-  osteal dissection of nasal floor and a subperi-  chondrial dissection of the inferior portion of  the septum.   - Septum is separated from the maxillary crest  using a nasal-septal osteotome.   - Sagittal osteotomy of the maxilla in the midline  using initially a reciprocating saw then a small  spatula osteotome for completion.   e Closure of oral mucosal wound using 3.0 vicryl in a  watertight manner  e Maxillary splint placement   - The maxilla is wired into a splint fabricated  pre-operatively from an impressions and model  surgery which have placed the maxilla in the  proper transverse relations with the mandible.   @ Fixation (Figure 77.25)  e ‘The fixation is similar to that described in section  ‘Box Osteotomies’.  © Bone grafts  e The bone grafts utilized are similar to that described  in section ‘Box Osteotomies’.  © Separation of anterior cranial fossa from sinuses  - A large sheet of gel foam is placed over the superior  remnant of ethmoid air cells. Tisseel is then placed  sealing off the sinuses. The harvested pericranial  flap may then be placed in the defect.  @ Anterior cranial vault  e ‘The bones are reshaped and advanced as needed  and fixed to the superior orbital rims.  © Additional procedures (often necessitated)  e Described under section “Box Osteotomies.’    Figure 77.23 Sagittal osteotomy of the maxilla as used in the bipartition procedure. (a) Small midline vestibular incision with expo-  sure of the piriform rim, nasal floor and septum. (b) Nasal-septal osteotome used for separation of the septum along the maxillary crest.  (c and d) A straight osteotome is then used to complete the segmentalization, and small bone spreaders confirm mobility of the two  maxillary halves. (From Posnick JC, Craniofacial dysostosis syndromes: A staged reconstructive approach, In: Turvey TA, Vig KWL, Fonseca  RJ, editors, Facial Clefs and Craniosynostosis: Principles and Management, W.B. Saunders, Philadelphia, PA, 1995. With permission.)    Figure 77.24 (a) High arched palate and narrowed maxillary arch width are common findings in children with craniofacial dys-  ostosis syndromes and craniofrontonasal dysplasia. (b) During the facial bipartition, upper facial movements towards the midline  result in lateral expansion of the maxillary arch form. Resistance is encountered from palatal soft tissues at this location.    © 24%-25% underwent some type of bony revision  © 52% underwent some type of soft-tissue revision    Medial excision followed by bone grafting of the  dorsum commonly produces restricted nasal  growth, therefore a nasal revision with secondary  bone grafting should be expected.   If anatomy permits, the septum and dorsum should  be preserved during the first surgery — in most cases  this is not possible.    Mortality: 0%-2%  Cerebrospinal fluid (CSF) leak: 0%-10%  Subdural haematoma: 1%  Epidural haematoma: 1%  Infection: 1%-10%  Permanent V2 sensory loss  Hyposmia: 21%"  Ophthalmologic  + Post-operative enophthalmia  + Anincrease in orbital volume occurs secondary to  the resection of the ethmoids and the anterior  rotation of the lateral orbital walls’  + Exotropia: Common immediately post-op but usually  self corrects  + Esotropia: Likely related to a bowing of the medial  rectus muscle across the medial osteotomy site!°  + The need for additional strabismus surgery is common  in this patient population    Sources: Marchac D et al., Plast Reconstr Surg. 2012; 129(3): 713-727;    Whitaker LA and Vander Kolk C, Otolaryngol Clin North Am.  1988; 21(1): 199-214; McCarthy JG et al., Plast Reconstr Surg.  1990; 86(2): 214-125; Ortiz Monasterio F et al., Plast Reconstr  Surg. 1990; 86(4): 650-657.   2. Relapse due to failure of the bone segments to remain  stable (secondary to young age of surgical intervention  or inadequate bone grafting at osteotomy sites).    Operation should not be considered before the age of  5 years.   Transverse osteotomy below the orbits is made high to  avoid tooth buds.   Complete mobilization of the orbits or hemifacial seg-  ments must be achieved.    and Freudlsperger C. The value of three-dimensional  printing modelling for surgical correction of orbital  hypertelorism. Oral Maxillofac Surg. 2015; 19(1):  91=95.    gical attempts. Material and methods. Causes and  mechanisms. Scand J Plast Reconstr Surg. 1972; 6(2):  135-155.    Lauer G. Telecanthus and hypertelorism in fronto-  ethmoidal meningoencephaloceles and the surgi-  cal correction of these conditions: Part I. An orbital  anthropomorphometric evaluation of the Khmer  subpopulation of Cambodia. J Craniofac Surg. 2008;  19(1): 137-147.    . Breakey W, Abela C, Evans R, Jeelani O, Britto J,    Hayward R et al. Hypertelorism correction with  facial bipartition and box osteotomy: Does soft tis-  sue translation correlate with bony movement?  J Craniofac Surg. 2015; 26(1): 196-200.    Marchac A. Hypertelorism correction: What hap-  pens with growth? Evaluation of a series of 95 surgi-  cal cases. Plast Reconstr Surg. 2012; 129(3): 713-727.    facial bipartition osteotomies. Atlas Oral Maxillofac  Surg Clin North Am. 2002; 10(1): 131-148.   Songur E, Mutluer S, Kececi Y, Alper M, Giiner U  and Totan S. Late results of hypertelorism correc-  tion. J Craniofac Surg. 1997; 8(1): 29-31.   Moreira Gonzalez A, Elahi M, Barakat K, Yavuzer  R, Brinkmann B and Jackson IT. Hypertelorism:  The importance of three-dimensional imaging and    trends in the surgical correction by facial bipartition.  Plast Reconstr Surg. 2005; 115(6): 1537-1546.  McCarthy JG, La Trenta GS, Breitbart AS, Zide  BM and Cutting CB. Hypertelorism correction in  the young child. Plast Reconstr Surg. 1990; 86(2):  214-225; discussion 226-228.   Richardson D and Thiruchelvam JK. Craniofacial  surgery for orbital malformations. Eye (Lond). 2006;  20(10): 1224-1227.   Converse JM and McCarthy JG. Orbital hyper-  telorism. Scand J Plast Reconstr Surg. 1981; 15(3):  265-276.   Hoffman WY, McCarthy JG, Cutting CB and Zide  BM. Computerized tomographic analysis of orbital  hypertelorism repair: Spatial relationship of the  globe and the bony orbit. Ann Plast Surg. 1990; 25(2):  124-131.   Converse JG. Reconstructive  Philadelphia, PA: Saunders; 1977.  Posnick JC, Waitzman A, Armstrong D and Pron G.  Monobloc and facial bipartition osteotomies: Quanti-  tative assessment of presenting deformity and surgical  results based on computed tomography scans. J Oral  Maxillofac Surg. 1995; 53(4): 358-367; discussion 368.  Ortiz Monasterio F, Medina O and Musolas A.  Geometrical planning for the correction of orbital  hypertelorism. Plast Reconstr Surg. 1990; 86(4):  650-657.   Posnick JC. Monobloc and facial bipartition oste-  otomies: A step-by-step description of the surgical  technique. J Craniofac Surg. 1996; 7(3): 229-250; dis-  cussion 251.    Hemifacial microsomia is the second most common con-  genital anomaly of the craniofacial region. Abnormal  development of the structures derived from the first and  second branchial arches results in unilateral hypoplasia  and asymmetry of the orbit, mandible, ear, cranial nerve  VII and overlying soft tissue. Extracranial anomalies may  occur. The characteristic finding of hemifacial microso-  mia, including bilateral involvement, is the asymmetry in  craniofacial development.   Treatment is determined by the age of the patient  (potential for growth) and the severity of the facial defor-  mity affected by the mandibular type. The patient’s psy-  chosocial development should be considered in the timing  of the surgical treatment. The timing of treatment remains  controversial and influenced by the theories surrounding  progressive or stable asymmetry.   Using the Pruzansky classification with the Kaban  modification, most surgeons agree that the mandible types  I and Ha may be treated with conventional orthognathic  surgery or distraction osteogenesis. The mandible types  lb and III typically require reconstruction of the missing  or deficient glenoid fossa-condyle-ramus (GCR) unit using  costochondral grafts. Reconstruction of the affected ear  often occurs between 6 and 9 years of age when the child  is of adequate size to harvest an adequate amount of cos-  tochondral cartilage. The soft-tissue augmentation is typi-  cally carried out after skeletal construction. Augmentation  can be achieved with microvascular free-tissue transfers,  most commonly the scapular free flap, or fat injections,  as we have noted with excellent aesthetic results. This  chapter will describe the comprehensive work-up and the    craniofacial surgical skeletal treatment after growth is  complete for the type Hb or II] mandible in a patient who  has completed pre-surgical orthodontic preparation.    Many patients tend to posture the head towards the  affected side or may have musculoskeletal restrictions. In  such cases, the patient should be examined in resting and  corrected position with the horizontal facial plane estab-  lished (Figure 78.1). Skin markings may help establish the  facial planes. The extent of the facial asymmetry should  be documented and diagnostic photographs should be  obtained.  Assessment should include the following:   ® Occlusal cant (a tongue blade may be helpful) and posi-  tion of dental midlines   ©@ Temporomandibular joint examination (deviation with  opening, any symptoms and range of motion, although  it is not often limited)   @ Intraoral examination, including the overjet and  overbite relationship, the amount of oral opening, the  presence of a lateral shift or centric relation-centric  occlusion (CRCO) discrepancy that is often seen in  hemi facial microsomia (HFM) patients, and the move-  ment of the soft palate.    Figure 78.1 Pre-operative frontal smiling view with patient  in corrected head position. The mandible and chin point are  deviated to the right and there is an obvious maxillary and man-  dibular cant and rotation. The facial nerve is intact.    Figure 78.2 Pre-operative right lateral view demon-  strating right microtia, retrognathia and short posterior face  height.    As well as the two-dimensional (2D) radiographs, pan-  orex, lateral and posterior—anterior (PA) cephalograms,    Figure 78.3 Pre-operative submental view demonstrat-  ing the extreme rotation of the chin point and deficiency of  the right facial soft tissues.    Figure 78.4 Pre-operative 3D reformatted computed  tomography (CT) showing the frontal view of a patient with  left dominant hemifacial microsomia and type IIb mandible.  From the 3D images, it is clear that hemifacial microsomia  is not a unilateral condition but a condition that ultimately  affects growth bilaterally.    three-dimensional (3D) images such as a spiral or cone-  beam computed tomography (CT) with 3D reformatting  prior to surgery helps to appreciate the skeletal deformity  in all planes ( and ). The 3D images have  demonstrated skull base asymmetry and the extreme rota-  tion of the maxilla and mandible. The 3D CT allows for  the fabrication of anatomical models that may be incorpo-  rated into the model surgery.    Figure 78.5 Pre-operative 3D reformatted CT of the lat-  eral view of the same patient as in Figure 78.4.    Advanced technology is allowing for surgical treatment  planning using virtual surgery software. This chapter  will describe the more conventional treatment planning  method.   Ideally, two anatomical models are requested for each  surgical patient. One anatomical model is marked at all  the midline structures whilst the second model is used to  compare the baseline asymmetry. Using the orbital rims  for the horizontal facial plane or an arbitrary horizontal  facial plane if there is orbital dystopia, the projected facial  midline is established by bisecting the horizontal plane  with a perpendicular line. The foramen magnum or sella  in the skull base may provide a reasonable midline struc-  ture in the submental view of the skull. The mandible and  maxilla are then disarticulated from the skull base. For  an ideal aesthetic result, particularly in profile, the steep  occlusal and mandibular planes need to be corrected,  often with the fulcrum in the anterior maxilla on the unaf-  fected side. The affected side often requires even further  lengthening to correct the cant, thus, the surgical move-  ments on the affected side become greater than 10 mm in  most cases. The maxilla is often advanced and rotated to  the facial midline (Figure 78.6). The mandible is then posi-  tioned to the maxilla. The muscle attachments and struc-  tures, such as the inferior alveolar neurovascular bundle,  may limit the ease of moving the mandible into an ideal  position. If necessary, the unaffected side is shortened.   Conventional model surgery is then performed on plas-  ter models of the patient mounted in a semi-adjustable  articulator.    ® Slight over-rotation of the maxilla (1-2 mm beyond the  midline) is helpful.   © The intermediate splint is often bulky and demonstrates  the significant change in position of the maxilla.   ® The final splint can be fabricated in a non-adjustable  articulator with the models in ideal maximal intercus-  pal position and then opened 2 mm at the molars on    Figure 78.6 Model surgery on the anatomical model  demonstrates the significant changes in the position of the  maxilla and the expected rotation of the mandible in the inter-  mediate phase.    the affected side in anticipation for costochondral graft  settling and remodelling.   © The maxillary occlusal plane is obtained with the face-  bow parallel to the projected horizontal facial plane  without placing the ear rod in the external auditory  canal on the affected side if it is abnormally positioned.   @ It may take multiple attempts to establish the CR of the  mandible due to the absence of the GCR unit.    Once the patient is nasally intubated and positioned as  if for an orthognathic procedure, a small area is shaved  over the affected side to allow for a temporal extension of  a preauricular incision (Figure 78.7). Pre-operative anti-  biotics, such as clindamycin and corticosteroids, such as  dexamethasone, are provided. A shoulder roll is placed  for extension of the neck with the head resting in a jelly  doughnut. The patient is prepared and draped in the  standard fashion for an orthognathic procedure. A sterile  kirshner rod (k-rod) is placed between nasion and glabella  to establish the pre-operative vertical position of the max-  illary canines and central incisor and the alar base width.  A throat pack is placed. Local anaesthetic, typically 1%  lidocaine with 1:1,00,000 epinephrine, is injected along the  unaffected ramus and in the maxillary vestibule. As with  a two-jaw orthognathic surgical procedure, the unaffected    side sagittal split osteotomy is initiated but not completed  (see Chapter 72).   Epinephrine-soaked neuropatties are placed in the  incision site for haemostasis. Attention is then directed  to the maxilla where a LeFort I osteotomy is performed  (see Chapter 73). Mobilization of the maxilla with Rowe  disimpaction forceps is critical. Both descending palatine  arteries are routinely preserved. The intermediate splint  is then secured between the mobile maxilla and the man-  dible by using 26 gauge wires. With the mandible carefully  placed in centric relation, the maxilla is rigidly fixed using  2.0 plates at the piriform rims and buttresses (a total of  four plates), starting with placement of the plates on the  unaffected side (Figure 78.8). A laminar spreader is often    Figure 78.7 The skeletal structures and landmarks are  identified and the preauricular incision with the temporal  extension is mapped.    Figure 78.8 The maxilla is mobilized and rigidly fixed.  Note the large intermediate splint and the intermediate posi-  tion of the mandible.    used to stent down the maxilla on the affected side whilst  the plates are placed. Measurements are taken from the  k-rod to the canines and central incisor to confirm that  the cant is corrected according to the planned movements.  The sagittal split osteotomy is completed on the unaffected  side and epinephrine-soaked neuropaddies are placed for  haemostasis. Hypotensive anaesthesia is requested during  the orthognathic procedures.    Sterile preparation and draping of the patient is necessary  for the extraoral approach to the remnant joint and ramus  on the affected side and the harvesting of the costochon-  dral bone grafts. The patient is positioned with the affected  side exposed including the temporal, preauricular and  submandibular incision sites. A soft roll is placed under  the chest, preferably the contralateral chest to take advan-  tage of the favourable anatomy of the rib. A sterile adhesive  drape should be placed adjacent to the oral commissure  to separate the oral cavity from the sterile field. Draping  should be done such that access to the mouth is possible  without contaminating the field. A two-team approach is  ideal and efficient (see Chapter 19 and Chapter 63).   The preauricular incision is made anterior to the con-  structed ear and in the vicinity of the zygomatic root of the  temporal bone. It is not unusual to find the reconstructed  ear over the future site of the reconstructed condyle since  the abnormal ear is often anterior and inferior in position.  Care must be taken not to disrupt the soft tissue overly-  ing the cartilage of the reconstructed ear. The site is anaes-  thetized with local anaesthetic. The preauricular incision  extends to the constructed earlobe inferiorly and has a  temporal extension that allows for greater anterior flap  release and access to the temporalis myofascia if needed  to line the reconstructed glenoid fossa. Despite the hypo-  plasia or agenesis of the local skeletal structures, there is  some remnant of the anterior component of the tempora-  lis muscle. Additionally, identifying the temporalis myo-  fascial plane provides orientation, access to the zygomatic  arch (if present) and allows for protection of the facial  nerve if dissection is kept deep to this plane. Nerve stimu-  lation is performed throughout the dissection to preserve  the facial nerve. Once at the zygomatic arch, the dissection  is carried out to the potential superior joint space. Medial  dissection is kept minimal due to the potential vascula-  ture that resides medially and due to the goal of position-  ing the reconstructed condyle laterally and posteriorly.  A 2-3 cm submandibular incision is made approximately  2 cm below the rudimentary ramus and mandibular angle.  This allows the incision to be below the final position of  the angle and constructed ramus. Dissection is carried  down to the affected mandible using nerve stimulation.  Subperiosteal dissection is continued along the vestigial  ramus to its most superior aspect. Muscle detachment,  including the medial attachments, is necessary around the  vestigial ramus to allow lengthening of the affected side. If    a remnant disc is present, it can be seen around the rudi-  mentary condyle. It typically cannot be used. Blunt dis-  section is used to create a throughway from the mandible  to the superior incision in the region of the zygomatic  root where the glenoid fossa will be reconstructed. Gentle  enlargement of this throughway is possible with blunt fin-  ger dissection to accommodate the costochondral graft.  If there is an elongated coronoid process, it is resected  through either incision. At this point, one person can  access the oral cavity without contaminating the preau-  ricular field and secure the final splint to the maxilla and  place the patient in intermaxillary fixation (IMF) using 26  gauge wires.   The costochondral bone graft with a 3-5 mm cartilage  cap, is positioned from the vestigial ramus to the superior  joint space (Figure 78.9). A 6-7 cm costochondral graft is  often required and positioned posteriorly and as far lat-  erally as possible. A second 6-7 cm rib graft without a  cartilage cap is cut into two shorter grafts; one graft is set  aside for the maxilla and one is used to reconstruct the  glenoid fossa and deficient or missing zygomatic arch, thus  functioning as a posterior and lateral stop (Figure 78.10).  This bone graft is secured to the deficient zygomatic arch  or temporal bone with washers and 10-12 mm 2.0 screws.  Prior to reconstructing the condyle, a temporalis myofas-  cial flap is elevated and wrapped over the zygomatic arch  and secured to the medial tissues with 4/0 interrupted vic-  ryl sutures. This interpositional flap lines the newly recon-  structed glenoid fossa and appears to prevent ankylosis of  the joint. The costochondral bone graft is then secured to  the native mandible (vestigial ramus) using three wash-  ers and 10-12 mm 2.0 screws (Figure 78.11). All sites are  irrigated and a butterfly drain is placed in the area of the  reconstructed condyle which exits in the submandibular    region. The incisions are closed in layers with 4/0 vicryl  with staples for the superficial layer of the scalp and 5/0  nylon for the superficial layer of the preauricular and sub-  mandibular incisions.   Attention is then turned to the oral cavity. The IMF is  released and the mandible is gently opened and closed to  determine the stability of the posterior/superior/lateral  stop and mobility as a unit. Once confirmed, attention is  then turned to the chin to complete the sliding genioplasty  (see Chapter 72). The chin is often advanced, lengthened  and rotated.   With the remaining rib graft, the lengthened maxilla on  the affected side is stabilized with the interpositional bone  graft. It is secured with a plate or sutured to one of the    Figure 78.10 The second rib graft is used as a lateral stop  and augments the deficient zygomatic arch.    Figure 78.11 The costochondral graft is secured to the  native mandible with screws and washers.    fixation plates. All intraoral sites are irrigated and closed  with running 4/0 vicryl sutures. The patient is placed in  IMF elastics for 3-4 weeks (Figure 78.12).   © Resume orthodontics once maxillary splint is removed  (at 7-8 weeks after surgery).   © Soft-tissue augmentation after 6 months, may include  free flap or fat injections.    Figure 78.12 Three years post-operative assessment  demonstrating good facial symmetry and a stable occlusion.  The patient had fat injections of the right face for soft-tissue  augmentation 1 year after the skeletal surgery.    © Prior to soft-tissue augmentation and as patient’s  oedema decreases, soft-tissue asymmetry becomes  marked, skeletal symmetry is stable.    e Preparation and work-up of the hemifacial patient is  the most critical step.   e Diagnostic imaging, particularly 3D imaging, and ana-  tomic models are critical for treatment planning in  patients with severe facial asymmetry.   Anatomic limitations may restrict complete mobili-  zation and ideal positioning of either the maxilla or  mandible.    Brent B. Technical advances in ear reconstruction with  autogenous rib cartilage grafts: Personal experience  with 1200 cases. Plast Reconstr Surg. 1999; 104:  319-334; discussion 335-338.   Inigo F, Jimenez-Murat Y, Arrovo O, Fernandez M and  Ysunza A. Restoration of facial contour in Romberg’s  disease and hemifacial microsomia: Experience with  118 cases. Microsurgery. 2000; 20: 167-172.   Kaban LB, Moses MH and Mulliken JB. Surgical correction  of hemifacial microsomia in the growing child. Plast  Reconstr Surg. 1988; 82: 9-19.   Kaban, LB, Padwa BL and Mulliken JB. Surgical correction  of mandibular hypoplasia in hemifacial microsomia:  The case for treatment in early childhood. J Oral  Maxillofac Surg. 1998; 56: 628-638.   Kearns GJ, Padwa BL, Mulliken JB and Kaban LB.  Progression of facial asymmetry in hemifacial  microsomia. Plast Reconstr Surg. 2000; 105: 492-498.   Longaker MT and Siebert JW. Microsurgical correction  of facial contour in congenital craniofacial malfor-  mations: the marriage of hard and soft tissue. Plast  Reconstr Surg. 1996; 98: 942-950.   Polley JW, Figueroa AA, Liou EJ and Cohen M.  Longitudinal analysis of mandibular asymmetry in  hemifacial microsomia. Plast Reconstr Surg. 1997; 99:  328-339.   Posnick JC. Surgical correction of mandibular hypoplasia  in hemifacial microsomia: A personal perspective.  Journal Oral Maxillofac Surg. 1998; 56: 639-650.   Pruzansky S. Not all dwarfed mandibles are alike. Birth  Defects. 1969; 1: 120.   Rune B, Selvik G, Sarnas KV and Jacobsson S. Growth in  hemifacial microsomia studied with the aid of roent-  gen stereophotogrammetry and metallic implants.  Cleft Palate J. 1981; 18: 128-146.   Werler MM, Sheehan JE, Hayes C, Padwa BL, Mitchell AA  and Mulliken JB. Demographic and reproductive  factors associated with hemifacial microsomia. Cleft  Palate-Craniofac J. 2004; 41: 494-550.    Obstructive sleep apnoea syndrome refers to the condition  of complete or partial airway obstruction during sleep  which disrupts sleep architecture. It also results in exces-  sive daytime somnolence (EDS).   Snoring is noisy breathing during sleep and represents  partial airway obstruction. If loud enough, snoring can  disrupt sleep architecture.    © Excessive daytime somnolence  © Respiratory distress index (RDI) > 20    805  805  805  805  805  806  806  806  806  807  807  807  807  808  809  814    © Fujita classification of obstructive regions  e Type I palate (normal base of tongue)  e Type II palate and base of tongue  e Type III base of tongue (normal palate)  © Radiographic evaluation: lateral cephalometric film -  radiographic analysis (Figure 79.3)   © Safety pinning a tennis ball in a sock to the sleep garment  is helpful in preventing sleep in the supine position.   © Protriptyline may reduce obstructive events by dimin-  ishing rapid eye movement (REM) sleep.   ® Serotonin uptake inhibitors may increase upper airway  muscle tone, particularly in REM sleep.    Nasal dilators may decrease upper airway resistance.  Intra- and extra-nasal dilators only help a few select  patients with nasal airway issues. Nasopharyngeal air-  ways have limited utility because of poor tolerance.   Mandibular repositioning devices are helpful in mild  to moderate cases (Figure 79.4).   Continuous positive airway pressure devices (CPAPs):  Nasal CPAP remains the first line of treatment of obstruc-  tive sleep apnoea (Figure 79.5).    Nasal CPAP pneumatically stents the airway open during  sleep (Figures 79.6 and 79.7).    Initiation of CPAP therapy should commence within a  sleep lab, monitored during polysomnography. Airway  pressures should be increased to the level necessary to  overcome obstruction. Proper instruction is critical to  proper utilization. Compliance is also critical. The device  must be worn all night to correct the ill effects of obstruc-  tive sleep apnoea on sleep architecture.    Studies have shown that refusal rates for prescribed CPAP  therapy range from 58% to 80%. Objective evaluation for  compliance shows that only 40% of patients use nasal  CPAP for at least 4 hours for seven nights out of ten. Poor  compliance can usually be attributed to intolerance of the  device.    Figure 79.6 Lateral view with continuous positive airway  pressure devices (CPAP) and airway pneumatically stented open.    Figure 79.4 (a and b) Mandibular repositioning device,  lateral film tracing of dental device in place.    The goal of surgery should be a cure of the disease.  The particular surgery should be directed at the site of  obstruction.   Phase I therapy is directed towards the upper airway.  The simplest and most conservative option is considered  at a specific anatomic region only when obstruction exists  there.    @ Nasal regions: Correction of nasal obstruction directed  at the specific deformity: nasal valve deformities, septum,  turbinates.   © Hypopharynx: Advancement of tongue base through  genioglossus advancement, infra-hyoid myotomy and  suspension.   © Tongue reduction through partial glossectomy, laser  reduction and temperature-controlled radiofrequency  reduction.    Phase II therapy utilizes maxillofacial skeletal advance-  ment referred to as mandibulo-maxillary advancement  (Figure 79.9).   Pre-surgical preparation involves obtaining accurate  dentofacial records through plaster casts of the jaws.  The dental models must be mounted on an articulator  (Figure 79.8).   In the pre-surgical planning the mandible is advanced  maximally. This is usually about 10-12 mm depend-  ing on the patient and bony morphology of the man-  dible. The maxilla is then advanced to achieve the  original maxillary-mandibular dental relationship.  Cephalometric evaluation of the genial region is con-  sidered to allow maximal advancement with facial aes-  thetics in mind. An acrylic dental splint is fabricated to  allow the desired repositioning of the mandibular dental  model (Figure 79.10).    General nasal endotracheal anaesthesia is required.  A hypotensive anaesthetic technique reduces blood  loss. Patients with obstructive sleep apnoea syndrome  have airways which can present challenges to intuba-  tion. Consequently, jet ventilation equipment must be  available. An awake fibre-optic intubation may be nec-  essary to secure the airway. It is critical that the anaes-  thesiology team be competent in the management of  the difficult airway.   After securing the endotracheal tube, the patient must  be padded, the arms tucked and pneumatic compression  devices placed on the lower extremities to prevent deep  venous thrombosis. Surgery is directed to the mandible  first. Local anaesthetic with epinephrine is injected  along the anterior ramus in a standard fashion. The inci-  sion extends laterally along the mandibular body region    and terminates in the molar region. A full-thickness  mucoperiosteal flap is elevated exposing the lateral    Figure 79.8 (a) Lateral view of pre-and post-MMA diagram.  (b) Post-operative panoramic view. Note increase is posterior  airway space (PAS).    ramus and body region. Dissection is then directed  along the medial ramus region taking care to protect the  inferior alveolar neurovascular bundle. A forked retrac-  tor is extended up the anterior ramus to the coronoid.  A clamp is then used to retract the tissues. A horizontal  osteotomy is then made through the medial cortex. The  osteotomy then is continued anteriorly to the body of the  mandible, staying medial to the external oblique ridge.  It terminates in the first or second molar region depend-  ing on the amount of anterior movement required. A  vertical osteotomy is then made in lateral body. A sagit-  tal split is then made and the segments freely mobilized.  The inferior alveolar nerve is gently mobilized from the  proximal segment (Figure 79.11).   The acrylic splint is then affixed to the teeth and the  jaws are wired shut and into the new desired occlusion.   The mandibular condyles are then seated into the most  posterior-superior portion of the glenoid fossa. The bony  segments are then clamped together and rigidly fixed  together with titanium bone plates and/or screws.   The jaws are then released and the occlusion and bony  segments are checked for accuracy and stability with the  condyles seated.   Attention is then directed to the maxilla. Once again,  local anaesthetic with epinephrine is injected in the area  of planned surgery (Figure 79.12).   A modified incision is then made in the anterior  maxillary vestibule with the electrocautery unit from  the anterior maxilla and terminating in the zygomatic  buttress region. A full-thickness mucoperiosteal flap is  elevated exposing the anterior maxilla. The anterior nasal  spine is exposed and the nasal floor mucosa is elevated.    Figure 79.11 (a-c) Sagittal split advancement of the  mandible, manually mobilize segments.    Figure 79.12 Attention is then directed to the maxilla.  Once again, local anaesthetic with epinephrine is injected in  the area if surgery is planned.    A horizontal osteotomy is made from the lateral  pyriform rims extending posteriorly to the malar region.  Osteotomes are then used to osteomotize the lateral nasal  bony walls. A guarded osteotome is then used to achieve  nasomaxillary separation. Finally, a curved osteotome is  used to achieve pterygomaxillary separation.   Disimpaction forceps are then used to down fracture  the maxilla. The maxilla must be freely mobilized so that  it will passively advance to its new anterior position.   The jaws are then brought back into the original occlu-  sion taking great care to seat the mandibular condyles  again. The jaws are wired together again. The advance-  ment of the maxilla is such there is little bony overlap and  this can result in poor stability. This can be addressed with  the mortizing of a piece of cadaveric cortical bone between  the segments (Figure 79.13).   Rigid fixation is then used in the pyriform rim and  malar buttress regions with titanium plates and screws.   A demineralized bone matrix can be applied to the oste-  otomy sites along with a restorable membrane. This modi-  fication can result in a more rapid bony healing and lessens  sinusitis issues from a large gap in the bony segments.   Whilst the jaws are still wired together, attention is  directed to the genial region. Once again, local anaes-  thetic with epinephrine is injected in the planned area  of surgery.   An incision is then made in the labial mucosa and then  advanced ina stepped fashion to the anterior genial region.  The genial region is degloved. A horizontal osteotomy can  be performed in the standard fashion (Figure 79.14) or just  the segment containing the genial tubercles (Figure 79.15).   It is critical that with each technique, the genial tubercles  be included in the mobilized segments.   The segment including the genial tubercles is advanced  and secured with rigid fixation. Demineralized bone  matrix may be used to fill any osteotome gaps (Figure 79.16)    If the chin contour would be damaged by an advance-  ment genioplasty, the genial tubercles can be advanced in  isolation (Figure 79.17).    Attention is then directed to the hyoid region. The area  of planned incision directly overlying the hyoid bone  is marked with a pen. An incision is then made in the  skin with the scalpel. Haemostasis is obtained. Blunt  dissection is continued until the hyoid is encountered.  The hyoid bone is exposed. Then, infra-hyoid muscles  are released. Two permanent braided synthetic nonre-  sorbable sutures are then passed around and under the  hyoid laterally and passed subcutaneously up into the  genial region. Two holes in the mobilized genial segment  are made with the drill and the sutures passed through  them. The sutures are then passed around and under the  hyoid laterally and passed subcutaneously up into the  genial region. Two holes in the mobilized genial segment  are made with the drill and the sutures passed through  them. The sutures are then tightened to the desired level  of hyoid suspension and tied securely.    Figure 79.16 (a and b) Demineralized bone matrix to fill  osteotomy gap.    In this technique, the inferior body of the hyoid is  stripped of muscle and then advanced over the thyroid  cartilage and sutured to its superior aspect. The superior  hyoid musculature is left intact.   Wound closure of the mandibular and hyoid regions  can be accomplished in a standard fashion. However, clo-  sure of the maxillary wounds merits some elaboration.  The standard technique using an alar cinch suture in the  lateral nasal region to prevent unaesthetic widening of the  nose should be used with caution. Since this surgery is for  an airway problem, the alar cinch should not be so tight as  to narrow the nasal airway.   The maxillary mucosa closure should incorporate a  V-Y advancement to prevent wound contracture and  undesired shortening of the upper lip.   After wound closure, a pressure dressing should be  adapted to the mandibular regions.   Closure of the incision of the hyoid region is performed  in a standard fashion after haemostasis has been obtained.   It is prudent to keep these patients intubated and in  the intensive care unit overnight. As their clinical status  dictates, they can usually be weaned and extubated on  post-op day 1. It is also wise to keep them in the intensive  care unit one additional night after extubation.   The post-surgical management of the sleep apnoea  patient is similar to other orthognathic patients, with a  few exceptions. Their airways will hopefully be greatly  improved after surgical intervention. Nonetheless, post-  surgical oedema will impact their airway in a negative  fashion until it resolves. In most cases, the airway is so  greatly improved that nasal CPAP is not necessary, even in  the presence of post-surgical oedema.   In the personal experience of the authors, the post-  surgical management of sleep apnoea surgery patients  has been remarkably trouble-free. This supports the  concept that once the airway is open for normal respira-  tion during sleep, the associated co-morbidities are often  ameliorated.    Kribbs NB, Pack AI, Kline LR, Smith PL, Schwartz AR,  Schubert NM et al. Objective measurement of pat-  terns of nasal CPAP by patients with obstructive sleep  apnea. Am Rev Respir Dis. 1993; 149: 287-288.   Powell N, Riley RW, Guilleminault C and Murcia GN.  Obstructive sleep apnea, continuous positive airway  pressure and surgery. Otolaryngol Head Neck Surg.  1988; 99: 362-369.   Riley R, Powell N and Guilleminault C. Cephalometric  roentgenograms and computerised tomographic scans  in obstructive sleep apnea. Sleep. 1986; 9: 514-515.   Riley R, Guilleminault C, Powell N and Derman S.  Mandibular osteotomy and hyoid bone advancement  for obstructive sleep apnea: A case report. Sleep. 1984;  7: 79-82.   e Use bone grafts in the maxilla along with demineral-  ized bone matrix and resorbable membranes to aid in  complete bony union.   e Advance the hyoid so far to allow for some relapse, and  still stent the airway open.   e Keep the patient sedated and on the ventilator for the  first post-operative night.   Introduction 817  Indications 817  Case selection and pre-procedure preparation (general principles) 817  Fillers 818  Ideal Properties of a filler 818  Principles of autogenous fat injection as fillers 818  Techniques of fat harvesting and transfer 818  Post-operative instructions and care after fat transfer 821  Complications 821  Synthetic fillers 821  Technique for nasolabial fold augmentation 822  Silicone oil 822  Polymethylmethacrylate microspheres (Artefill, Artecoll) 823  Polyacrylamide hydrogel (Aquamid) 823  Botulinum toxin type A (botox) 824  Preparation and recommended method for usage 825  Patient selection, counselling and informed consent 826  Suggested readings 828    Methods of restoring facial aesthetics in a non-invasive  or minimally invasive way is now well established. The  armamentarium of the modern cosmetic surgeon includes  Botox, fillers, peels, lasers and radiofrequency wave appli-  cation. The skin is a major indicator of a person’s age and  health. With ageing, the dermis becomes thinner and the  epidermis becomes either thicker or thinner. There is, in  addition, bone resorption, the appearance of furrows,  wrinkles, crow’s feet and platysmal bands in the neck.  One of the main reasons why patients seek treatment  for age changes is to restore soft-tissue volume, contour  and absorption or reduction of wrinkles with the aim to  restore a youthful appearance.    © Soft-tissue atrophy, e.g. thinning of the lips  © Appearance of crow’s feet, glabella furrows  ® Lipoatrophy of the face, e.g. cheeks   ® Bony resorption leading to reduction of facial bony con-  tour, loss of facial height    e Any patient who wishes to look younger is a potential  candidate for rejuvenation by non-invasive methods  provided he or she fully understands what is realis-  tically possible to achieve and accepts the potential  complications.   In general, smokers and those who indulge in heavy  or regular consumption of alcohol are not good  candidates.   Patients with adverse medical histories, for example  uncontrolled diabetes, those on warfarin, abnormal  bleeding disorders and those prone to developing fre-  quent herpetic infections in the peri-oral region are not  good candidates.    Medications containing aspirin and nonsteroidal anti-  inflammatory agents should be discontinued at least  5-7 days before any minimally invasive surgical pro-  cedure. Likewise, herbal formulations, gingko biloba,  ginseng, garlic and ginger should also be discontin-  ued. Minimally invasive procedures such as injection of  fillers intradermally should be avoided during active acne  eruptions.   Patients should be given a detailed explanation regard-  ing the likely outcome of the procedure and techniques  involved, materials being used and their known adverse  effects before any procedure is undertaken.    Soft-tissue augmentation may be accomplished by surgery  or intradermal injection of synthetic or biological mate-  rials. Soft-tissue augmentation using various fillers has  gained enormous popularity as there is no recovery time  and it can be conveniently undertaken at the end of a week  to allow recovery during a weekend.    Ideally, it should be of non-animal origin, biocompatible,  biodegradable, having low risk of allergic reaction, easy  to use and having minimal side effects such as bruising,  infection, migration and tissue reaction.   An injectable filler should be able to restore facial con-  tour. There are several fillers available and they include the  following:    © Autologous fat is harvested with an open tipped blunt  cannula under tumescent local anaesthesia.   © Harvested fat is transferred to 1-mL syringes for  injection into the areas concerned.   ® Injection of fat into the deep tissues of the face is carried  out using a small bore blunt cannula.   e Any patient who wishes to restore their facial  contour would be a good candidate for pan facial fat  augmentation.    @ Any patient who has a recent history of deep venous  thrombosis, pulmonary embolism, compromised liver  function, allergy to lignocaine, coagulopathy or  inability to stop anticoagulant drugs is contraindicated  for fat augmentation.    1. Pre-operative assessment using photographs: discuss  with the patient areas for augmentation. If adjunctive  microliposuction is planned, e.g. neck, jowls, indicate it  on the photograph. An A4 photograph permits a large  image for discussion. Take frontal, lateral and inferior  oblique views.   2. Laboratory work-up includes pregnancy test if  premenopausal, clotting profile, full blood count, renal  and liver profiles.   3. An antibiotic is administered orally or intravenously  1 hour before the procedure. A first generation cepha-  losporin is preferred.   4. Tumescent local anaesthesia solution is prepared using  500 mL of Ringer’s Lactate, 0.5 mg of epinephrine,  1% lignocaine 25 mL. Anaesthetic solution is admin-  istered into the prospective donor site for fat harvest  (Figure 80.1). I prefer the anterior abdominal wall  (Figure 80.2) or outer thigh. When the local anaesthetic  has taken effect, make an incision with a size 11 blade  as a stab and introduce a curved haemostat to create a  subcutaneous tunnel (Figure 80.3). Other areas which  can be used are hips or posterior waist. Subsequently,  the tumescent solution is infiltrated (Figure 80.4). After  injection wait 15-20 minutes.   5. A low negative pressure is created in a 10-mL syringe.  An open tipped cannula (Figure 80.5) is attached  to the syringe and is inserted into the donor site  through the same small stab incision. The cannula  is moved back and forth within the donor site 1-cm  below the skin surface. This will help to avoid surface    Figure 80.2 Anterior abdominal wall donor site. Figure 80.4 Infiltration of tumescent solution.    Figure 80.5 Aspiration of fat using 10-mL syringe from  anterior abdominal wall.    irregularities. The plunger of the syringe containing 6. Injection of fat is carried out with blunt cannulas and    the harvested fat is released, the cannula removed  and the syringe is capped (Figure 80.6) and allowed  to stand in a test tube. Centrifuge the collected fat  in 10-mL syringes placed in a centrifuging machine  at 3400 rpm for 20 seconds. The centrifuged fat will  separate from an infranatant which consists of, at the  top, liquid triglyceride, blood and tumescent fluid,  and below, the fat (Figure 80.7). Carefully decant off  the top layer. Transfer the fat from the 10-mL syringes  into 2-mL syringes using a connector (Figure 80.8).  From these syringes fat is injected into the recipient  sites which have been marked at the commencement  of the procedure (Figure 80.9).    the injection is done as a ‘layering’ technique  (Figures 80.10 through 80.12). If injection is done in  the forehead, small incisions are made at the hairline.  Injection is done in a plane above the galea. Fat can  be transferred to the glabella, forehead, upper eyelids  and brow. Fat can also be injected into the lower eyelid,  for example when too much fat has been removed dur-  ing blepharoplasty or tear-trough deformities seen in  ageing. In this area, fat is injected in a subcutaneous  plane.    . Fat augmentation of the buccal area is via a stab inci-    Harvested fat in 10-mL syringe being  Fat in harvested syringes. transferred from 10-mL syringe to 2-mL syringe via a connector.    Harvested fat in 10-mL syringe allowed to  stand vertically, supernatant fluid is injected.   ing lines and lips can be augmented. Prior to introduc- .  tion of the fat to augment the lips, carry out an incision  between the muscle and the skin and introduce fat  into this plane. The vermilion of the lips can also be    Typically, the author uses approximately 3 mL for the =<  upper and 2-3 mL for the lower lip. -    8. Fat augmentation can also be successfully used  in the nasolabial creases and labiomental creases Harvested fat being injected into recipient  (Figure 80.13). site, demonstrating the layering technique.    Figure 80.11 Harvested fat being injected into recipient  site, demonstrating the layering technique.    © As oedema after fat transfer by blunt infiltration can  be profound, prescribe oral steroids in a dose of 40-mg  prednisolone 1 hour before the procedure and a daily  dose post-operatively for 2 days.   ® Ice packs for 48 hours for at least 20 minutes/hour.   ® Medications such as aspirin, plavix, blood thinning  supplements or vitamin E should be avoided for  72 hours.   ® No active physical exercise, such as jogging, weight  training or swimming, should be undertaken for  1 week.    Figure 80.13 Appearance after injection of fat into recipi-  ent areas (4 weeks after injection).   pulse light (IPL) can be used and, with two or three ses-    Polymers of lactic acid are currently available commer-  cially as injectable poly-t-lactic acid, a biodegradable poly-  mer. They are in the same family of aliphatic polyesters  such as glycolic and citric acid. They are available as mic-  roparticles measuring 40-63 tm in diameter suspended in  sodium carboxymethyl cellulose. Upon injection into the  subcutaneous tissue or deep intradermal space, it under-  goes gradual degradation over a period of years and there  is increased collagen fibre formation around the micropar-  ticles with the passage of time.   It is available as a lyophilized powder which is  reconstituted with 3-5-mL sterile water. The powder  is mixed thoroughly with water to achieve a homog-  enous mix and the preparation is carried out prefer-  ably 2 hours before the injection. The author prefers to  use 5-mL dilution except in cases where there is marked  lipoatrophy when 3-mL dilution is used. I usually apply    a eutectic mixture of local anaesthetics (EMLA) cream  topically 45 minutes before injection or give a local  anaesthesia. Upon injection, a sculpting massage is car-  ried out for approximately 2-3 minutes. The injection  can be repeated at 4-week intervals.   The author has used this product as a filler for deep  nasolabial folds, as a subperiosteal injection over the  dorsum of the nose for subtle augmentation and subperi-  osteally in the lower orbital rim for tear-trough deformi-  ties. Granuloma formation has been encountered in two  of ten patients. The granuloma was difficult to treat and  hyaluronic acid derivatives are now used instead.   For several years, bovine collagen was the gold standard  as a soft-tissue augmentation material. However, it is only  short-lived and serious hypersensitivity reactions have  been reported. To overcome this, human-based collagen  has been used.   Hyaluronic acid-based fillers are ideal because they  are less immunogenic and have a longer duration effect  than collagen. Patient tolerability is good. Hyaluronic  acid as smaller particles is marketed by Q-Med Uppsala  as Restylane and larger particles as Perlane. Restylane  usually lasts approximately 6 months and Perlane can last  6-12 months. The same company also produces hyaluronic  acid of even greater size (Macrolane). The hyaluronic acid  injections can be repeated at 4-6 month intervals. These  fillers are a useful adjunct in facial cosmetic procedures.  They very rarely cause allergic reaction. The US Food and  Drug Administration (FDA) has approved hyaluronic acid  (Restylane) as a filler for nasolabial fold augmentation.  Injection-related side effects include bruising, erythema,  pruritus and discolouration. Sometimes granulomas  occur and they respond well to injection of corticosteroids  followed by massage.    Prior to injection, the area is cleaned with an antiseptic  solution. A local anaesthetic is used. The filler of hyaluronic  acid origin is injected into the deep and mid-dermis with  Perlane and subsequently Restylane is used for surface  feathering. The material is injected while withdrawing the  needle. Complications include bruising, bleeding, swelling  and uneven surface irregularities (rarely), discolouration  of skin, pruritus and delayed skin reactions.    Silicone oil has been used in its injectable form for filling  defects of the facial soft tissue in HIV positive patients who  develop lipodystrophy. Use of silicone in its liquid form as a  filler is controversial. Currently, the FDA has approved liquid  silicone for retinal tamponade (a viscous compound of 5000  centistokes) manufactured by Bausch & Lomb, California.    The persistence is longer according to particle size. Silicone  liquid of 1000 centistokes manufactured by Alcon Labs,  Fortworth, Texas, is also useful for soft-tissue augmentation.  It is inexpensive, can be sterilized, does not permit bacterial  growth and it can be stored without refrigeration. Currently,  there are multicentre trials in progress using liquid silicone  oil for soft-tissue augmentation. To avoid complications sili-  cone should only be used in small amounts.   ® Patients who have complications due to silicone  injection by another practitioner    1. Inject using microdroplet technique as very small  amounts into deep dermis  2. Treatment can be repeated after 6 weeks   @ Facial skin necrosis, granuloma formation, formation of  nodules (Figure 80.14).   @ When injected superficially, it produces erythema over  the overlying skin and recurrent inflammatory oedema  (Figure 80.15).   © The only way to prevent complications is to use only  small amounts of pure silicone oil.   @ Delayed reactions such as rosacea and rosacea-like  syndromes can develop years after injection. Likewise,  granulomas can develop years later.    ® Oral prednisolone starting with 40 mg/day and tapering  over 10 days   @ Intralesional corticosteroid injection starting at  5 mg/cm? and increasing up to 30 mg/cm? every 3 weeks    Figure 80.14 Injected silicone producing nodule over the  glabella and granuloma at the tip of the nose.    This product has been approved by the FDA as a soft-tissue  augmentation material. It is a suspension of polymethyl  methacrylate microspheres in 3.5% bovine collagen. It is  useful to fill subcutaneous atrophy and atrophy of the buc-  cal fat pad. It is best to inject small amounts each visit in  incremental doses 4-6 weeks apart as it is a permanent filler.   ® Granulomas and nodule formation can occur after  years.  The author has encountered this in a patient who had  it injected 3 years previously. If the nodule does not  respond to corticosteroid injection, excision would be  the choice.   @ Artecoll should not be used in areas of thin skin,  e.g. lower eyelid.    @ Artecoll should not be injected intradermally. It should  only be injected subdermally.   elt is best to inject it in very small amounts  incrementally.    Note: As bovine collagen is the vehicle for the micro-  sphere particles, allergy testing must be carried out prior  to use.    In the last few years, the author has used this prod-  uct as the preferred choice. It is supplied in 1-mL  syringes as an injectable form containing 97.5% non-  pyrogenic water. It is long lasting, biocompatible and  does not migrate from the site of injection. It contains  no animal extracts and has been authorized for sale in  Europe since March 2001 and requires no prior allergy  testing.    @ It is best injected under local anaesthesia by an  appropriate nerve block. It is best to use a 27-gauge  needle for injection.   ® Do not overcorrect.  If in doubt, add in increments as a touch up 1 week later.   ©® The gel should not be injected intradermally. Do not  inject polyacrylamide gel into an area where another  filler has been injected previously until absorption has  been complete.    ® Do not inject sites where there is active skin disease or  inflammation.   © Injection when herpes labialis is present should not be  carried out.    ® Ice pack application locally for 48 hours for at least  20 minutes per hour for 12 hours.  @ Avoid direct sun exposure for 24 hours.    © Bruising and oedema.  @ In very few instances, allergic reactions have been  reported.    In general, injectable fillers can result in adverse reac-  tions and complications and are summarized below as  follows:    @ Reactions at the site of injection - pain, bruising,  oedema, erythema, itchiness   © Hypersensitivity reactions - erythema, nodules, formation  of granulomas resulting in lumps (Figures 80.14 and 80.15)    Facial enhancement using Botox (Allergan Inc., Irvine,  California) is a safe and effective procedure for the abo-  lition of lines and wrinkles on the face. Lines typically  occur due to muscular contractions of the facial muscles  (Figure 80.20). Botulinum toxin type A can temporar-  ily eliminate these lines and enhance the effect of laser    resurfacing procedures. It is now well accepted by cosmetic  surgeons that pretreatment of wrinkles and lines due to  hyperfunctioning of the muscles with Botox followed by  laser resurfacing gives optimal results.   It has been observed that, in Asians, resurfacing results  in troublesome pigmentary complications and hence it is  not a good option for elimination of wrinkles and lines.  Botox is the best primary line of treatment for abolition  of these lines. In Caucasians, where skin resurfacing is  undertaken for facial rejuvenation, rhytides can reappear  after resurfacing, particularly in the glabella and crow’s  feet area.    Botox is supplied in a vial which contains 100 units of  vacuum dried complex of neurotoxin (Figure 80.21). Dilute  this with 2 or 2.5 mL of 0.9% preservative free saline to a  concentration of either five or four units/0.1-mL dilution.  In most instances, use 2-mL dilution as it minimizes dif-  fusion of the solution to neighbouring muscle groups.  Upon reconstitution with preservative-free saline, it can  be stored at 4°C and be used with no decrease in efficacy  for up to 2 weeks.    1. Open the bottle of Botox (botulinum toxin A) by remov-  ing the cap.   2. The rubber cover is sterile and does not need to be wiped  with a spirit swab.    3.2.5 mL of preservative free saline is drawn up in a  2.5-mL syringe with a size 25-gauge needle with no air  bubbles.   4. The syringe containing saline is held vertically and the  needle pierces through the rubber bung of the freeze-  dried Botox vial. There is no necessity to inject as the  negative pressure in the bottle will suck in the saline. The  bottle should not be shaken but gently rolled between the  palms of the hands to ensure a good, even mix.   5. The mixed Botox solution is now drawn through the  25-gauge needle into insulin syringes. Use either a  30-gauge half-inch or 32-gauge half-inch needles  attached to the insulin syringe to inject the Botox.    In order to reduce pain, always use ice application to the  area concerned for at least 10 minutes and after injection  for another 5-10 minutes. Upon injection, it should not be  massaged as this will result in rapid diffusion producing  undesired side effects.   @ Skin thickness (thicker skin in some Asians will require  a higher dose)    Table 80.1 illustrates the units used for the various  applications in facial rejuvenation.  The following illustrates the various sites for injection:    When injecting into the muscle mass, the injection needle  should be perpendicular to the skin and into the muscle. In  areas where skin is thin, for example peri-ocular, the injec-  tion needle should be in a subcutaneous plane.    Masseteric hypertrophy Women 30, men 35  Bunny lines on the nose 3  Lines along the lateral wall 4  of the nose  Poppy chin Women 5, men 8    Figure 80.22 The points for injecting Botox in treating the  glabella complex.    Figure 80.23 The points at which Botox is injected typically  for forehead horizontal lines and the glabella complex.    Figure 80.24 The injection sites for crows feet. It should  be a minimum of 1 cm lateral to the orbital bony rim.    The initial consultation is critical in understanding the  patient’s expectations of the treatment if unhappy patients  are to be avoided. A medical and drug history is essential.  Patients on aspirin, nonsteroidal anti-inflammatory drugs  or vitamin E should stop the medications 7-10 days before  treatment to avoid bruising. Likewise, anticoagulants  should be adjusted appropriately by the treating physician  to bring the international normalized ratio (INR) to around  two or if there is no contraindication to stop the warfarin at  least 72 hours before the procedure.   In the initial examination, document the wrinkles and  lines seen in a static position and in a dynamic setting.  Most patients would like to know the safety of Botox,  particularly if they are having the treatment for the first  time. There is adequate evidence to support the fact that  botulinum toxin when used in facial areas has long-term  safety issues. It is important to discuss known adverse  effects reported such as ptosis, headache, pain at injection  site, bruising, unexpected results such as brow asymme-  try, drooling of saliva and asymmetry at the angle of the  mouth. Botulinum toxin A should not be given in the fol-  lowing conditions:    Some of the specific uses at certain anatomic locations  are listed below.    The musculature responsible for producing the deep fur-  rows in the glabella complex are corrugator supercilii,  procerus and depressor supercilii (Figure 80.27). The  fibres of ocularis oculi and frontalis interdigitate with the  corrugator. The corrugators move the eyebrow medially  inwards and depress the brow. Procerus is also a depres-  sor of the medial eyebrow. Orbicularis oculi also depresses  the medial eyebrow. Injection sites for the glabellar com-  plex are shown in Figure 80.22. In general, for the glabella  complex an average of 20-25 units of Botox at 2-mL dilu-  tion is used. Men require a greater dosage (approximately  30-35 units). In oriental women with epicanthal folds, a  lower dose is used and the author does not exceed 15 units.  Patients are seen at 2 weeks and another 5-10 units rein-  jected, if necessary. Use four or five units at each injection  point depending on the depth of the furrows. Always see  these patients at 2 weeks and carry out ‘top ups’. If this area  has to be retreated, the author waits 4-6 months.    The hyperactivity of the large vertically oriented fron-  talis muscle is responsible for the horizontal lines.  The frontalis elevates the brow. It is very important while  injecting Botox into the frontalis that the needle should be  2 cm above the orbital rim to prevent brow ptosis. Do not  inject the horizontal lines at the same sitting as the vertical  furrows of the glabellar complex. The author usually defers  it by 2 weeks. Inject the first horizontal line and ensure  that you are 2 cm above the orbital rim. Three injection  sites are generally used on either side of the midline for  each line for men and two sites for women. Use a total of  approximately 20 units for women and 30 units for men.  If brow elevation in a female patient has been discussed as  part of the treatment, use 2—4 units into the lateral orbicu-  laris oculi so that the frontalis is unopposed.   Recall all patients after 2 weeks and carry out ‘top ups’.  One important aspect of injecting Botox into horizontal  lines is to assess brow asymmetry at the initial visit and  show this to the patient.    These result from hyperactivity of the orbicularis oculi  muscles. Prior to injection of this area, assess for lower eye-  lid laxity and lid retraction. The orbicularis oculi encircles  the eye as a sphincter. In treating crow’s feet, an injection  is made into the lateral orbital component of the orbicu-  laris oculi. Depending on the lines, typically use three to  five injections.   The injection site should be 1.5 cm from the orbital rim.  The author would normally use four or five units per site.  Recall patients in 2 weeks and top up if necessary. Prior    to injection, ice application is used to minimize bruis-  ing as the injection is made subcutaneously. Injection  should not be carried out for at least 4 weeks following a  blepharoplasty or a rhytidectomy or laser assisted in situ  keratomileusis (Lasik).    They are seen on the sides of the nose and result from con-  traction and hyperactivity of the transverse portion of the  nasalis. Into each line no more than two units is necessary  and another two units in the midline into the procerus  (dilution 2.5 mL).   The use of Botox in the peri-oral area should be avoided  and instead fillers used. Dimpled chin is due to hyperactiv-  ity of the mentalis muscle. Typically the author uses five  units/injection into two sites (usually 10 units in total) and  top-up 2 weeks later (Figure 80.26). Platysma bands can  also be treated by Botox (see Figure 80.20). They appear as  vertical bands. Typically for a vertical band, use five to six  injection sites (25-30 units in total) and top up 2 weeks later.  One of the complications of injecting into the platysma  bands is dysphonia, dysphagia and neck weakness.    Figure 80.27 (a) Pre-Botox injection — 40-year-old female.  (b) Post-Botox injection (4 months later) - 40-year-old female  showing abolition of furrows in glabella complex and brow  elevation. Brow plasty done with Botox injection four units on  each side.    Harvested fat can be stored long term at -20°C for up to 2 years.   Fat can be reinjected at 6-12 weeks intervals by rapid thawing.   When fat is stored, it is best saved in labelled 10-mL syringes. The infranatant should be decanted, but the triglyceride layer  kept intact.   In the first post-operative visit a week later, fat protrusions may exist. Use a Coleman cannula to ‘feather’ this using a negative  suction in a 10-mL Luer-Lock syringe (lipo-sculpturing).   Fat injected into the lips disappears rapidly and is not the ideal choice as a filler for the lips.    Give as much information as possible to your patient regarding the filler you propose to use. In particular, discuss all  complications and your reasons for recommending the particular fillers.   Avoid using them in patients taking medications likely to promote bleeding and bruising, e.g. aspirin, plavix, anticoagulants.  Stop these medications including supplements, e.g. gingko biloba, for at least 5-7 days before the procedure and do not  recommence until after 48 hours.   Each agent requires a different technique and when you begin, learn from someone who has used the material for some time  and attend a course.   Select your filler according to your wish for a more permanent, semi-permanent or temporary result. If a permanent filler is  to be used, over-correction should be avoided. Inject permanent fillers ina much deeper plane. Liquid silicone is notorious in  producing fibrosis if injected subcutaneously.   In general | advise against the use of collagen or collagen containing fillers.   The safest are hyaluronic acid derivatives of synthetic origin and polyacrylamide gel.   Inject fillers, when possible, under local anaesthetic block to avoid pain.   Ask your patient to report immediately if any adverse reaction is noted.    Carry out a careful assessment of the wrinkles and lines at rest and in function.   Give a detailed explanation of the underlying problems, your proposed treatment plans, known complications and contact  details of the clinic should any complications arises.   e The patient must understand that the effect of Botox is temporary and further treatments will be necessary.   e Stop all medications such as vitamin E, aspirin, anticoagulants, supplements, e.g. gingko biloba, at least 7 days before the  procedure.   e Apply an ice pack for at least 10 minutes prior to injection and another 5 minutes after injection.   e Noinjection of Botox should be given into areas where there is skin infection.   Aronsohn RB. A 22-year experience with the use of silicone Personal experience over 5 years. Dermatol Surg.  injection. Am J Cosmet Surg. 1984; 1: 21-28. 2005; 31: 1561-1565.   Barnett JG and Barnett CR. Treatment of acne scars Carruthers A, Carey W, De Lorenzi C Remington K,  with liquid silicone injections: 30-year perspective. Schachter D, Sapra S. Randomized, double-blind  Dermatol Surg. 2005; 31: 1542-1549. comparison of the efficacy of two hyaluronic acid   Butterwick KJ. Fat autograft muscle injection (FAMI): New derivatives, restylane perlane and hylaform, in the  technique for facial volume restoration. Dermatol treatment of nasolabial folds. Dermatol Surg. 2005;    Danesh-Meyer HV, Savino PJ and Sergott RC. Case reports  and a small case series: Ocular and cerebral isch-  emia following facial injection of autologous fat. Arch  Ophthalmol. 2001; 119: 777-778.   Dreizen NG and Framm L. Sudden unilateral visual loss  after autologous fat injection into the glabellar area.  Am J Ophthalmol. 1989; 107: 85-87.   Duffy DM. Tissue injectable liquid silicone: New perspec-  tives. In: Klein A (ed.), Augmentation in Clinical  Practice: Procedures and Techniques. New York, NY:  Marcel Dekker; 1998. pp. 237-263.   Duffy DM. Liquid silicone for soft tissue augmentation.  Dermatol Surg. 2005; 31: 1530-1541.   Duffy DM. Complications of fillers: Overview. Dermatol  Surg. 2005; 31: 1626-1633.   Egido JA, Arroyo R, Marcos A and Jimenez-Alfaro I.  Middle cerebral artery embolism and unilateral visual  loss after autologous fat injection into the glabellar  area. Stroke. 1993; 24: 615-616.   Feinendegen DL, Baumgartner RW, Schroth G, Mattle HP  and Tschopp H. Middle cerebral artery occlusion and  ocular fat embolism after autologous fat injection in  the face. J Neurol. 1988; 245: 53-54.   Mattle HP, Regli F, et al. Autologous fat injections  for soft tissue augmentation in the face: A safe proce-  dure?. Aesthet Plast Surg. 1998; 22: 163-167.    Klein AW and Rish DC. Substances for soft tissue augmen-  tation: Collagen and silicone. J Dermatol Surg Oncol.  1985; 11: 337-339.   Le AT. Rhinoplasty using injectable polyacrylamide gel -  A patient study. Austral J Cosmet Surg. 2005; 1: 1.   Lee DH, Yang HN, Kim JC and Shyn KH. Sudden unilateral  visual loss and brain infarction after autologous fat  injection into the nasolabial groove. Br J Ophthalmol.  1996; 80: 1026-1027.   Orentreich D. Liquid injectable silicone. Clin Plast Surg.  2000; 27: 595-612.   Orentreich DS and Orentreich NO. Injectable fluid silicone:  Principles of dermatologic surgery. In Roenigk RK and  Roenigk HH (eds.), Dermatologic Surgery: Principles  and Practice. New York, NY: Marcel Dekker; 1989:  1349-1395.   Teimourian B. Blindness following fat injections. Plast  Reconstr Surg 1988; 82: 361.   Thaler MP and Ubogy ZI. Artecoll: The Arizona experience  and lessons learned. Dermatol Surg. 2005; 31:  1566-1576.   Vleggaar D. Facial volumetric correction with injectable  poly-t-lactic acid. Dermatol Surg. 2005; 31:  1511-1518.    Modern hair restoration surgery (HRS) has evolved  significantly since its original introduction in the United  States in 1959. HRS includes many different techniques  including hair transplantation (HT), scalp reduction,  scalp flaps and tissue expansion. The most common cause  of hair loss is androgenic alopecia (AGA), more commonly  known as male pattern baldness. Other processes that lead  to hair loss are trauma, diseases such as alopecia areata  and lichen planopilaris, and iatrogenic causes, most com-  monly prior surgery.    The modern surgical treatment of AGA was introduced in  the United States by Norman Orentreich with the publica-  tion of his landmark article hypothesizing his theory of  donor dominance. He postulated that autografted hair fol-  licles grew in bald scalp because the hair-bearing donor  tissue retained its dominant expression despite being  transplanted into a bald scalp. Thus, the modern HT  was born.   The essence of HT is the movement of hair-bearing  donor tissue from the ‘permanent’ occipital scalp to the  balding frontal scalp in the same patient. This is sim-  ply rotation of current hair inventory; more hair is not  produced, just simply rearranged. Orentreich originally    accomplished this by taking 4-mm round punch biop-  sies of occipital scalp and placing them in the bald  frontal scalp. The grafts would take and hair would  grow in the previously barren scalp. For most balding  men and women, this was a miracle and an answer to  their hair loss concerns. For Orentreich’s patients at the  time, any hair was good hair regardless of its unnatural  appearance.    Factors affecting the success of an HT procedure are  numerous and must be considered in the treatment of any  hair deformity. Natural cosmetic results are highly depen-  dent on these factors, which include the following:    © Extent of hair loss. This determines the amount of work  required to cover the defect.   © Age of the patient. Bear in mind that the extent of hair  loss increases with age. Young men with AGA will have  less hair to transplant and more bald area to cover as  they grow older.   © Adequate donor tissue. There must be sufficient donor  hair density and tissue to provide enough grafts to  cover the hair defect. HT does not produce more hair  but rather relocates existing hair on the patient’s scalp.  Unfortunately for most patients, the more hair they  need, the less donor tissue they have.    ® Hair colour affects perceived coverage. The darker the  colour, the greater the apparent coverage per graft; how-  ever, dark hair also tends to create a more unnatural  appearance.   @ Hair curl increases the apparent volume of hair present in  that curly hair covers more area as it bunches up on itself.   @ Hair contrast plays an important role in naturalness.  The greater the contrast, e.g. black hair on white skin,  the more unnatural the appearance. Care must be taken  to use the finest single hair grafts in the most exposed  area, i.e. the hairline.   © Hair shaft diameter is an important determinant in how  much hair is moved in a graft. The thicker the diameter,  the more prominent the hair and the more contrast it  provides. Thick hair shaft diameters make producing a  fine natural hairline challenging.   @ Hair direction of the grafted hair must be matched to  the existing naturally occurring hair follicles of area  being transplanted.   © Hairline considerations. A natural hairline is actually a  misnomer. A natural hairline is a zone of fine irregular  hairs that create the feathering zone as the bald scalp  gradually yields to hair-bearing scalp.   @ Ethnic differences are wide and varied and usually can  be described as a combination of the earlier-listed char-  acteristics. For example, Asian hair is less dense than  Caucasian hair, but the hair shaft diameters are typi-  cally thicker. The converse is also true that Caucasians  typically have greater density (hair follicles/mm7’) but  smaller shaft diameters.    The most important area of challenge to HRS surgeons is  the hairline, which is the transition from bald skin to hair-  bearing skin. Hairline is actually a misnomer as it is not a  line at all. The natural hairline is more of a zone at the bald  skin-hair perimeter that exhibits the characteristics of an  uneven undulation of the hairs along the border of the bald  skin-hairline interface as well as a gradually increasing hair  density gradient. Figure 81.la demonstrates a 17-year-old  boy with no hair loss. Note the large numbers of fine vellus  hairs present in the anterior border that will eventually be  lost as he ages. Figure 81.1b shows a 15-year-old boy who  lacks any vellus hairs but note the strikingly nomadic hair-  line. Figure 81.1c shows the hairline of a 50-year-old man.  Note the loss in density in the hairline with a more gradual  density gradient. These examples are not transplanted hair-  lines and they all exhibit an uneven undulating zone of hair.   Also note the important variations in hair direction.  The vellus hair gives clues as to the true natural hair direc-  tion that the transplant must simulate to achieve a natu-  ral result. In general, frontal scalp hairs point forward,  parietal scalp hairs point lateral and inferior and occipital  scalp hairs orient posteriorly and inferiorly.   When designing a hairline for transplantation, the sur-  geon must be aware of these subtleties to avoid drawing    Figure 81.1 (a) A 17-year-old man with no hair loss. (b) A  15-year-old boy who lacks any vellus hairs but note the strik-  ingly nomadic hairline. (c) The hairline of a 50-year-old man.    attention to the transplantation. Most laypeople do not  understand what a natural hairline is but they can usu-  ally detect an unnatural hairline. The results produced  with contemporary techniques go virtually undetected  (Figure 81.2a through d). Unfortunately, the old pluggy    results (Figure 81.3) still exist as a constant reminder of  our struggle to perfect the technique and of why the lay-  people hesitate to seek out a surgical treatment for hair loss  until they have exhausted all other possibilities.    In the last two decades, the trend has been to transplant  very small grafts using one to four hair follicles per graft  unit. Now termed ‘follicular unit transplantation’ (FUT),  modern technological advances have increased the num-  ber of follicle units transplanted in each session from an  average of 1000 up to 3500.    @ AGA (hereditary baldness or male pattern hair loss)  ® Loss of scalp hair in selected cases following burns and  accidents    © To cover surgical scars  e Moustache creation to camouflage bilateral cleft  lip scars  e Bicoronal scalp scars associated with loss of hair  ® Loss of eyebrow hair  - Alopecia areata  ©® Lichen planopilaris    The process of consultation is an interactive decision for  ascertaining the goals of the patient and assessing if these  are achievable. The key points are as follows:    @ The ascertainment of patient goals. An experienced sur-  geon must exercise the power of judgement in eliciting a  patient’s goals. A specific question needs to be asked on  what area of hair loss is most bothersome to the patient  and understanding the motivating factor for seeking  HT. Upon understanding the patient’s goals, analyse    Figure 81.2 (a) Hair transplant. (b) Close-up of transplanted hairline. (c) Hair transplant. (d) Close-up of hair transplant.    if these are achievable or unrealistic. An experienced  surgeon would not hesitate to refuse a proportion of  patients who seek HT in view of unrealistic goals. It is  imperative to recognize a patient who will not be satis-  fied with the HT procedure. The long-term satisfaction  of the patient depends largely on decisions arrived at  the initial consultation rather than the technical ability  of the surgeon. It is customary for most patients who  seek hair transplants to have tried medical treatment,  herbal therapies, previous hair transplants but dissatis-  fied with the result and may have obtained referral from  your patients, physicians known to the surgeon or seen  photographs in the web page of the surgeon. Hence,  when such a patient seeks treatment, it is most impor-  tant to be honest in revealing what you can achieve and  the required process to achieve the goals.   Explanation regarding the progressive nature of hair  loss. Despite transplantation, hair loss may be progres-  sive and at present we are unable to predict the extent of  a persons baldness. It must also be made clear that in  view of this, the long-term result is unpredictable.  Requests for transplantation into vertex. Transplantation  into the vertex is accompanied by progressive substan-  tial hair loss resulting in an unnatural appearance.  However, anterior hairline restoration can be natural  and the aim of any practising hair transplant surgeon  must be to achieve a natural looking result.   Hair restoration in a bald patient returns the natural  facial appearance and unquestionably restores the cen-  tral face as the focus of attention. This is an important  factor to realize in the initial consultation.  Transplanted hairline. This is initially permanent.  Upon restoring the hairline, there is an appreciable dif-  ference in facial appearance. As hair loss is progressive,  the created hairline must be acceptable throughout the  lifetime. A young person seeking hair transplant may    address only the frontotemporal troughs. However, in  an older person, it would be an unrealistic expectation  if bald in the hairline.   At the very onset, elicit if the patient is seeking hair  restoration only by medical treatment. If the hair loss  and associated baldness cannot be restored by medical  treatment alone, the surgeon should clearly explain that  this would not be possible. If the patient accepts the  recommendation of surgical restoration, at this junc-  ture explain the necessity to be treated with supportive  adjunctive medical therapy.   If a surgical option is being planned, a detailed medical  and drug history is important. The most pertinent  questions to be asked are as follows:   e Intake of medicines such as aspirin, warfarin and  clopidogrel. When possible, these medications  should be stopped. It is customary to stop aspirin  for 1-2 weeks and clopidogrel 5 days before HT.   e Intake of dietary supplements, such as ginkgo  biloba, vitamin E, garlic and ginseng, increase ten-  dency to bleed. They should be stopped for a week  before the procedure.   e Patients with prosthetic heart valves or prosthetic  joints may require standard antibiotic prophylaxis  regimes in selected cases as guided by the physician.    In an HT practice, we highly recommend employment  of either a full- or part-time counsellor. Patients often  feel more comfortable speaking about the procedure  other than to the treating doctor. The counsellor should  reinforce the following:    Discussion of limitations. Convey at the very outset  that the hair loss is not static and further transplanta-  tion may become necessary. Do not give a time frame. A  patient who has understood very clearly that balding is  progressive would easily accept maintenance transplant  sessions at a later stage. Adjunctive medical therapy can  be useful in preventing continued hair loss.   Explain very clearly that in the immediate post-operative  period there would be hair loss (post-operative efflu-  vium). It is believed to occur due to local tissue trauma.  Vellus hair is the most susceptible although terminal  hair can also be affected. Some believe prescribing fin-  asteride immediately after transplantation may modify  this loss. However, there are no double-blind studies to  support this observation. The surgeon and the counsel-  lor should emphasize that there would be an interval of  approximately 6-9 months between the transplantation  and the expected result of new hair growth.    ® Selection of the appropriate patient. This is governed  by (a) degree of baldness, (b) patient expectations,  (c) calibre of the hair shaft, (d) donor hair availability  and its quality and (e) age of patient. In general, it is best  to avoid young patients in the age group of 20-25 years.  Young men in this age group usually consult to explore  transplantation to restore the areas of baldness due to  frontotemporal recession (Norwood stages 1 and 2). In  these patients, if facial framing is intact, there is no ben-  efit in transplantation. Calibre of the hair can vary from  fine to coarse hair. The larger the diameter, the better  the result. Patients with fine hair have a diameter of  less than 60 um. Fine hair covers less surface area and  hence yields poor results. Some would refuse to carry  out transplantation in these individuals.   ® Donor hair quality determines surgical outcome. In  general, men require 40 follicular units per cm? in the  occiput for successful transplants. In general, Caucasians  have more follicular unit counts than Asians. The ulti-  mate determining factor for the success of HT depends  on the patient’s expectations. If the patient’s expecta-  tions are unrealistic and, through the process of consul-  tation and use of the counsellor, cannot be modified, the  patient should not be accepted for transplantation. For  patients with fine hair, a limited donor site source can-  not provide transplanted hair of satisfactory density. In  such patients, time spent in detailed explanation is very  worthwhile. Patients who seek vertex transplantation  should be warned of significant future loss. Likewise,  patients who request transplantation from vertex to  frontal scalp should be discouraged.    ® Establishment of hairline. This is often an area for mis-  understanding. An unrealistic request to make the hair-  line too low which would be unnatural must be pointed  out clearly in the discussion. A good method to adopt  is to seat the patient in front of a mirror and draw the  proposed hairline on their skin.  ® Assessment of the state of baldness and assigning the  patient to the Norwood classification (Figure 81.4). At  this stage, bring it to the attention of the patient that  baldness is progressive.  ® Once the discussions have been completed and the deci-  sion for transplantation has been made, discuss other  surgical options such as scalp reduction and the reasons  why as a procedure this is no longer popular.  ® No consultation is complete without a discussion of  risks and complications and obtaining informed con-  sent (Table 81.1).  © Photographs - the following views are required:  e Frontal view  e Lateral views (right and left)  e Vertex view  e Posterior view  e Hairline close up    It is important for the transplant surgeon to be aware of  medico-legal issues. This surgery is not dealing with ‘life-  and-death issues’ and therefore litigation is more common.    The procedure of hair transplantation has been explained to  me. The area to be transplanted and the areas of anticipated  coverage have been discussed and mutually agreed upon. |  am aware that hair transplantation is to be completed over  several sessions and a final appraisal of the results cannot be  adequately done until the procedure is complete.   3. Swelling around the forehead and occasionally the  tissue around the donor area, nose, cheeks and eyes  Numbness or loss of sensation on the scalp   9. Insufficient growth of hair requiring more than  anticipated transplantation procedures to provide  expected results   10. Irregular, uneven or delayed hair growth. Many  transplanted hairs will shed after each session.  Generally, 3-4 months after the transplantation new  hair growth begins. The new hair will sometimes grow in  with a variation in texture (coarser, finer, darker or  lighter) until it normalizes    I give permission to perform the hair transplantation on me and  agree to follow-up as directed by the hair transplant surgeon.    The following principles and guidelines must be adhered  to in achieving success in HT surgery.    © Harvesting hair from the occiput should be from  within a margin of clearance of about 2.5 cm from  the lateral and inferior fringes of the occipital hairline  (Figure 81.5). Avoid harvesting above and medial to the  mastoid area.   © The lateral limit of harvesting should not extend  beyond a vertical line extending into the scalp from  the pre-auricular line. Harvesting performed anterior  to this line can result in visible scar formation. The  upper limit of the donor site is 5 cm from the upper-  most point of the external ear. The lateral limits are  the vertical line of the pre-auricular crease extended  vertically into the scalp. Where there is paucity of the  donor area, the temporoparietal areas can be consid-  ered (Figure 81.6).   ©® The donor tissue can be harvested using a multi-bladed  knife or asa single ellipse (Figure 81.7). The multi-bladed    Figure 81.5 Donor area will be 2.5 cm below superior  edge of fringe border and 2 cm above inferior occipital fringe.    knife can have between two and four blades. If harvest-  ing is carried out as a single ellipse, a size 10 scalpel  blade (Bard-Parker) is utilized (Figure 81.8).    ©@ The incision lines should be parallel to the orientation of  the hair follicles to avoid transection and parallel to the  lines of minimum tension (Figure 81.9). Use local anaes-  thesia in the strength of 1% lignocaine with 1:100,000  epinephrine (adrenaline) when using the tumescent  technique. If using a multi-blade knife to harvest multi-  ple strips, use the tumescent technique to achieve tissue  turgor. Subsequently, 100 mL normal saline is injected  into the donor site for tumescence to build up the turgor  pressure.    For harvesting the donor tissue as a single ellipse, use 2%  lignocaine with 1:80,000 epinephrine (adrenaline) up to  three vials or 1% lignocaine with 1:100,000 epinephrine  (adrenaline) and inject up toa maximum of 15 ml.   If the tumescence technique is used, use 100 ml of cold  normal saline solution for harvesting a strip 12-cm long  and 1l-cm wide. Debate continues as to whether tumes-  cence is essential. However, if tumescence is used, mullti-  strip harvesting is easier. If a single strip is to be harvested  utilizing a single blade, it is not necessary to inject tumes-  cent solution. If a tumescent solution is to be injected, it  must be done slowly, 2 ml per time.    Option 1: Patient is placed in prone position with the  head down on a headrest for harvesting of the donor  graft and once this is completed, the patient sits on  a comfortable dental chair in a partially reclined  position.   Option 2: The patient sits on a reclined dental chair for the  entire procedure.    A multi-blade scalpel is utilized. The type most commonly  used is an Arnold multi-blade knife. According to the  number of strips required, the number of blades used var-  ies. For each 2-mm strip, one blade is required. The width  between each blade can be adjusted by utilizing the appro-  priate spacer. Spacers come as 1.25, 1.5 or 2 mm (Figure  81.10). Multi-blade harvesting increases follicular transec-  tion. Most prefer a single-blade technique. However, the  disadvantage is that the strips have to be cut and prepared  from the main elliptical harvest and is more time-con-  suming. However, the transection rate is less.    e The hair in the designated donor area is trimmed.  The incision is made along the lines marked parallel to  the hair follicles and deepened through below the follic-  ular bases but above the deep vasculature. It is necessary  to maintain a small amount of subcutaneous fat at the  base of the hair follicles. While the strip is being ele-  vated, the surgeon should be careful to ensure that the  depth is correct, follicles are not being transected and    Figure 81.10 Multi-bladed knife for harvesting multi-  strips and single blade for harvesting an ellipse.    there is subcutaneous fat at the base of follicles. Use a  4x magnifier when harvesting (Figure 81.11). Use of  cautery must be avoided and hence only pressure is  applied to control bleeding. During closure, carry out  minimal undermining (Figure 81.12). Apply tension  clamps across the edges to approximate and use a few  deep dermal sutures of 2.0 polydioxanone (PDS) at least  5 mm away from the wound edges (Figure 81.13). The  preferred choice for skin closure is staples as it gives the  best scar. However, if using a suture, use a continuous  4/0 nylon suture. Remove the staples or sutures on the  10th day. See the patient on the following day and apply  hair gel, wash the hair and inspect the wound to ensure  that there is no blood collection.  The preparation of grafts from the harvested multi-  blade strip or ellipse (Figure 81.14):   ellipse or as a multi-strip, it should be placed in cold    envisaged, microscopes are used for dissection of  follicular units.  The strips or sectioned ellipses are placed on a  spatula (Figure 81.15a) and using a Personna blade  size 10, the hair technologist will start section-  ing them carefully leaving some subcutaneous fat  below the follicles as either mini- or micro-grafts  (Figure 81.15b). When prepared, the grafts must  be placed in a separate dish with cold saline and  they should be placed into the recipient sites within  4 hours to give maximum viability of the grafts.  During the preparation, the surgeon should oversee  the team preparing the grafts to ensure there is no  transection of the follicles and there is atraumatic  tissue handling. At the commencement of the pro-  cedure, a calculation would have been done to esti-  Minimal undermining of the donor site prior mate the number of mini- and micro-grafts needed  to closure. for the planned restoration.    Figure 81.15 (a) Harvested ellipse cut into a strip. (b) Strips  being cut into further smaller strips on a spatula.    © Techniques of recipient site preparation and graft inser-  tion are as follows:   e Local anaesthesia is administered as a nerve block  or ring block with 1 or 2% lignocaine containing  1:100,000 epinephrine. If recipient sites are to be  created in the frontal hairline, bilateral supraorbital  nerve blocks would be adequate. Similarly, if poste-  rior scalp is the recipient area, occipital ring block  can be used.   e When anaesthesia is established, the recipient sites  are created as follows: for single graft use 19G nee-  dle (Figure 81.16); for mini-grafts use 15C blade  (Figure 81.17).    Slits are made as single-stab incisions and can be made in  large numbers. Some use 19G Nokor needles. With each  slit there may be brisk bleeding. Usually it stops after  the application of pressure for a few minutes with gauze.  Sometimes, dilators are necessary to facilitate closer  placement of grafts. However, dilators do take more time.  Nevertheless, it is an important surgical tool in the arma-  mentarium ofa hair transplant surgeon.   Insertion of grafts at the recipient site is carried out  using jewellers’ forceps (Figure 81.18). Use the finer    version of jewellers’ forceps. It is only with considerable  patience and effort that the skill of graft placement is mas-  tered. If the grafts are placed too close, adjacent grafts will  ‘pop out’. This can be controlled by gentle pressure with  moist gauze or a graft stick. Regular spraying with saline  is done to keep the grafts moist.    When hairline restoration has been planned, in decid-  ing on the hairline, the rule of thirds of the face is fol-  lowed. The lower third, middle third and upper third of  the face are in equal proportions. It is most important  NOT to place the hairline too low. The line is usually  8-10 cm above the glabella (Figure 81.19). In patients  suffering from severe hair loss, the hairline can be raised  higher by 1-2 cm. However, in some patients the line is  elevated higher by 1-2 cm, creating a ‘widow’s peak’  (Figure 81.20) giving a camouflaging effect to create a  lower hairline.   The aim of hairline restoration is to create a most  natural hairline which cannot be detected. The hair-  line consists of an anterior portion (transition zone)  and a posterior portion (defined zone) (Figure 81.21).  The transition zone is usually 0.5-1 cm and is irregu-  lar. Variation of hair density in this zone is normal  (Figure 81.22). In this zone (0.5-1 cm), only single-hair  follicular units or micro-grafts must be used to ensure  the result appears natural.   The defined zone is usually 2-3 cm in width and should  have a higher density of hair. In this zone, mini-grafts con-  taining two to four follicles or two to three follicular units  are placed (Figure 81.23).    Figure 81.19 Proper placement of the anterior border of  the hairline. Common guidelines for locating the anterior bor-  der of the hairline include (1) four finger-breadths above the  glabella, (2) 8-10 cm above the glabella and (3) the point where  the horizontal plane of the scalp meets the vertical plane of  the face.    Figure 81.21 Hairline zones: The hairline consisting of two  zones: the anterior portion (transition zone) and the posterior  portion (defined zone). The transition zone (TZ) should be  soft and irregular, and the defined zone (DZ) should be more  defined and dense. Both these zones are important to the  overall appearance of the hairline.    Creating the lateral border of the hairline and  the frontotemporal angle    In all men, the frontal hairline meets the temporal hairline  at the frontotemporal angle (Figure 81.24a through c). The  angle at its union between the frontal and the temporal  line is called the apex (Figure 81.25).    Figure 81.22 Note the hair between the dotted line and  the solid line denotes transition zone. The solid line demar-  cates posteriorly the ‘defined zone’. Variation of hair density in  transition zone is normal.    Figure 81.23 Estimated area of the hairline area: the total  hairline area is the combination of the TZ the DZ. The average size  of the total hairline area ranges from 20 to 30 cm2. At 25-30 fu/cm?,  it takes about 600-750 follicular units for this area.   ® In achieving this point, draw a line from the lateral  epicanthus to where it meets the existing temporal hair.    Figure 81.24 (a) Frontotemporal angle. (b) Frontotemporal  angle. (c) The frontotemporal hairline in a 24-year-old Asian male.    @ Mark the anterior border of the hairline, the transition  zone and the defined zone.    @ Mark out the area of baldness over the occiput or vertex.  Draw the intended lines along which the mini-grafts are  to be placed (four to five hair follicles).   ® Transplant in each row, placing the follicles at least  2 mm apart and 1 mm between each row. If the follicles  are placed too close during the placement, the hair fol-  licles will ‘pop out’.    e For restoring the anterior and temporal hair-  line, supraorbital and supratrochlear nerve blocks  are given using 2% lignocaine with 1:80,000  epinephrine (adrenaline) in a dental syringe con-  taining 2.2 mL cartridges. Usually, 4-5 ml would  suffice and anaesthesia can be obtained up to mid  scalp.    Figure 81.25 Placement of frontotemporal hairline when  there is moderate hair loss.    ® Iforal or intravenous sedation is used, continuous oxygen  saturation and blood pressure monitoring is mandatory.  The most preferred sedative agent is midazolam.   ® Prior to the administration of local anaesthesia in an  anxious patient, conscious sedation can be used (relative  analgesia using nitrous oxide and oxygen combination).   © The most preferred local anaesthetic agent is ligno-  caine. Some prefer bupivacaine. Bupivacaine is four  times more potent than lignocaine. Therefore, 0.25%  bupivacaine would be equivalent to 1% lignocaine.  It also has a longer duration of action. The greatest  danger of using bupivacaine is its property to induce  arrhythmia resulting in ventricular tachycardia resis-  tant to treatment.    e The maximum recommended dose for lignocaine  with epinephrine is 7 mg/kg or 0.7 mL/kg of 1%  lignocaine. One per cent lignocaine has 10 mg/mL.   e For an average 70 kg man, the maximum dose  would be 50 mL of 1% lignocaine with epinephrine.   e The maximum recommended dose for 0.25%  bupivacaine with 1:100,000 epinephrine is 90 mL  or 225 mg.    © After HT, the hair is shed within 3-4 weeks. New hair  growth will only be seen after 12 weeks and should grow  at approximately 1 cm per month. After the transplan-  tation procedure, there may be a temporary increase in  natural hair loss but this will regrow within 3-6 months.   @ Every hair follicle has a life cycle. Therefore, when trans-  planted into a new site it will produce hairs which are of  a more permanent nature.   © The newly transplanted hair will grow, but with time it  will become thin and undergo greying.   © Harvesting of donor hair will not damage the remain-  ing hair.   ® Information regarding creation of the frontal hair-  line and temporal hairline should be given. Ideally,  they should be drawn and the consensus obtained  and, if agreement is reached, photos should be taken.  Personal preference of the patient is an important  consideration.   © Advise to stop supplements such as ginkgo biloba and  vitamin E 7 days before surgery. Aspirin should be  stopped 5 days before the surgery. Alcohol should be  forbidden for 24 hours before the surgery.   © An approximate estimate of time to be taken for the pro-  cedure should be given. The patient should be accom-  panied by another person and arrangements should be  made to stay for at least 2 hours after the procedure is  completed.    @ There will be a bandage applied over the forehead to  reduce oedema if a frontal hairline has been created.  The patient is instructed to wear a theatre cap loosely  if required. No shower is to be taken for 24 hours after  the first review.   ® Instructions regarding pain at the donor site and  recipient site should be given. Before leaving the  surgical suite, analgesics should be prescribed. The  patient should be instructed to sleep on their side.  To avoid post-operative oedema, steroids are pre-  scribed at the commencement of the transplantation  and continued 8 hourly for 3-5 days. Instructions are  also given to take the analgesics regularly with antac-  ids to avoid gastric irritation by the steroids and the  analgesics.   © Generally, there is only a faint scar at the donor site.    © Bruising around the forehead and eyelids usually on the  third day, which may last up to a week.   ® Scalp may ooze from the donor and recipient sites for  24 hours.   © Recommend to be off work for 2-3 days if necessary. No  active sports should be undertaken for 1 week.    Currently, the US Food and Drug Administration-  approved agents that promote hair regrowth are as  follows:    ® Topical minoxidil solution which comes in strength  2% for women and 5% for men. Women may use 5%  minoxidil; however, it has been associated with greater  side effects, most notably scalp irritation and increased  growth of facial hair.    These two agents will increase hair density, spread of  regrowth of transplanted follicles and slow or stop hair  loss in areas of active alopecia.   Hair growth is a dynamic process which consists of  repeated cycles of active growth (anagen 2-6 years), invo-  lution (catagen 2-3 weeks) and rest (telogen 2-3 months).  Approximately 90% of all scalp follicles are in the anagen  phase. Androgenic hair loss in male and female pattern  hair loss is induced by androgens in genetically suscepti-  ble hair follicles. Under the influence of dihydrotestoster-  one, the hair follicles shrink in size and the anagen phase  becomes shorter.   The majority of hair transplant surgeons recommend  the use of minoxidil and finasteride after the initial con-  sultation for hair loss. These two medications have a syn-  ergistic effect. However, when finasteride is given, patients    must be warned that there may be side effects during  treatment, such as loss of libido, ejaculation disorders and  erectile dysfunction. These effects are reversible and affect  2% of men. It usually takes 3-4 months to see demonstra-  ble effects with minoxidil treatment.   The advantages of using minoxidil prior to surgery are  as follows:   © The primary benefit of using minoxidil is within and  surrounding the areas of hair loss.   © In the donor area, they may transform telogen follicles  into the anagen phase and thereby these grafts would be  more visible during the transplantation.    ® Increase in number of hairs in the anagen phase.  ® Promotion of growth in the transplanted follicles  and surrounding areas, reduction of post-surgical  ‘shock’ and telogen effluvium. It also enhances the  diameter of the hair shaft, increases hair density and  thereby enhances the result. In particular, the follow-  ing two categories of patients require minoxidil after  transplantation:  e Young male patients with diffuse hair thinning.  e Female patients with diffuse hair thinning.    Minoxidil should be stopped 5 days prior to transplanta-  tion as it may cause increased intra-operative bleeding and  it can sometimes cause scalp irritation. After transplanta-  tion, minoxidil is restarted 5-14 days after surgery to avoid  damage to the transplanted hair follicles. This delay also  allows time for the healing of the epithelium. Finasteride,  however, can be continued until the day of the surgery and  continued immediately after surgery.   Use minoxidil 5% as greater density has been noted than  when 2% is used. There is uniform consensus among most  hair transplant surgeons to use finasteride and minoxidil  pre-operatively and post-operatively in men and minoxi-  dil in women. There is now emerging new evidence that  finasteride can also be used in female patients.   © Patient is seen 24 hours later and the forehead bandage  is removed and a hair wash given.   @ Daily hair wash is permitted, but no scrubbing of the  scalp is allowed.   @ Staples over the donor site are removed on the 10th to  12th day (Table 81.2).    1. Do not take any medications (other than prescribed),  vitamin E or alcohol for 48 hours after hair transplant.  No dental work 72 hours following surgery.   3. If at any time should any graft begin to bleed or pull  out, simply apply direct pressure to the site for a  minimum of 15 minutes. If that does not stop the  bleeding, continue to apply pressure and immediately  call the hair transplant surgeon.   4. You will come back to the office in approximately 10  days to have your staples removed.    Peri-operative complications and side effects are uncom-  mon but may include   © Discrepancy between recipient slit size and donor grafts  resulting in dropping out of the grafts    Guidelines for deciding the width and length  of donor strip to harvest    1. Make a decision of how many grafts are required,  e.g. 1450.   2. Measure the circumference of the back of the head,  e.g. 22 cm.    One graft per millimetre length is the rule of thumb.  Therefore, in a 22-cm-long strip, 220 grafts can be  obtained. Hence, to harvest 1450 grafts, six strips would  be required. If a 1.75- and 1.25-mm spacer is used in a  multi-bladed knife, you could accordingly obtain micro-  and mini-grafts.   ® If the sites are too deep, damage is done to the deeper  vascular plexus. Likewise, if the sites are too shallow,  graft loss can occur. If the site created is too small,  excessive manipulation is required to implant the graft  and this would cause damaging pressure on the graft.    ® Patience and flexibility in preparation of recipient sites  is the key for success. Sometimes, during recipient site  creation, bleeding occurs with the slightest manipula-  tion and the adjacent grafts pop up with each new graft  insertion. Patience is the virtue. Do not rush the cre-  ation of recipient sites. Depth control, angulation and  direction of the grafts govern success in a transplant  procedure (Figures 81.28 through 81.30).    e Asians have a much greater tendency to form  hypertrophic scars and keloids. Hence, scalp reduction  is a poor option. Likewise, donor site scars may also  become hypertrophic. At the earliest detection, intra-  dermal steroids should be injected.   @ Asians like to have a low hairline and this request should  be resisted and the hairline should only be chosen  according to facial proportions and what is most natural.   © Figure 81.31 illustrates a pre-operative view ofan anterior  hairline in an Asian patient. Figure 81.32 illustrates the  hairline after restoration with micro- and mini-grafts.    : Top tips  Figure 81.30 Grafts in place at the recipient sites.  e Harvesting of grafts (donor site - occipital scalp):   e If a multi-bladed knife is used, spacers between  the blades come as 2 or 1 mm. If a previous scar is  incorporated into the graft, a 4-mm spacer is used  so that in such cases two strips can be obtained.  The hair follicles can be dissected from these two  strips. To harvest the follicles from these strips,  the author uses the 15 blade for monografts and  a Personna blade size 10 in the multi-bladed knife  between the spacers.   e If the donor graft is to be harvested as a single  ellipse, a conventional scalpel is used with a size  10 blade. Prior to harvesting, trim the hair to a  plane where you can just see the hair direction as  you would alter the direction of the scalpel with  the direction of the hair follicles. From the har-  vested strip, small strips are made by slicing into  small pieces. From each small piece, one, two and   e At no time should the harvested hair follicles be  allowed to dehydrate. The grafts must be kept  moist throughout the procedure. The best solution  in use is either cold Ringer’s lactate or cold saline.   e Warning: while preparing the grafts, DO NOT cause  damage to the pilosebaceous unit and transection  to the follicles.   e Creating recipient sites in the bald areas or areas to be  transplanted:   e Place the grafts 3 mm apart laterally and 1 mm apart    American Society of Hair Restoration Surgery. Available at  www.cosmeticsurgery.org  Ayres S. Prevention and correction of unaesthetic results of  © Usually hair density is lower when compared to hair transplantation for male pattern baldness. Cutis.  Caucasians. The hair is coarse and straight. Hair is darker. 1977; 19: 117-121.    The following are key facts to be taken into consideration  for hair transplant in Asians:    Bernstein RM and Rassman WR. Follicular transplantation.  Patient evaluation and surgical planning. Dermatol  Surg. 1997; 23: 771-784; discussion 801-805.   Limmer BL. Elliptical donor stereoscopically assisted  micrografting as an approach to further refinement in  hair transplantation. J Dermatol Surg Oncol. 1994; 20:  789-793.   Marritt E. Transplantation of single hairs from the scalp as  eyelashes. Review of the literature and a case report.  J Dermatol Surg Oncol. 1980; 6: 271-273.   Marritt E. Single-hair transplantation for hairline refine-  ment: A practical solution. J Dermatol Surg Oncol.  1984; 10: 962-966.   Marritt E. Follimmerlicular transplantation. Giving credit  where credit is due. Dermatol Surg. 1998; 24: 925-929;  discussion 929-932.    Nordstrom RE. Methods to improve old results of punch  hair grafting. Plast Reconstr Surg. 1983; 72: 803-809.   Orentreich N. Autografts in alopecias and other selected  dermatological conditions. Ann NY Acad Sci. 1959;  83: 463-479.   Shapiro R. Creating a natural hairline in one session using  a systematic approach and modern principles of hair-  line design. Int J Cosmet Surg Aesthet Dermatol. 2001;  3: 89-99.   Stough D. Presentation at International Society of Hair  Restoration Surgery Live Surgery Workshop, Orlando,  FL. 21 February 2001.   Unger WP. (ed.). Hair Transplantation, Fourth Edition.  New York, NY: Informa Healthcare; 2004.    Brow lifts and facelifts are commonly performed aes-  thetic procedures of the facial region. Hallmarks of the  ageing process include descent of the brows, redundant  tissue in the upper lids, rounding of the lower lids, pto-  sis of the midface and the superficial musculoaponeurotic  system (SMAS), fullness of the nasolabial fold, loss of the  jawline, dermatochalasia of the facial region, formation  of jowls, platysmal redundancy and submental fullness.  Goals of any facial aesthetic surgery must include reposi-  tioning of ptotic tissues to their original position, reversal  of the vector of the ageing process from an inferior and  medial direction to a superior and posterior direction, and  obtaining a natural appearing ‘unoperated’ final result.  It is imperative to remember that total facial rejuvena-  tion requires addressing three distinct regions: forehead  and brows, face and neck. Each region requires a separate  operation; each procedure can be carried out simultane-  ously with the other two or, in some instances, some can  be performed independently. A brow lift will address the  forehead, brows and, to a lesser extent, the upper eye lids.  A facelift will address the central and lateral portions of    847  847  848  849  849  850  850  852  852  853  853  856  857    the face, jowls and the posterior neck. A cervicoplasty  (with platysmaplasty and open submental liposuction)  addresses the anterior or central portion of the neck. The  most consistent method to obtain a long-lasting total facial  rejuvenation involves a brow lift (endoscopic), a deep plane  facelift and a cervicoplasty. The purpose of this chapter is  to discuss pre-operative assessment and patient selection,  surgical execution and potential complications of each  surgical procedure used in facial rejuvenation.    Pre-operative assessment for the patient seeking a cervico-  plasty must include evaluation of the following structures  (Figure 82.1):    ® Position of the mandible and chin and assessment of the  occlusion    Ideal neck appearance should include smooth neck  skin, lack of submental lipomatosis, presence of defined  jawline, subtle inframandibular concavities anterior to the  sternocleidomastoid (SCM) muscles, a small thyroid car-  tilage and a cervicomental angle of 110°. It is important to  remember that an isolated cervicoplasty will not dramati-  cally improve jowling; this deformity is mainly addressed  by a deep plane facelift. Since many patients (over the age  of 40) who desire a facelift also have jowlings, the author  always performs a cervicoplasty at the time of a facelift.  Isolated cervicoplasty is indicated in patients who have  submental lipomatosis and platysmal redundancy in the  absence of jowls.    The patient should be marked in the pre-operative room  while sitting up. The inferior border of the mandible,  anterior borders of the SCM muscles, inferior extent of  the submental lipomatosis and any existing cervicomen-  tal crease are marked with ink (Figure 82.2). A 2-2.5 cm  incision (slight curved) is marked just posterior to any  existing cervicomental crease, since placing the incision  within the crease can create an exaggerated and deep  crease post-operatively. The procedure is carried out  under general anaesthesia with intubation. After admin-  istration of local anaesthetic with a vasoconstrictor, the  incision is made through the skin and subcutaneous fas-  cia (cervical fascia). Any existing cervicomental crease  (anterior to the incision) is sharply incised in the subcu-  taneous plane. Next, using curved facelift scissors, a skin    Figure 82.1 Anatomy of the central neck where a cervico-  plasty is performed. (From Fattahi T, Atlas Oral Maxillofac Surg  Clin N Am, 12, 263, 2004.)    flap with 3-4 mm of subcutaneous fat on its deep side is  elevated from the centre portion of the neck all the way to  the anterior borders of the SCM bilaterally. It is impera-  tive to keep 3-4 mm of fat on this skin flap in order to  prevent excessive scar contracture post-operatively. Once  the skin flap is elevated and free of any ligamentous  attachments to the underlying tissues, open liposuction  is performed via liposuction cannulas (2-3 mm ports) in  the central and lateral aspects of the neck in between the  SCM muscles (Figure 82.3). Care is taken not to perform    Figure 82.2 Typical markings fora cervicoplasty. The ante-  rior borders of the sternocleidomastoid (SCM), the inferior bor-  der of the mandible and the proposed incision are marked in  the pre-operative area.    Figure 82.3 Open liposuction of the submental region fol-  lowing elevation of a skin flap.    any liposuction above the inferior border of the mandible  to prevent damage to the marginal mandibular branch of  the facial nerve. Liposuction is completed when the invest-  ing layer of the deep cervical fascia is clearly visible atop  the platysma muscle. Next, a subplatysmal flap is elevated  and the central portion of the platysma (the redundant  portion or the aponeurosis) is sharply excised starting at  the genial tubercles and extending inferiorly to the thy-  roid cartilage. This is carried out with caution since the  anterior jugular veins run just deep to the muscle in this  region. The resected portion of the platysma should have  a diamond or oval shape to it (F ). The two edges  of the muscle are then brought together in the midline  and imbricated using 3/0 polydioxanone (PDS) sutures in  a continuous locking fashion in a cephalo-caudal direc-  tion. During the imbrication of the muscle, it is important  to close the patient’s mouth and establish occlusion; this  ensures the most posterior (deep) placement of the muscle  flap. After muscle closure, the author uses a fibrin seal-  ant (spray) under the skin flap to decrease the chances of  haematoma formation; no surgical drains are ever used  in cervicoplasty, facelift or endoscopic brow lift as long    Figure 82.4 (a and b) Appearance following excision  of redundant platysma. The two edges of platysma are then  imbricated together.    as fibrin sealants have been used prior to skin closure  (F 5). No skin is excised around the incision  since skin contracture and shrinkage over the next few  weeks obviate the need for this manoeuver. The incision  is closed in a two-layered fashion and dressed with Steri-  strips. A pressure dressing is applied over the patient’s  head and is maintained for 24-48 hours.    The patient is seen in the office within 24 hours post-  operatively to ensure that no haematoma formation  has occurred. The pressure dressing can be removed in  24-48 hours according to surgeon preference. The patient is  restricted from any strenuous physical activity for 2-3 weeks  to prevent dehiscence of the platysmal closure. The patient  is also asked not to turn his/her head during the same  period; rather it is advised that patient turns his/her entire  shoulder/body. This is also to prevent dehiscence of the pla-  tysmal closure. Perioperative antibiotics are administered  for 24-48 hours according to surgeon preference.    Complications associated with cervicoplasty are rare. The  most commonly encountered risks include haematoma  formation, skin asymmetry or dimpling, damage to the  marginal mandibular branch of the facial nerve and a  ‘cobra neck deformity’. Risk of haematoma formation is  significantly reduced by the use of fibrin sealants; some  surgeons advocate use of surgical drains, although it is the  opinion of the author that surgical drains are unneces-  sary as long as a fibrin sealant is used. Skin asymmetries    Figure 82.5 Application of fibrin sealant into the surgical  site in place of surgical drains.    and dimpling can occur as the skin flap contracts and  re-adheres to the underlying muscle. Minor asymmetries  are easily managed by massage. If persistent, scar revi-  sion and/or lysis of adhesions may be required. Marginal  mandibular nerve injuries can easily be avoided by adher-  ing to sound surgical techniques; skin flap elevation and  liposuction should not be performed superior to the infe-  rior border of the mandible. The marginal mandibular  branch can cross the inferior border of the mandible in an  inferior-superior direction to reach the depressors of the  lower lip and can be injured if the dissection or liposuction  is performed above the inferior border of the mandible.  The ‘cobra neck deformity’ can occur when excessive and  injudicious liposuction has been carried out. Also, if an  adequate amount of subcutaneous fat (3-4 mm) has not  been maintained on the skin flap, damage to the subder-  mal vascular layer can occur which can lead to excessive  scarring and a ‘skeletonized’ look.    It is once again important to mention that a facelift only  addresses the central and lateral portions of the face, the  jowls and the posterior neck. Rejuvenation of the central  or anterior aspect of the neck requires a cervicoplasty  which, as stated previously, is always performed simulta-  neously with the facelift (when a facelift is indicted) by the  author. The patient desiring a facelift should be counselled  on the following:   © Loss of volume (especially in thin patients along the  pre-zygomatic space anterior to the masseter muscle)    The youthful face exhibits no redundancy or ptosis of  the facial skin and its subcutaneous tissues. Hallmarks of  an attractive and youthful face also include a triangular-  shaped face, high cheek bones, mild depression in the  pre-zygomatic space anterior to the masseter muscles,  absence of nasolabial fullness or a crease, a well-defined  jawline and no jowling. A facelift, when performed prop-  erly, can reposition the ptotic facial tissues back to their  original position. Since the vector of descent in the aged  face is in an anterior and medial direction, redundant  tissues should be redraped in a posterior and superior  direction. It is important to establish pre-operatively  if the patient can benefit from bony volume augmenta-  tion, such as cheek, chin or mandibular angle implants.  If the patient has lost volume in the face due to the ageing    process or congenital hypoplasia of the facial skeleton,  simultaneous placement of the implants at the time  of facelift surgery can significantly improve the final  outcome.   The main benefit of a deep plane (SMAS flap) facelift is  the ability to reposition the SMAS, which in turn reduces  the amount of tension placed on the skin flap. It is easy  to recognize patients who have had a ‘skin’-only facelift  by the ‘pulled’ appearance of the face, which can be quite  unnatural. Since the ageing process is not simply limited  to the skin, it is logical to address all of the tissues of the  aged face during a facelift by performing a deep plane  facelift.    The patient is marked in the pre-operative area while sit-  ting up. The incision is composed of temporal, pre-auric-  ular and post-auricular components (Figure 82.6). The  vertical portion of the temporal incision is marked just    Figure 82.6 (a and b) Proposed incision for a facelift. Note  the temporal extension just inside the hairline, the posterior  extension of the temporal incision, the pre-auricular and post-  auricular markings.    inside the temporal hairline. This is only about 1-1.5 cm  in length. The horizontal component is also just inside  the most inferior aspect of the side burn (usually at the  level of the top of the helix). This portion of the incision  must be bevelled about 20° for cosmesis and future hair  growth. The posterior aspect of this incision is hidden  behind the superior helix for about 1 cm. The pre-auric-  ular aspect of the incision is marked from the posterior  aspect of the temporal incision inferiorly following a natu-  ral skin crease anterior to the ear to just above the tragus.  The incision must not be in a straight line; rather curl-  ing the incision to just above the tragus provides a much  more aesthetic result. From the superior aspect of the  tragus, the incision can be again made pre-auricularly or  retrotragally, depending on surgeon’s preference. The pre-  auricular incision must also be made with a 20° bevel for a  more aesthetic closure. The marking for the post-auricular  component begins from the most inferior aspect of the  pre-auricular incision, curls around the ear lobe, extends  cephalad on the posterior ear skin, 1-2 mm from the  junction of the mastoid skin and ear skin, and then gently  curves posteriorly and inferiorly along the posterior hair-  line. The height of the post-auricular incision is at the level  of the widest portion of the ear. The inferior aspect of the  marking along the posterior hairline is determined by the  amount of lateral pull necessary to define the jawline. The  more inferior the incision, the more posterior and lateral  the vector of the flap will be.   The procedure is performed under general anaesthe-  sia with the patient intubated. After administration of  local anaesthetic with a vasoconstrictor, the incision is  made from the temporal aspect with a No. 15 blade, pay-  ing special attention to the areas which require a bevel.  Once the entire incision is made, attention is directed  towards the pre-auricular area. While applying counter  traction on the cheek (assistant’s hand on the cheek), a  skin flap is elevated leaving adequate amount of fat on its  underside (3-4 mm). This is initially done with a blade  and can be advanced using facelift scissors. The anterior  aspect of this flap is only about 5-6 cm (Figure 82.7).    This skin flap is easily elevated in supra-SMAS plane.  The post-auricular skin flap is more difficult to elevate  due to the fusion of multiple fascias in the area. Care is  taken not to enter the SCM muscle while elevating this  skin flap. Once an adequate skin flap is elevated circum-  ferentially, a SMAS flap is outlined extending from the  temporal side burn down on to the neck. This marking is  about 1 cm anterior to the skin flap incision (Figure 82.8).  Local anaesthesia with a vasoconstrictor is administered  into the SMAS. Next, using a No. 15 blade, the SMAS is  incised in a vertical fashion. There should be little con-  cern with the facial nerve at this point since the underly-  ing parotid capsule (which protects the nerve) is never  incised. Once the SMAS incision has been made, blunt  dissection under good visualization of the SMAS flap  is undertaken in an anterior direction over the parotid  gland between the zygomatic arch superiorly and 2 cm  below the jawline inferiorly (Figure 82.9). The anterior    Marking of superficial musculoaponeurotic  system (SMAS) incision approximately 1 cm anterior to the pre-  auricular incision.    Elevation of a SMAS flap. Note retaining liga-  ments attached to parotid capsule deep to the SMAS.    (medial) extent of the SMAS flap is dependent on the  amount of posterior and superior repositioning neces-  sary to efface the nasolabial fold and redundant skin.  However, once the zygomaticus major muscle is encoun-  tered, the sub-SMAS dissection must be converted into a  supra-SMAS dissection to prevent injury to the branches  of the facial nerve since almost all of the muscles of the  facial expression are innervated on the deep side. The  deep plane (SMAS) dissection also allows for sharp dis-  section of several osteo-cutaneous retaining ligaments  of the face such as the McGregor’s patch (Figure 82.10).  Release of these ligaments allows significant elevation of  the SMAS flap and allows for a much more aesthetic final  result. If the submandibular glands are ptotic, they can  be elevated through the SMAS flap.   Once the SMAS flap is elevated, it is placed on ten-  sion and pulled in a superior and posterior vector along  its entire length. Excess SMAS is incised (Figure 82.11).  Key sutures using 2/0 PDS are placed within the SMAS  and anchored on the deep temporal fascia, pre-auricu-  lar perichondrium and mastoid fascia posteriorly. This  should allow for a well-defined jawline. The SMAS flap  is essentially acting as a carrier for the skin flap. Once  the SMAS flap has been sutured properly, there should be  almost no tension on the skin flap above it. The skin flap  is then redraped; excess skin is incised. Care is taken to  incise the skin flap in a beveled fashion as well in order  to align the skin flap bevel with the pre-auricular bevel.  The skin is closed in two layers using 5/0 vicryl sutures  (deep) and 6/0 resorbable sutures on the skin. The author  routinely used skin adhesives (DermaBond) on the pre-  auricular aspect of the closure. The post-auricular aspect  is closed in two layers as well, using 5/0 vicryl and 5/0  skin sutures. Prior to closure of the skin flap, fibrin seal-  ant is sprayed on the field (between the SMAS flap and  skin flap). This obviates the need for placement of surgi-  cal drains. A compression dressing is then applied to the  patient head.    Figure 82.11 (a and b) Excised SMAS from left and right  following skin closure.    The patient is seen in 24 hours. The pressure dressing is  removed to determine skin flap viability and the presence  of any haematomas. ‘The pressure dressing is reapplied for  another 24-48 hours. The patient is instructed to avoid  strenuous physical activities and to apply ice packs to the  face to help with post-operative oedema. The patient’s  head must stay elevated compared to his/her body to  reduce swelling. Perioperative antibiotics can be discon-  tinued in 24-48 hours. Any permanent suture is removed  in 5 days.    The most common and feared complication of a facelift is  haematoma formation post-operatively. For this reason,  surgical haemostasis intra-operatively and use of fibrin  sealants is mandatory. No surgical drains are used when  the author performs a deep plane facelift, although many  surgeons continue to advocate their utility. Ifa haematoma  is present post-operatively, it must be drained in order to  prevent skin flap necrosis and significant post-operative  scarring. When performing a deep plane facelift, damage    to the branches of the facial nerve is a possibility. It is  imperative to elevate the SMAS flap in a blunt fashion and  use good visualization (surgical head lights). Neuropraxia  of the facial nerve branches usually resolves in a few weeks  post-operatively. Other complications include asymme-  tries between the right and the left sides, hypertrophic  scars, inadequate repositioning of the redundant skin flap,  malposition of the hairline and a pixie ear deformity. Mild  asymmetries between the two sides of the face may not be  noticeable to the patient and usually do not require any  treatment. Obviously, it is important to ‘pull’ equally on  both sides to ensure symmetrical repositioning of the skin  flap on both sides. Hypertrophic scars can be avoided if  no tension is placed on the skin flap at closing. If they are  present, intradermal steroid injection and constant mas-  saging may improve their appearance. In order to avoid  malposition of the hairlines, the skin flap must be adapted  properly. If a dog ear is created (usually around the ante-  rior aspect of the side burns and at the post-auricular  area), it must be excised carefully. Facelift incisions that  are carried superiorly on to the temple from the superior  helix usually lead to malpositioning of the hairline. Pixie  ear deformities occur when the ear lobe is reattached to  the facial skin improperly and no longer has mobility to it.  This is problematic, especially when earrings are attached  to the ear lobe. Ear lobe deformities can be avoided by  reattaching the most superior portion of the ear lobe to  the facial skin flap. It is also important to recall the posi-  tion of the earlobes pre-operatively when performing this  manoeuver (patient photos in the operating room is quite  helpful).    There are several key assessments necessary for any patient  undergoing an endoscopic brow lift. These include the  following:   @ Presence of dermatochalasia of the upper lids  © Forehead rhytids    An endoscopic brow lift is intended to elevate the ptotic  brows and brow (galea) fat pads to a more normal posi-  tion. The ideal eyebrow in a male is a straight brow that is  0-2 mm above the supraorbital rims. The ideal female brow  should be arched with the medial head 0-2 mm above the  supraorbital rim, apex 10-12 mm above the supraorbital  rim and the tail sloping slightly inferior (Figure 82.12).  The amount of brow ptosis is determined by measuring  the distance in millimetres from the inferior aspect of  the brow to the supraorbital rim. Dermatochalasia of the  upper lids may actually resolve once the brows are placed    Figure 82.12 Ideal brow positions in (a) male and (b)  female. (From Evans T, Atlas Oral Maxillofac Surg Clin North Am,  6, 118-119, 1998.)    into their normal positions. Often, patients will seek aes-  thetic rejuvenation of the upper lids when it is the ptotic  brows which are the actual culprit. Forehead rhytids, espe-  cially deep rhytids, are improved with an endoscopic brow  lift. Superficial and shallow rhytids usually require a laser  resurfacing. The position of the hairline, slope and length  of the forehead are also important parameters to assess.  The patient with a receding hairline will certainly require  modification of incisions which can make the surgical  procedure difficult. Similarly, a forehead that is sloped  too acutely will also present special challenges during an  endoscopic brow lift. Some surgeons will not use an endo-  scopic brow lift if the forehead is too long; rather, a pretri-  chial forehead lift is used in order to shorten an excessively  long forehead. If the corrugator muscles are too active and  have caused formation of vertical rhytids in the nasofron-  tal area, then a myectomy of the corrugator is necessary to  efface such rhytids.    The patient is marked in the pre-operative area while sit-  ting. Most clinicians use five ports for an endoscopic brow  lift including two temporal ports, two lateral (paramedian)  ports and a central (median) port. The median and para-  median ports are marked 1 cm inside the hairline. Each  of these incisions is 1-1.5 cm in length in a cranio-caudal  direction. The central port is marked in the middle of the  frontal hairline; the two paramedian ports are parallel  to the lateral limbus/canthus region. The two temporal    markings are made after drawing a line that intersects  the ala of the nose and the lateral canthus and extends on  to the temple. The temporal port is tangent to this line, is  2 cm in length and is obliquely directed (Figure 82.13).  The procedure is performed under general anaesthesia  with the patient intubated. After administration of a local  anaesthetic with a vasoconstrictor, the central and para-  median incisions are made with a No. 15 blade through  all five layers of the scalp onto the bone (Figure 82.14).  The two temporal incisions are then made with a No. 15  blade through skin, subcutaneous layer and temporo-  parietal fascia. The incision stops at the superficial layer  of the deep temporal fascia. All incisions should be bev-  elled along the length of hair follicles to reduce alopecia.  A subperiosteal dissection is then performed through the  median and paramedian ports. The dissection should  extend posteriorly to the vertex of the skull to allow    dissipation of the forehead flap in a superior and posterior  direction. The anterior aspect of the dissection is visual-  ized using a 30°, 4 mm endoscope inserted through any of  the three ports. An endoscopic sheath can facilitate inser-  tion of endoscope instruments (Figure 82.15). The dissec-  tion proceeds all the way anteriorly until the supraorbital  rims and the supraorbital neurovascular bundles are  visualized. A periosteal elevator is inserted through the  temporal ports and is advanced medially until the tempo-  ral fusion line is reached. Also known as the condensation  zone, this is the location of fusion of the deep temporal  fascia, temporoparietal fascia and the pericranium. While  the endoscope is in the paramedian ports, the fusion line  is released under endoscopic visualization using a peri-  osteal elevator (Figure 82.16). The fusion line must be  released all the way down inferiorly until the zygomatic  process of the frontal bone is reached. This causes release    Figure 82.14 Appearance of a midline central/median  incision. Note full-thickness nature of the incision.    Figure 82.15 Anendoscopic sheath with a curved tip. The  curved tip retracts the scalp flap away from the field and allows  for unimpaired visualization and dissection.    Figure 82.16 (aandb) Location of the endoscope and dissector over the temporal crest. (From Evans T, Atlas Oral Maxillofac Surg    of the orbital retaining ligaments which in turn allows  elevation of the forehead and the brows. Once the entire  forehead has been dissected, the periosteum must be  released at the supraorbital rim/frontal bar region. This  is accomplished under endoscopic visualization using  an endoscopic dissector. Release of this periosteum will  reveal the underlying brow fat pad (galeal fat pad, por-  tion of the retro-orbicularis fat [ROOF]), the corrugator  muscle and the deep branches of the supraorbital neuro-  vascular bundle (Figure 82.17). This is a critical portion  of the operation; failure to release the periosteum in this  area will not allow sufficient elevation of the forehead. In  patients who need to have elevation of the lateral canthus  region and even the midface, the endoscopic elevator  can be advanced down the fronto-zygomatic region onto  the zygoma to elevate the entire region (Figure 82.18). If  the corrugator muscles need a myectomy, using endo-  scopic alligator clamps, small pieces of the corrugator are  grasped and removed.    After the periosteum has been released, the forehead  flap must be elevated and fixated. Several methods exist to  fixate the forehead flap. The author routinely uses titanium  miniplates or resorbable plates to anchor the forehead flap  and fixate the flap in an elevated fashion. The amount of  elevation depends on the amount of brow ptosis measured  pre-operatively. Using calipers, the amount of brow ptosis  is added to the most inferior aspect of the two paramedian  incisions. One millimetre is added to each measurement  to allow for relapse. For example, if there is 5 mm of brow  ptosis at the apex, the calipers are set at 6 mm, inserted  into the paramedian incisions and the fixation device is  placed exactly at 6 mm. Then, using a 2/0 PDS suture, the  flap is elevated and secured to the fixation device. Usually  two points of fixation is sufficient unless severe medial  brow ptosis is present at which time three points of fixa-  tion (median, two paramedian) will be necessary. The two  temporal incisions are closed while the assistant elevates  the lateral brow region and the inferior limb of the incision    Figure 82.17 Endoscopic appearance of the supraorbital  neurovascular bundle at the supra orbital rim.    Figure 82.18 Dissection over the zygomatico-frontal area  to elevate the lateral canthus and midface.    is elevated and anchored to the deep temporal fascia supe-  rior to the initial incision using 2/0 PDS. This allows tem-  poral elevation of the lateral brow. Next, to obviate the  need for a surgical drain, fibrin sealant is sprayed into the  surgical field. Next, the three forehead incisions are closed  in two layers. Staples are used on the scalp. A pressure  dressing is applied to the forehead.    The patient is seen in 24 hours to remove the pressure  dressing and assess any haematoma formation. Ifa haema-  toma is present, it needs to be evacuated. Most patients will  experience transitory headaches following an endoscopic  brow lift; the author always tells the patient of this pos-  sibility pre-operatively. The patient is instructed to refrain    from strenuous exercise. The scalp stapes are removed  in 10 days. Perioperative antibiotics are discontinued in  24-48 hours as per the surgeon’s discretion.    Complications following an endoscopic brow lift are  minimal. The most common complications are paraes-  thesia of the forehead and scalp, mild alopecia along  the incisions, inadequate brow elevation, damage to the  frontal branches of the facial nerve and haematoma for-  mation. Paraesthesia of the forehead occurs due to neu-  ropraxia of the supraorbital nerve; this usually resolves  with time. Alopecia can be reduced if the incisions are  made parallel to hair follicles. Inadequate brow elevation  usually occurs due to improper release of the orbital liga-  ments and the periosteum along the supraorbital region.  Damage to the frontal branches of the facial nerve should  not occur as long as proper adherence to the different  planes of dissection has occurred during surgery. It is  imperative that the forehead elevation is under subperi-  osteally while the temporal dissection is atop the deep  temporal fascia. This will allow protection of the nerve  in the temporoparietal fascia superior to the surgical  field. Mild neuropraxia usually resolves within weeks.  Haematoma formation is very rare; the author routinely  uses fibrin sealants in place of surgical drains to prevent  haematoma formation.   ¢ Do not place incision in the cervicomental crease; place  it posterior to it and then obliterate the crease with scis-  sors or knife.   e Liposuction should be performed until the investing  fascia of the platysma muscle is clearly visible.   e Key sutures of the SMAS to the temporal fascia, peri-  chondrium and mastoid fascia are critical.   e Use of fibrin sealants in place of surgical drains is  advised.   e Subperiosteal dissection over the forehead and atop  the deep temporal fascia temporally is essential to min-  imize damage to the facial nerve.   e Releasing the periosteum and orbital retaining liga-  ments to ensure adequate elevation of the flap is nec-  essary to allow proper forehead elevation.    Behmand RA and Guyuron B. Endoscopic forehead rejuve-  nation: II. Long-term results. Plast Reconst Surg. 2006;  117: 1137-1143.   Evans TW. A case for deeper plane facelifts. J Oral Maxillofac  Surg. 1998; 56: 352-358.   Fattahi T. Management of isolated neck deformities. Atlas  Oral Maxillofac Surg Clin North Am. 2004; 12: 261-270.   Fattahi T, Mohan M and Caldwell G. Clinical applications  of fibrin sealants. J Oral Maxillofac Surg. 2004; 62:  218-224.    Guyuron B. Endoscopic forehead rejuvenation: I.  Limitations, flaws, and rewards. Plast Reconstr Surg.  2006; 117: 1121-1133.   Knize DM. The importance of the retaining ligamentous  attachments of the forehead for selective eyebrow  reshaping and forehead rejuvenation. Plast Reconstr  Surg. 2007; 119: 1119-1120.   Mitz V and Peyronie M. The superficial musculo-  aponeurotic system in the parotid and cheek area.  Plast Reconstr Surg. 1976; 38: 80-88.   Sykes JM. Surgical rejuvenation of the brow and forehead.  Facial Plast Surg. 1999; 15: 183-191.   Asian upper blepharoplasty: Suturing method  Asian upper blepharoplasty: Skin excision method  Acknowledgment    Since the first cervical flap was reported in the early part of  the nineteenth century by von Graefe, blepharoplasty has  evolved into a finite concept.   The eyes are the window to the world and their limits  extend to the forehead and mid-face. As the ageing pro-  cess advances, the peri-orbital profile changes from  convex to concave, and a full, elevated, defined, smooth  contour becomes deflated, ptotic, folded and irregular as  it descends. Ageing results in atrophy of fat, weakness of  the ligaments and resorption and apposition of bony sur-  faces. It is interesting that the electromyographic char-  acteristics of the orbicularis oculi do not alter with age.    The anatomy of the eyelid is divided into anterior, mid-  dle and posterior lamellae. The skin and the orbicularis  oculi form the anterior compartment; the tarsus, sep-  tum, arcus marginalis and orbital fat form the middle;  and the palpebral conjunctiva and the lid retractors form  the posterior compartment. In the upper eyelid, however,    859  859  859  860  860  860  861  863  863  864  865  866  866    the posterior compartment also involves the levator  aponeurosis, Muller’s muscle, in addition to the palpebral  conjunctiva. The lateral and medial canthal ligaments  are entirely different. The retinacular attachment along  the inner wall of the lateral rim is involved in the ageing  process, which results in various changes including mal-  position of the lower lid.   Three important anatomically distinct fat deposits are  directly or indirectly involved in blepharoplasties. First,  orbital fat is closely related to the arcus marginalis which  is more significant to lower blepharoplasty. Second, sub-  orbicularis oculi fat has two components and is divided  at the junction of the lid and cheek by the orbitomalar  ligament. Third is the malar fat pad, which is inferior to  the infraorbital foramen, mostly localized to the anterior  wall of the maxilla extending towards the malar eminence  (Figures 83.1 and 83.2).    Problems of the upper eyelid are excess skin with or without  ptosis of the lateral brow, herniation of fat (particularly the    Figure 83.1 Lateral view and fat distribution. Suborbic-  ularis oculi fat (GOOF), suborbicularis ocular fat.    medial fat), and also in the middle, with prominence of the  orbicularis oculi muscle and intrinsic changes in the qual-  ity of skin. Similar problems affect the lower lid and include  intrinsic changes in skin, hypertrophy of the orbicularis  oculi muscle and prolapse of orbital fat with deformities of  the tear trough and malar palpebral groove. Lateral canthal  laxity compounds these anatomical problems.    Technical advance in blepharoplasty has evolved in the  last 100 years, and the first tranconjunctival approach was  described by Julian Bourguet in 1924. In the recent past,  surgeons who have contributed most to aesthetic blepha-  roplasty are Flowers, Hamra, Barton and Hester. In 1991,  we identified using cadaver dissection an avascular post-  septal plane, which travels to the arcus marginalis behind  the septum in front of the fascial layer that envelops the  peri-orbital fat. This anatomical position, in our opinion,  makes the septal reset procedure in lower lid blepharo-  plasty a reality.    Patients are advised to stop smoking at least 3-4 weeks  prior to surgery. Any homeopathic medication such as  vitamin supplements should be discontinued during the  same period. Furthermore, routine anti-coagulant therapy  such as aspirin should be stopped a week prior to surgery.  If there is any contraindication, this should be discussed  with the patient’s physician. We recommend patients to  take Arnica tablets (30 g) five times a day starting a week  before. Anecdotally this practice has definitely reduced  bruising and swelling in the post-operative period.  Patients undergoing treatment under a local anaesthetic  are recommended medication as follows:   On the day of the surgery patients start oral antibiot-  ics, usually Flucloxacillin 250 mg four times a day. Two  hours prior to surgery we advocate 8-mg Dexamethasone  orally, which helps to reduce the swelling and bruising.  Some patients may require oral sedation, usually 10-mg  Diazepam is prescribed 45 minutes prior to surgery.    The aim is to create a supratarsal fold. This is usually  about 10 mm from the lid margin. The skin markings  are carried out while the patient is sitting up. The infe-  rior skin markings extend medially to the upper eyelid  fold. The lateral limit is just above the lateral palpebral  fold. To mark the superior aspect of the skin excision,  the accuracy of the excess upper lid skin should be  assessed carefully. While the patient is sitting up we use  an Adson toothed forceps to pinch the excess while the  patients open and closes the eyes with only a mild eleva-  tion of the eyelashes.   Once the middle part of the superior marking is judged  then the medial extension should follow the inferior mark-  ing to a tapered end. The lateral extension will be longer  than the inferior counterpart so that the final result can  also correct mild lateral brow ptosis (Figure 83.3).    Conservative eyelid skin removal is advisable to avoid  the consequences of over correction. Surgery can be  carried out under local or general anaesthetic. Even if  under general anaesthesia to achieve haemostasis and a  bloodless field we prefer to infiltrate 2% Lignocaine with  1:80,000 Adrenaline in a dental syringe. The injection  is carried out incrementally in a subcutaneous plane  to minimize bruising. Approximately 2-3 mL of local  anaesthetic is adequate to carry out surgery under local  anaesthetic.    The lower limb skin incision is carried out followed by  the rest of the skin markings. We prefer to use a No. 15  blade. The skin is excised using a sharp curved scissor with  simultaneous counter-traction over the orbicularis oculi  muscle. Once the skin is excised, haemostasis is achieved  by bipolar cauterization (Figure 83.4).    Approximately 2-3 mm of orbicularis muscle is excised in  order to correct the hypertrophic component. This is usu-  ally parallel to the superior margin of the tarsus and this  process gives exposure to the orbital septum.    Once the muscle is excised a gentle pressure along the  lower lid does show the bulging fat covered by the orbital  septum. The septum is incised to the entire length of  the incision which will expose the preaponeurotic fat  pad. Dissection to the medial fat is carried out sepa-  rately which has a somewhat paler colour compared  to the middle fat. The middle fat is excised in a con-  trolled fashion whilst achieving good haemostasis. The  adequacy of the fat excision would show the Whitnall’s  ligament.    The next step is to create an anchor point to the new  supratarsal fold. There are various techniques described  in the literature. We prefer to place a horizontal mattress  stitch, using 5/0 Vicryl undyed suture, starting under the  surface of the inferior orbicularis oculi and to the fascial  attachment, just above Whitnall’s ligament. Once this is  achieved the skin is repaired using a 6/0 Prolene suture.  The first 3-4 sutures are carried out in the middle part of  the new supratarsal fold as interrupted sutures extend-  ing to complete the lateral suturing, however, the medial  defect can be repaired by a continuous running suture.    Immediately after the operation we use 1% Chloromycetin  ointment as a topical application although it is not recom-  mended for percutaneous usage. We have used this tech-  nique for the last 25 years with no adverse effect. Patients  are discharged home with instructions, antibiotic and  analgesics.    Careful pre-operative assessment and planning is manda-  tory prior to any surgical procedure along the lower lid.  The consequences of over correction in the lower eyelid  surgery are much more obvious compared to the upper.  The aim here is to create a normal ‘S’ shaped curvature to  the lower lid.    Traditionally, a standard lower blepharoplasty is carried  out via a subcilliary approach. The incision is marked  approximately 2 mm below the ciliary margin of the  lower lid beginning from the medial end just below the  lower lacrimal canaliculi. The lateral extension is marked    extending into one of the naturally occurring creases  along the crow’s foot. The lateral extension varies from 5  to 7 mm (Figure 83.5).    The anaesthetic procedure is the same as for the upper lid.  If the surgery is carried out entirely under local anaesthetic  approximately 3-4 mL of 2% Lignocaine with 1:80,000  Adrenaline is infiltrated subcutaneously in an incremen-  tal fashion. This volume is adequate to carry out the whole  procedure.    The skin flap or skin muscle flap are the two basic opera-  tive procedures used for lower blepharoplasty.   If a skin flap is used, the skin is carefully separated  from the underlying orbicularis oculi muscle. This  can be done either using Tenotomy scissors or mono-  polar diathermy needle. Good haemostasis is achieved  (Figure 83.6).    If a skin muscle flap is used the skin incision is the  same. To elevate the muscle with the flap, the incision is  extended deep to the orbicularis oculi muscle. We use an  8-cm Reynolds tenotomy scissors to perform the dissec-  tion. The tip of the scissors is inserted through the orbi-  cularis oculi muscle and the areolar plane between the  septum and orbicularis oculi is defined by blunt dissec-  tion. An important measure with the skin muscle flap is to  leave at least 5 mm of the pretarsal muscle intact as a site  to anchor the flap once the surgery is completed. If a skin  flap is raised the orbicularis muscle is split half way along  the supra inferior dimension. This division would expose  the herniated fat encased in a pocket completely covered  by the septum (Figure 83.7).   The dissection is carried out along the plane superior  to the arcus marginalis to expose the tear trough and the  malar palpebral groove. This allows dissection of the her-  niated fat with the septum which is to be sutured along the  infraorbital rim (Figure 83.8). Once the redrapping of the  fat is achieved followed by haemostasis, the split muscle is  repaired using either 5/0 Vicryl Rapide suture or a bipolar  electric cauterization as ‘welding’.    Figure 83.8 Suture of the herniated fat to the arcus margi-  nalis (septal reset). (Courtesy of Jan Stanek.)    In both the skin flap and the skin muscle flap, once the  fat management is carried out the skin is draped over  the eyelashes. Passive excision of the excess skin or skin  muscle is carried out (Figure 83.9). Further haemostasis  is achieved. It is always helpful to divide the superior part  of the orbicularis oculi muscle laterally so that plication  of the muscle can be carried out using a 5/0 vicryl suture.  The excess muscle is trimmed. Subsequent to that the skin  is repaired with a 6/0 Prolene subcutaneous suture to the  eyelid skin and interrupted sutures to the lateral extension  or interrupted all the way (Figure 83.10).   The benefit of a septal reset on a background of skin flap  is that the innervation to the orbicularis oculi muscle is  undisturbed. The fat volume is preserved and over correc-  tion of the skin excision is minimized.   Many surgeons continue to carry out formal excision  of the medial, middle and lateral fats once exposed simi-  lar to the upper blepharoplasty. The technique here is to  incise the orbital septum to its entire length and careful  excision of the herniated fat with simultaneous haemo-  stasis. The rest of the surgical procedure is as described  earlier.   Pinch blepharoplasty is a well-known technique  where only excess skin is removed through a subcilliary    Figure 83.9 Excision of the excess skin following initial  anchor suture.    approach. This corrects only the skin excess in the anterior  lamellae and makes no other anatomical corrections.    A standard procedure to correct lateral canthal weakness  is a canthotomy followed by excision of the tissue and reat-  tachment of the lower lid tarsus by a deep suture. However,  this has been reported to produce webbing along the lateral  canthal contour. We prefer to use a technique described  by Hester (Figure 83.1la and b) where a limited composite  excision of the lateral lower lid with simultaneous repair  of the tarsus is done. This has the benefit of maintaining  the integrity of the lateral canthal contour and correcting  lid malposition.    The aim of Asian blepharoplasty is to create an upper eye-  lid crease which exists only in 50% of the Asian population.    Anatomically, the Asian eyelid is different from the  Caucasian eyelid at the anterior and middle lamellae. First,    Figure 83.11 (aandb) Management for lower lid malposi-  tion by composite excision of tarsal plate and primary repair  without blunting the canthal definition.    in the Asian eyelid, the orbital septum fuses diffusely with  the levator aponeurosis in a more inferior position allow-  ing the downward herniation of the orbital fat. Second, it  lacks the dermal attachment of the levator palpebrae apo-  neurosis. Third, there is more subcutaneous and preapo-  neurotic fat. This creates a fuller upper eyelid look without  an upper eyelid crease. There are a few ways to create the  superior eyelid crease, and these can be broadly classified  into suturing method and incision method.    This method is to create an upper eyelid crease by strategi-  cally placing nonresorbable sutures at the superior margin  of the tarsus.    The upper eyelid is everted and the tarsus is measured using  a pair of calipers. In the Asian population, the tarsal height  is 7-10 mm (Figure 83.12). Once it has been ascertained,  the height of the tarsus is marked on the eyelid skin as a  smooth line that would converge medially. One to three  pairs of points, each pair 4-5 mm apart, are marked on this  line. The centre pair of points is in line with the pupil, while  the other two pairs of points are placed equidistant from  the medial and lateral canthus to the centre point.    Topical Alcaine (proparacaine hydrochloride 0.5% oph-  thalmic solution) is applied on the conjunctival mucosa.  This eyelid skin and the mucosa are injected with 2%  Lignocaine with adrenaline at 1:80,000.    Suturing is carried with CV-11 6/0 Polypropylene suture  with double armed 3/8 13-mm needle commencing at the  mucosa side. This is first done at the centre pair of points.  The first needle is passed under the mucosa of the everted  upper eyelid (Figure 83.13). Once that is done, both nee-  dles are passed from the mucosa to the skin (Figure 83.14),  one at the medial and one at the distal point of the centre  pair, through the skin. The medial needle is then rein-  serted through the medial point to pass under the skin so  as to exit from the distal point. An interrupted suture is  then tied and buried in the skin. This bunches up the tis-  sues and creates a crease (Figure 83.15). At the mucosa, the  suture should be superior to the tarsus so that it sits on the  tarsal recesses and is kept away from the cornea.    Further points can be created at sites medial and distal  to the central point. This helps to maintain an upper eyelid  crease (Figures 83.16 and 83.17).    This method is to create an upper eyelid crease by excising  skin and muscle at the superior margin of the tarsus.  Occasionally, orbital fat can be trimmed if it is excessive.    The height of the skin excised is usually less than in  Caucasian counterparts. The skin pinch technique can be  used to ascertain how much skin is to be removed. Similar  to the suturing technique, the height of the upper eyelid  tarsus is everted and measured using a pair of calipers.  Once it has been ascertained, the height of the tarsus is  marked on the eyelid skin as a smooth line that would con-  verge medially. Laterally, it curves towards the most supe-  rior crow’s foot (Figure 83.18). Superiorly, the height can  be determined by the skin pinch test for a mature patient  with excess skin. For younger patients, the skin excision is  more conservative and is about 2-3 mm in height.    This eyelid skin is injected with 2% Lignocaine with  adrenaline at 1:80,000.    The skin is excised as per skin marking (Figure 83.19). The  skin is undermined inferiorly to expose the pretarsal orbi-  cularis oculi muscle. Up to 1/3 of the pretarsal orbicularis  oculi muscle can be excised (Figure 83.20).    The septum is divided with an electrocauthery, No. 11  blade or tenotomy scissors to expose and allow the middle    orbital fat to prolapse out. The fat to be excised is clamped  with a mosquito artery forceps, and the fat excised and  haemostasis achieved by cauterization (Figure 83.21).    Suture with 6/0 Prolene. Start by catching the lower  eyelid skin, septum, levator aponeurosis if seen, prese-  ptal orbicularis oculi muscle and upper skin and plac-  ing interrupted or continuous running sutures (Figures  83.22 and 83.23).    Figure 83.22 Pre-operative view of an Asian eyelid prior  upper blepharoplasty.    Figure 83.23 Pre- and post-operative view after upper  eyelid skin and fat excision.    We are grateful for the help and support of Anna Sayan  and Jane Porter in preparing this manuscript.   e Pre-operative photographs are essential as a record  should the patient question the result at future date.   e Pre-operative markings should be made with the  patient sitting up. The soft tissues redraw in the supine  position.   e When operating remember to infiltrate the fat pads  before manipulating them to prevent an acute brady-  cardia due to occulocardiac reflex.    Barton FE Jr., Ha R and Awada M. Fat extrusion and sep-  tal reset in patients with tear trough triad: A critical  appraisal. Plast Reconstr Surg. 2004; 113: 115-2121.   Bourget J. La veritable chirurgie esthetique du visage. Paris:  Plon. Pub 1936.   Castanares S. Blepharoplasty for herniated intraorbital fat:  Anatomical basis for a new approach. Plast Reconstr  Surg. 1951; 8: 46-58.   Hamra ST. The zygorbicular dissection in composite rhyt-  idectomy. Plast Reconstr Surg. 1998; 102: 1646.   Hamra ST. Arcus marginalis release and orbital fat preser-  vation in midface rejuvenation. Plast Reconstr Surg.  1995; 96: 35.   Hamra ST. The role of the septal reset in creating a youth-  ful eyelid-cheek complex in facial rejuvenation. Plast  Reconstr Surg. 2004; 113: 2124.   Hester TR, Codner MA and McCord CD. Subperiosteal  malar cheek lift with lower lid blepharoplasty.  In McCord CD, Codner MA (eds.), Eyelid sur-  gery: Principles and Techniques. Philadelphia, PA:  Lippincott-Raven; 1995. p. 210.   Hester TR, Codner MA, McCord CD, Nahai F and  Giannopoulos A. Evolution of technique of the direct  transblepharoplasty approach for the correction of  lower lid and midfacial aging: Maximising results and  minimizing complications in a five year experience.  Plast Reconstr Surg. 2000; 105: 393.   Hester TR. Evolution of lower lid support following lower  lid/midface rejuvenation. The pretarsal orbicularis  lateral canthopexy. Clin Plast Surg. 2001; 28: 639.   Ilankovan V. Transconjunctival approach to the infraor-  bital region: A cadaveric and clinical study. Br J Oral  Maxillofac Surg. 1991; 29(3): 169-172.   Jeong SI, Lemke BN, Dortzbach RK, Park YG and Kang  HK. The Asian upper eyelid: An anatomical study    with comparison to the Caucasian eyelid. Arch Wong JK, Zhou X, Ai Y and Wang Z. A simple, minimally    Ophthalmol. 1999 Jul; 117(7): 907-912. invasive method for creation of the superior palpe-  Pottier F, El-Shazly N and El Shazly AE. Aging of the orbi- bral fold in Asians with the modified continuous  cularis oculi: Anatomophysiologic consideration in buried tarsal stitch: A joint assessment from Toronto,  upper blepharoplasty. Arch Facial Plast Surg. 2008; Ontario Canada, and Chengdu, China. Arch Facial    Children frequently present, or their parents or friends  advise them to come, complaining of ‘not liking their ears’,  Their ears are too prominent, too big, too small, unusual  shapes, unusual positions and, because of them, they are  being teased. The problem is made worse for the child  because the ears approach adult size early in the grow-  ing face. The psychological problems associated with this  deformity are significant and often only come to light after  discussion (Figure 84.1).   These defects are very common (3%-5%) and relatively  easily corrected. The usual problem is lack of definition of  the anti-helical fold and/or conchal overdevelopment. A  choice of techniques is necessary. There is not one tech-  nique for all cases although it is best to rely mainly on one  technique to begin with. There are so far over 100 methods  described. Ely, in 1881, was the first to describe a technique  for correction of prominent ears.    The most important aspect in management is assessment.  Compare left with right and with normal population (n)  for racial group from in front, behind and above:    ® Distance between helical rim and skull (n = 1-2 cm)   ® Vertical height: approximately 5-6.5 cm (males >  females and right slightly > left)   ® Presence or absence of Darwinian tubercles, sinuses  and pre-auricular tags    The surgeon should know and understand the anatomy  of the normal ear (Figure 84.2) and its three-dimensional  position (Figure 84.3).   The ear has a very rich blood supply via the superfi-  cial temporal, posterior auricular and occipital vessels.  The sensory nerve supply is via the auriculotemporal,  the lesser occipital and the greater auricular nerves,  and the concha also receives sensory innervation via  the vagus nerve. The vascular supply and innervation  are such that the procedures can easily be carried out  under local anaesthetic, local anaesthetic and sedation  or general anaesthesia (which should be used for chil-  dren <14 years). The aim is to achieve ears of equal and  normal prominence and shape with a soft gentle appear-  ance and no evidence of breaks or pinch effects. Ideally,    Tragus === :  = - F  or rf  a 1 Anterior  Lobule i helix i 20°  (b)  (a through c) Three-dimensional ear position.    size should be equal, but not necessarily so. It is promi-  nence that is more obvious to the on-looker rather than  size (Figure 84.4).    There is good evidence now that, ifthe deformity is obvious  ina child at birth, it can be corrected by the application of  ear moulds held in place for a month. The cartilage can be  moulded significantly and permanently at this stage. Most  prominent ears are not detected, however, until later.    Figure 84.4 (a) Right normal ear; (b) left ear following exci-  sion of lesion 3 x 3.cm.    The next best time to correct the deformity is when the  child is older (>14 years), under local anaesthetic and seda-  tion, unless the deformity is obvious and causing psychologi-  cal problems and then the ears should be corrected at the age  of 5 years before the child starts school. There is no indication  to correct the deformity surgically before the age of 5 years.    There are multiple techniques: they must eliminate tension  and left and right ears should be exposed and symmetry  obtained.    This is a very simple, efficient and reliable technique for  the inexperienced surgeons, but does not address con-  cha or scapha problems and often gives an unnatural and  poorly defined appearance (Figure 84.5).    This is a fairly complicated but excellent aesthetic technique  involving incising, mobilizing and deforming the cartilage  with sutures to develop an anti-helical rim with prominent  superior and inferior crura (Figure 84.6).    This technique involves creating space posterior to the  concha to allow the concha to be pinned back with-  out the cartilage bulging forward and occluding the  external auditory meatus. It requires two stitches of  non-resorbable material to be placed between the peri-  chondrium of the concha and periosteum of the mastoid  (Figure 84.7).    This technique is the mainstay of the author's management  supported by the Furnas conchal-mastoid suture.   Both ears are prepared with an antiseptic and exposed  (Figure 84.8). The proposed antihelix and superior and    inferior crura and their junction are tattooed with the use  of a 22G green needle (Figure 84.9).   A dumb-bell ellipse of skin is outlined in the post-auricular  area; the amount of skin to be excised is proportional to the  prominence of the ears and can be judged by folding back  the ear to simulate the proposed ear position. This should be  excised mainly from the ear aspect (Figure 84.10).   When the ear is folded back into its proposed position,  feel the maximum area of resistance and look to see if the  external acoustic meatus has been compromised by the  conchal cartilage bulging forward. Outline the areas of  excess tension. If the conchal cartilage is bulging forward,  a Furnas suturing technique is required.   Infiltrate the post-auricular area with 2% lignocaine  and 1:80,000 epinephrine (adrenaline). The dumb-bell  ellipse is excised and the post-auricular muscle identified  and preserved (Figure 84.11).   Dissection is continued in a subperichondrial plane  until the tattoo marks plus 5 mm are visible. The pro-  posed antihelix and superior and inferior crura are    drawn on the cartilage. An acrylic or diamond burr is  used to weaken a l-cm area simulating the crura and  antihelix (Figure 84.12).   The cartilage is weakened until the ear can be easily  bent back with no tension and no sharp ridge. Attention  needs to be paid especially to the helical tail and antitra-  gus which may require further trimming (burr or knife) to  prevent the lobule protruding (Figure 84.13).   The ear is allowed to lie freely and then gently placed in  its new position to allow the surgeon to decide the most  advantageous position for the two to four holding sutures.  The number of sutures is dependent on the extent of the  original deformity. The proposed holding suture sites are  outlined on the anterior ear lateral to the proposed antihe-  lix. A 2-3-mm incision with a No. 15 scalpel blade is made  down to the cartilage and then, with scissors, the cartilage  is gently cleaned (Figure 84.14).   For each external incision, a 3/0 clear nylon suture is then  passed from the retro-auricular dissection through the car-  tilage and then back again, with a millimetre bite of carti-  lage. This technique avoids fixation to the overlying skin.   The need for a mastoid conchal stitch is now decided.  It is best to place at least one of these and, if placed, it will  involve dissecting the posterior auricular muscle free from  its auricular attachment to create space for the conchal ret-  ropositioning. The ear is held in its proposed position and  the mastoid fascia marked to allow the holding stitches  to get the best purchase and best direction of support.  The holding stitches are used to pick up mastoid fascia    (and periosteum). The attachment to the fascia should be  tested by traction on the suture before the final position is  accepted (Figure 84.15).   The sutures are then clipped and the other ear is pre-  pared. In unilateral cases, the holding sutures are tight-  ened until the ear is slightly over-reduced. In bilateral  cases both ears are reduced, one suture at a time and again  slightly over reduced (Figure 84.16).   The post-auricular incision is closed with an inter-  rupted subcuticular resorbable suture, the skin with inter-  rupted (or continuous) 4/0 nylon. Bupivacaine 0.5% (2 mL)  is infiltrated into the retro-auricular area.    The wound and the three stab wounds are liberally dressed  with chloramphenicol eye ointment. A proflavine wool  dressing is applied just to support the posterior of the ear  and also to cover and shape the lateral surface of the ear.  A crepe dressing in the form of a mastoid-like bandage is  applied which is kept in situ for 7 days (Figure 84.17).   Analgesics are prescribed and the patient told to  attend if moderate pain is experienced. A support dress-  ing, such as a hairband or a knitted hat, is then worn at  night for a further 2-3 weeks. The final result is shown  in Figure 84.18.    The most common complication is relapse, usually owing  to an inappropriate technique or suture slippage. This  warrants recorrection. Inappropriate placement of sutures  can lead to the deformity known as telephone ear with the  mid portion of the ear pinned back and prominence of the    superior and inferior aspects of the ear. The most serious  complications are chondritis, haematoma and infection.  Haematomas require immediate drainage. Infection  requires drainage and antibiotics. Haematoma and infec-  tion can lead to severe destruction and distortion of auric-  ular cartilage, correction of which can be very difficult.    Bradbury ET, Hewison J and Timmons MJ. Psychological  and social outcome of prominent ear correction in  children. Br J Plast Surg. 1992; 45: 97-100.   Brent B. Auricular repair with autogenous rib cartilage  grafts: Two decades of experience with 600 cases.  Plast Reconstr Surg. 1992; 90: 355-374.   Converse JM. A technique for correction of lop ears. Plast  Surg. 1955; 15: 411-418.   Ely ET. An operation for prominence of the auricles. Arch  Otolaryngol. 1884; 10: 97.   Farkas LG. Anthropometry of the normal and defective ear.  Clin Plast Surg. 1990; 17: 213-221.    Furnas D. Correction of prominent ears by concha-mastoid  sutures. Plast Reconstr Surg. 1968; 42: 189-193.   Langdon JD, Patel MF (eds). Operative Maxillofacial  Surgery. London: Chapman and Hall; 1998.   MacDowell AP. Goals in otoplasty for protruding ears.  Plast Reconstr Surg. 1968; 41: 17-27.   Mustarde JC. The correction of prominent ears by using sim-  ple mattress sutures. Br J Plast Surg. 1963; 16: 170-178.    Rubin LR, Bromberg BE, Walden RH and Adams A. An  anatomic approach to the obtrusive ear. Plast Reconstr  Surg. 1962; 29: 360-370.   Stark RB and Saunders DE. Natural appearance restored  to unduly prominent ears. Br J Plast Surg. 1962; 15:  385-397.    Rhinoplasty is the most frequently requested aesthetic  procedure usually directed towards reduction, augmenta-  tion or subtle refinement of the bony-cartilaginous skel-  eton. The skin soft-tissue envelope (SSTE) redrapes to its  new foundation. Many components of the operation can  be variably affected by the healing process. The philosophy  is preservation, reconstruction and cartilaginous grafting,  providing tip support (TS) and creating a strong, high pro-  file that provides and maintains the shape to the overly-  ing SSTE by opposing the distorting scar contracture, and  preserving or correcting the nasal airway.    1. Paired nasal bones, thick at the frontal bone junction  (no osteotomies)   2. Nasal processes of the maxilla overlap the upper lateral  cartilages (ULCs) (no downward rasping)    877  877  877  878  879  879  880  883  883  886  887    The quadrangular septal cartilage acts as a supporting  strut and contributes to the convex dorsum (nasal hump).  It extends anteriorly as the posterior septal angle (PSA)  from the anterior nasal spine (ANS) as a cantilever, to sup-  port the nasal tip at the anterior septal angle (ASA), and  posteriorly articulates with the vomer and perpendicular  plate of the ethmoid. Superiorly, it connects deep to the  nasal bones and the paired ULC to form the cartilaginous  vault. The septum's most caudal mobile aspect articu-  lates with the medial aspect of the lower lateral cartilages  (LLCs), supporting the tip, and facilitates LLC movements  during respiration.   Inferiorly, the ULC are folded back on themselves at the  plica nasi, where they articulate with the overlying supe-  rior border of the LLC, and their inferior borders makes  an angle of 10°-15° with the septum at the valve area.  The integrity of this angle is important for nasal airway  patency and may be disrupted by disarticulation of the  ULC from the nasal bone, rupture of the connection with  the LLC and disconnection with the SSTE (Figure 85.1  and 85.2).    Angle of  rotation  Lateral crus  Middle crus  Medial crus  Angle of  divergence  Dome  (lateral genu) Middle crus    Figure 85.1 Surgical anatomy of the nose. (a) Soft tissues.  (b) Osseocartilaginous structures and landmarks: (1) nasal  bone, (2) ULC, (3) LLC: 3a LC, 3b MC, 3c ImC, (4) nasion,  (5) rhinion, (6) ASA, (7) dome. (c) Alar cartilages and tip-structures.    Figure 85.2 Surgical anatomy of the septum: (1) nasal  bone, (2) ULC, (3) quadrangular septal cartilage, (4) ASA, (5)  middle septal angle, (6) PSA-ANS, (7) maxillary crest, (8) per-  pendicular ethmoid plate.    The LLC is composed of a medial (MC3b) and a lateral  crus (LC3a) to form an arch with domes at the level of their  connection by an intermediate crus (ImC3c). The straight  and thin MC is connected by the interdomal ligament and  by the suspensory ligament to the ASA at the soft medial  triangle of Converse. They come together in the midline  to be part of the columella where they strongly articulate  with the septum by ligaments in the mobile membranous  septum. They end posteriorly in the MC foot plates around  the ANS, and superiorly diverge (angle of divergence) as  ImC, also making an angle of rotation (infra-tip break) to  form the dome and then the quadrangular and convex LC.  At the dome and LC the lower border of the cartilage is  some distance from the nostril border; the space of super-  position of skin and vestibular skin is the soft triangle of  Converse or facet, to be respected by the marginal incision  which follows the caudal LC margin. The LC extend down  to the pyriform orifice and are connected with the ULC  by fibrous and musculoaponeurotic tissue or superficial  musculoaponeurotic system (SMAS). The weak triangle  of Webster is located between the ULC, the LLC and the  pyriform aperture (osteotomies can disrupt the triangle  and result in airway obstruction).    Support mechanisms are divided into major and minor  components (Figure 85.3). The nasal pyramid is a tripod  concept consisting of the LLC (Anderson). The LC repre-  sents the upper legs and the linked MC the lower leg of the  tripod. Tip-characteristics [tip projection (TP), tip rota-  tion (TR) and nasal length] may be adjusted by alteration  of the tripod limbs and the tip-supporting structures.    Figure 85.3 Tripod concept and elements of structural  tip support (TS): (1) major, (2) and (3) minor; (1) size, shape and  strength of LLC (major TS), (2) medial crural-septal ligament,  (3) intercartilaginous ligament, (4) SSA and cartilaginous dor-  sum, (5) interdomal - suspensory ligament to ASA,  attach-  ment LLC and ULC to SMAS, (7) ANS and membranous septum,   thickness skin and SMAS, (9) alar sidewalls.    The superficial muscoloaponeurotic system (SMAS) covers  the nasal pyramid in a continuous sheet of mimetic  muscles interconnected by a tendon-like aponeurosis. The  SSTE is elevated in the plane just deep to the SMAS, above  the perichondrium and beneath the nasal bone periosteum  to which it is adherent. The SSTE overlying the nose varies  in thickness, mobility and pliability; thickest at the nasion,  the supratip and at the naso labial angle (NLA), thinnest  at the rhinion and the domes (Figure 85.1b). The mimic  muscles of nasal animation can influence long-term heal-  ing with regards to the position of the tip, the upper lip or  NLA and can be individually and synergistic overactive.  A ‘plunging tip’ deformity can be due to overactivity of  levator labii alaeque nasi (LLAN) and depressor septi nasi  (DSN) muscles.    Besides the classical divisions in thirds and fifths, exami-  nation should include: the curved unbroken aesthetic  line from the eyebrow or supraciliary ridge over the nasal  root to the lateral wall of the dorsum till the tip-defining  (highlight) point, the width of the dorsum, the base of  the bony pyramid, the ULC and the alar base (no larger  than the intercanthal distance), nasofrontal angle (NFA)    Figure 85.4 Nasal analysis: (a) morphology; (b) projection  (AB: nasal length, CB: tip-base distance).    and soft-tissue nasion or sellion (deepest portion of NFA):  normally positioned horizontally 12 mm anterior to the  corneal plate and vertically between upper eyelash and  supratarsal fold.   Double break (lateral view, Figure 85.4): supra tip break  (STB) and columellar-lobular angle (CLA) or infra tip  break defining transition from mesial to intermediate  crus. The tip position is determined by TP and TR. TP =  CB (Figure 85.4), overprojection if CB >60% of AB. TR is  reflected in the nasio-labial angle (90°-120°).   The columella should be visible and project 2-3 mm below  the alar rim, as ‘columellar show’. Overprojection of the  columella and retracted alar rim exposes the columella and  membranous septum in a ‘true and pseudo hanging colu-  mella. A hypertrophic ala is a hanging ala. Retraction of  the septum in drooping tips with acute NLA diminishes  the columellar show in a ‘retracted’ columella (Figure 85.5).    Pre-operative photographs in a frontal, lateral, oblique and  base view and smiling to check the synergic muscle activity  for plunging tip and gum smile, are essential. Differences  in anatomical shape of the LLC, thickness, strength and  recoil or ‘spring’ of the ASA and the LLC are assessed by  palpation as well as skin thickness and quality. Oily thick  skin limits post rhinoplasty tip definition because of lack  of contractility even after defatting. Thin skin shows all  post-operative irregularities and may necessitate interpo-  sitioning of temporoparietal fascia.  Evaluation of the airway is critical (see Chapter 87).    The choice is based on the anatomical deformity and  the training and experience of the surgeon. The closed  or endonasal access combines an interseptocolumellar  (transfixion) incision with lateral intra- or intercartilagi-  nous incisions.   In the transcartilaginous approach (cartilage splitting  technique), the amount of cephalic resection of the LLC  is determinated pre-operatively, before the through nasal  skin and cartilage incision. The transfixion incision (TI)  (Figure 85.6c) is initiated over the SSA, continues between  cartilaginous and membranous septum and extends vari-  ably from SSA to the anterior nasal septum (ANS). The  complete TI divides the septo-crural ligaments with poten-  tial loss of TP. The cephalic strip of cartilage is removed. The  incision does not interrupt the plica nasi. A low incision,  3-6 mm from the lower border of the LC, with resection of  one piece of LLC that can be reinserted if required (Millard  and Peck) gives, even in thick skin noses with narrow nos-  trils, good access for scalpel dissection on the dorsum.   Non-delivery techniques are conservative with stable  healing and minimal tip numbness only indicated for  minimal tip refinements (minimal volume reduction),  little TR, in thin skin noses with symmetric strong LLC  needing maximal cartilage preservation.   In the intercartilaginous approach (delivery tech-  nique) (Figure 85.7), bilateral intercartilaginous    Hanging alar  Hanging alar rim, <1 mm  Normal columella, 1-2 mm    Pseudo hanging columella  Retracted alar rim, >2 mm  Normal columella, 1-2 mm    Retracted columella  Normal alar rim, 1-2 mm  Retracted columella, <1 mm    incisions are combined with marginal incisions follow-  ing the lower border of the alar cartilages, respecting  the soft triangle of Converse. The LLC is delivered as  chondrocutaneous bipedicled flaps, allowing for direct  inspection and appropriate tip modifications, dome  sutures and asymmetry correction. The intercartilag-  enous incision can disturb the valve and interruption of  the interdomal ligament can lead to decreased nasal TS  and TP loss.   The open approach or external rhinoplasty technique  (Figure 85.8) combines marginal incisions, 1 mm behind  the columellar border, with a mid-transcolumellar con-  nection. The SSTE is then dissected off the nasal skeleton  under direct vision.    1. Advantages: Perfect visualization of the cartilages,  better diagnosis, an intact valve, easier and precise  grafting.   2. Indications: Severe post-traumatic deformities, second-  ary rhinoplasties, difficult and cleft noses, simultane-  ously maxillary orthognathic surgery to reconstruct TS  and a strong profile.   3. Disadvantages: Increased scarring by dissection of the  skin from the cartilages, potential trauma to the tip and  dorsal skin by manipulation and retraction.    Exposure of the osseocartilaginous vault requires sharp  dissection as close as possible to the cartilages and    Figure 85.6 Transcartilaginous approach: (a) the cartilage  splitting incision through the vestibular skin; (b) and through  the LC; (c) transfixion incision (TI): the partial Tl stops short of  the ANS. The complete TI divides the septo-crural ligaments  with potential loss of TP.    subperiosteally at the nasal bones keeping the SMAS  intact; in thick skin noses defatting or resection of the  SMAS is possible (Figure 85.9). For hump resection, an  extramucosal dissection is utilized elevating the mucosa  of the ULC and the nasal bones periosteum starting  from the submucoperichondrial layer of the septum  to prevent mucosal tearing during hump reduction    Figure 85.7 Intercartilaginous access or delivery tech-  nique: (a) intercartilaginous and (b) marginal incisions.    and endonasal mucosal retraction. Cartilage grafting  has less risk of infection, elimination or rejection in a  closed compartment (Figure 85.9b). Hump resection is  performed with a scalpel for the cartilage as a single  unit (ULC and septum) and with a Rubin guided osteo-  tome, introduced in the ‘fish mouth’ created, for the  bony hump. Bony irregularities are corrected with bone  scissors or upwards rasping. An ‘open roof deformity’  results after hump resection.   Overresection of the bony hump and underresection  of the cartilaginous hump causes a ‘pollybeak or surgi-  cal look’. A slight residual convexity should be preserved  at the rhinion after hump resection as straight line  removal of the skeletal hump can result in a concave,  over-reduced bridge. This can be corrected by cartilage  onlay grafting or reintroduction of a reduced resected  hump (Skoog).    Figure 85.8 The open/external approach: (a) (1) transcolu-  mellar, (2) bilateral vertical columellar and marginal incision;  (b) elevation of the SSTE offering a direct view on the tip and  middle vault.    The primary indication for narrowing the nose by lateral  osteotomies is to close the open roof deformity following  hump resection (Figure 85.10).   The standard approach is intranasal after stab inci-  sion and tunnelling, or directly through the mucosa, at  the pyriform rim just superior to the inferior turbinate,  respecting the valve area at Webster's triangle. The lateral  osteotomy runs low in the nasofacial groove to below the  medial canthus, where it is angled towards the midline. In  primary rhinoplasties, the lateral osteotomy alone is suf-  ficient, because, by twisting the osteotome and finger pres-  sure, a back fracture creates superior and medial fractures.    Figure 85.9 Dorsal hump surgery: (a) dissection below the  SMAS and exactly on the perichondrium and ideally below the  periosteum at the bridge leaving the lateral side of the nasal  bones attached to the SSTE; (b) separation of the nasal mucosa  away from the ULC and septum; (c) hump resection initiated  with scalpel on cartilaginous portions of hump (Peck); (d)  hump resection completed with rounded edges osteotome  (Rubin) on the bony portions of hump.    If not, transnasal medial osteotomies with an osteotome  placed laterally along the septum and driven upwards till  the sound change indicates thick bone, and transcutane-  ous superior osteotomies are performed.   For more predictable and precise osteotomies, a trans-  cutaneous approach, lateral to the nasofacial groove, with  a 2-mm osteotome, leaving no visible scar, is preferred.  The superior transverse osteotomy, as well as an osteotomy  of a deviated bony septum, can be carried out through the  glabellar skin.   Common problems: ‘rocker’ formation (osteotomy too  high), lateral depression (too low), stair step deformity (too  medial) and recoil of bony flap or drop into the nasal fossa  (too wide undermining or too thin maxilla).    As described earlier, the nasal tip can be likened to a tripod  (Figure 85.3) with the LC representing two legs and the  conjoined MC a third. Selective increase or decrease in the  length of the tripod legs can be used to attain the desired  TP and/or TR, for example, by shortening the two superior  legs of the tripod, one can increase TR and decrease TP,  or by shortening the conjoined MC, one decreases TP and  TR. It is nearly impossible to alter TP without changing  TR (Anderson and Webster).    Cephalic volume reduction: Complete and  interrupted strip, rim strip and lateral crural  flap procedures    In tip refinement, the complete strip (Figure 85.11), leav-  ing behind a 6-mm caudal LC for alar support, is a basic  and conservative technique, for mild increase in tip defi-  nition with slight decrease in TP and increase in TR. The  complete strip will resist upwards rotation and refinement,  unless additional manoeuvres as incomplete incisions,  cross-hatching or morselization are added. Sectioning the    lateral parts of the LC will also increase TR. The amount  of upwards rotation and decrease in TP is more important  with more developed ULC.   In more aberrant anatomy, interrupted strip procedures  with vertical lateral excisions are indicated; they require  suture reconstruction and need supportive struts or con-  touring grafts to stabilize and prevent loss of projection,  alar collapse, notching, pinching and asymmetry. The rim  strip (Figure 85.12) and lateral crural flap (Webster)  (Figure 85.12) are useful in thick skin noses, strong enough  to support the alae and prevent them from collapsing,  needing tip repositioning: increased TR and decreased TP.    Complementing complete strip techniques, interdomal  sutures and transdomal horizontal mattress sutures are  indicated for greater tip-narrowing in broad-boxy or  bifid tips with excess divergence of intermediate crura.  After removing the soft tissue occupying the interdomal  space, a more triangular lobule and improved support  are obtained. If obliteration of the external soft triangle  occurs due to medialization of the LC, the cartilage has to  be trimmed (Figure 85.13).    Essential in correction of a long nose, performed through  a (high) TI or directly in the open technique. The shorten-  ing encroaches on the ANS and can be modified as illus-  trated in Figure 85.14.    Septal surgery is performed to correct septal deviations  with airway obstruction or aesthetic problems due to  anterior deflections, and to harvest (osseo) cartilaginous  grafts. All displaced structures should be exposed with    Figure 85.12 Cephalic volume reduction: (a) rim strip  technique; (b) lateral crural flap (Webster) technique.    limited mucoperichondrial detachment and maintain-  ing 1 cm of dorsal and caudal structure to prevent dorsal  saddling, tip drooping, columellar retraction and septal  flaccidity.    Through a hemi-TI down to the spine to the cartilage, a  submucoperichondrial dissection is performed with a  Cottle's elevator. If fracture adhesions, cartilage overlaps,  or severe scarring interfere, the area is infiltrated with  local anaesthesia to facilitate further elevation.    Anterior cartilaginous thickenings can be thinned by  shaving, concave cartilaginous deviations are corrected by  resection of excess inferior cartilaginous combined with  full thickness incisions on the concave side of the contra-  lateral pedicled cartilage to break the spring (memory)  (Figure 85.15). The swinging-door technique is used to  reposition a displaced caudal septum. After unilateral  elevation of the mucoperichondrial flap, the septal carti-  lage is excised along the floor of the nose and repositioned  on the premaxillary crest, and fixated on the contralateral  mucoperichondrium by a bur hole in the ANS. Bony spurs  and angulated deformities (see Chapter 87) need resection  or osteotomy.    Cartilage incision 1 cm posterior to the border of the cau-  dal septum. Elevation of the untouched mucoperichon-  drium on the contralateral side where needed, mostly at  the junction of the cartilage-maxillary crest.    1. Resection/osteotomies: most common method for sep-  tal correction and graft harvesting. Deviations limited  to the posterior septum are treated by endonasal sub-  mucous resection after bilateral mucoperichondrial  flap elevation. A 1-cm caudal and dorsal L-shaped strut  is left attached to the perpendicular ethmoidal plate  and maxillary crest-ANS area to maintain support.  Cartilage and bone for grafting can be harvested.    Figure 85.15 Anterior septal corrections through a hemi-  transfixion incision and unilateral flap elevation: (a) incision on  the concave side and partial resection; (b) repositioning of cau-  dal deflections with displacement from bony groove, resec-  tion of cartilaginous spur, osteotomy of palatal/vomeral crest  offending medial reposition of caudal septum.    3. Swinging-door flaps, indicated in angular deviations of  the dorsal strut, which are incised at the angle to 2 mm  of the dorsal border. Repositioning in the midline and  splinting for stabilization before multiple cartilage inci-  sions interrupt a twisting dorsal strut, as well as stabili-  zation of the caudal septum on the ANS.   4. Morselization, only possible after bilateral flap eleva-  tion, is sparingly used, as results are unpredictable.    In Tardy's modified method (Figure 85.16), a vertical sinu-  ous incision sited just cephalically to the caudal end of  the septum and proximal to the mucocutaneous junction,  avoiding scar formation or retraction in the cutaneous  portion of the caudal septum allows full septal exposure  through retrograde dissection to and around the caudal  septum while maintaining the vital medial crural foot-  plate attachment to the septum.    Figure 85.16 Tardy's septoplasty technique: (a) serpentine  mucoperichondrial incision 2-3 mm above caudal septum bor-  der; (b) unilateral mucoperichondrial flap, disarticulation of the  cartilaginous septum and contralateral subperiosteal dissec-  tion; (c) resection of subluxated cartilage (and bone) along the  floor of the nose and replacement of the anteriorly pedicled  septum as a ‘swinging door’ to the midline.    After unilateral flap elevation, and if osseocartilaginous  grafts are not needed, disarticulation with slight pressure  with the elevator at the chondro-osseous junction or in  previous fracture lines, exposing the contralateral peri-  chondrium permitting contralateral submucoperiosteal  dissection. This often allows the deviated cartilage to return  to the midline asa ‘swinging door’, sometimes after resection    of fibrous tissue bands, subluxated cartilage or bone along  the nasal floor. Correction of bony obstructions is per-  formed with a biting forceps. Cartilaginous obstructions  are corrected by incisions in different directions through  the cartilage but not into the opposite mucoperichondrium,  to create multiple cartilage islands, supported and nour-  ished by the opposite intact mucoperichondrial flap.   e@ In secondary septoplasties and post-traumatic rhi-  noplasties for anterior bony crest (re)sections or graft  offers the possibility of separate elevation of the flaps to  reduce the chances of perforation.    The open rhinoplasty technique offers a remarkable expo-  sure for anterior and infero-anterior septal corrections,  secondary septoplasties and graft harvesting from the  ASA and caudal septal border to correct caudal deviations.   Separation of the domes and the MC to the ANS, with  submucoperichondrial dissection cranially to the ethmoid.  Caudally, separate elevation of the periosteum by tunnelling  from the ANS on the floor of the nose. By semicircular sweep-  ing motions both tunnels are connected over the chondro-  osseous junction area to prevent lacerations. Bilateral dissection  is possible but in angulated deformities, a unilateral attachment  is preferred for stabilization. The medial crural support is re-  established by suturing the MC together post-septoplasty.   From the anterior septal border to correct anterior devi-  ations in secondary septoplasties, where the dissection  from the caudal border is impossible due to scar forma-  tion, and has to be dissected from anteriorly at the middle  third after section of the ULC at their septal junction;  modification and graft harvesting can then be carried out  behind the area of adherences.   At the end of the procedure redundant bony-cartilagi-  nous fragments can be repositioned as free grafts between  the septal flaps, to prevent a flaccid septum (floating during  inspiration and expiration). Through-and-through mat-  tress resorbable sutures reapproximate the septal flaps and  stabilize the repositioned fragments. Inadvertent perfora-  tions of the mucoperichondrium are meticulously closed  if they are opposing each other. Incisions are closed and  disrupted supporting ligaments: interdomal and medial  crural-septal attachments are restored. Bilateral soft silas-  tic stenting is placed for 5-7 days (Figure 85.17).    Grafting provides shape and definition, establishes solid  TS, opposes scar contracture and distortion of the SSTE  and functionally grafting is used to improve and maintain  an open nasal airway.    Figure 85.17 Reapproximating the mucoperichondrial  septal flaps and stabilizing the septal remnants.    Septal cartilage is the preferred source of grafting mate-  rial. Other excellent sources include remnants of the  resected osseocartilaginous dorsal hump and the cartilage  obtained from the cephalic trim of strong LLCs. Conchal  ear cartilage can also be used. Thin bony plates from the  perpendicular ethmoid and vomerine septum may be  used where a more rigid graft is needed. Description of  all grafting techniques is beyond the scope of this section,  they include columellar struts, tip onlays, infratip lobular  grafts etc. In addition to these tip grafts, contouring grafts  are frequently required.    Aesthetic narrowing of the nasal skeleton and tip must  be balanced by concomitant reduction of the alar base.  Alar surgery is one of the final steps in aesthetic rhi-  noplasty in a conservative and symmetric manner  (Figure 85.18).    ® Internal nostril floor reduction preserving the nostril  sill provides subtle improvement in repositioned nasal  tips without visible scar.   @ Alar lobule excision at the nostril floor and sill results  in reduction of flare as well as in slight reduction of the  alar bulk, and provides medial alar repositioning.   ® In reduction of overprojecting tips, alar wedge excisions  reduce the overall length of the alar sidewalls.   ®@ Maximal alar reduction with medial repositioning will  be effected from the alar sliding flap technique, with a  generous incision in the alar-facial junction. Reduction  of the volume, curve and flare will result, the extent of  each dependent on the angulation of the excision. Skin  repair is accomplished with intradermal absorbable  suture. Skin sutures are placed 1 mm above the alar-facial  groove to avoid sebaceous glands located in the junction.  The repair can be further supported and enhanced with  the use of an alar cinch suture of 3/0 PDS.    Figure 85.18 Alar base surgery: Alar resection in com-  bined vertical and horizontal part.    General anaesthesia with orotracheal intubation is pre-  ferred. The nose is packed with neurosurgical cottonoids  in a cocaine-epinephrine (adrenaline) solution for vaso-  constriction and shrinkage of the mucosae; local anaesthe-  sia (0.5% xylocaine — 1:100,000 epinephrine) is infiltrated  between the skin and the skeleton and submucosally.   The mid-columellar incision (inverted V) to the level of  the medial crura at a site just anterior to and above the flare  of the medial footplates is made with a No. 15 blade. The  transcolumellar incision is connected to bilateral columel-  lar marginal incisions running 1 mm behind and parallel  to the rim of the columella. The lateral part of the marginal  incision is placed along the caudal margin of the lateral  crura. The back of the scalpel is used to palpate the edge of  the cartilage to identify the correct position for the lateral  incision. A double skin hook retracts the alar margin while  simultaneously applying finger pressure over the LLC to  evert the caudal margin. Then the hook is placed between  the lateral portion of the marginal incision and the columel-  lar portion, with simultaneous traction on the nasal skin  with a single hook to make the connecting incision, respect-  ing the facet or soft triangle of Converse, which should be  preserved; incisions too close to the nostril rim can result in  alar notching or distortion of the facet.   Using small pointed serrated scissors or a scalpel, the  SSTE overlying the medial crura is dissected without  injuring the underlying cartilage. By using three-point    counter-traction, sharp dissection along the medial crura  and LLC is performed in the avascular immediate supra-  perichondrial plane, preserving the subdermal plexus and  avoiding flap breakdown. Flap elevation is carried laterally  to the point of attachment of the lateral crura with soft tis-  sue. The interdomal ligament is not disturbed.   The loose connective tissue (Pitanguy's ligament) over-  lying the ASA at the soft supratip triangle is resected and  an avascular supraperichondrial plane is identified over  the lower dorsum. At the rhinion, the remainder of the  dissection of the nasal bones is performed subperiosteally,  using sharp dissection. An Aufricht retractor is placed and  lateral bands between the SSTE and the osseocartilagi-  nous structure are divided bluntly, until the entire nasal  skeleton can be clearly observed.   For septoplasty and cartilage harvesting for later graft-  ing a hemi-T1 is used. In difficult septoplasties or in asym-  metric tips, the interdomal ligament is cut and the medial  crura separated. Using a speculum the caudal edge of the  septal cartilage is visualized. The subperichondrial plane  is established using the tips of pointed scissors or Cottle's  elevator and the mucoperichondrium is elevated using  sweeping motions. Incisions are made in the cartilaginous  septum at 1 cm parallel to the caudal septum and dorsum,  leaving in an inverted L-shape support, allowing the max-  imal amount of cartilage to be harvested. Deviated carti-  laginous fragments are disarticulated and removed.   Routinely, the author prefers to address the osseocarti-  laginous vault before the tip and lower third with alar base  correction as the last step.   Under direct visualization, reduction of the cartilaginous  dorsum is performed with a No. 15 blade, the cartilage is  maintained in continuity with the nasal bone. Sharpened  Rubin osteotomes are used to resect the bony hump to nasion  in continuity with the cartilaginous resection. Initially, a  16-mm osteotome is placed in the ‘fish mouth’ created by the  cartilage resection, then a 14-mm Rubin as the line of resec-  tion approaches the narrower naso-frontal angle. In the gla-  bellar area, the hump is sharply separated from the attaching  soft tissues, before being removed and preserved together with  the harvested cartilage in a physiologic solution. Irregularities  are removed with sharp resection to avoid disruption of the  osseous-cartilaginous junction.   Closure of the open roof deformity is through the use  of osteotomies, under direct vision using a 3-mm micro-  osteotome, creating a laterally fading line for controlled  back-fracture created by the lateral osteotomies. Only  in broad strong noses are medial osteotomies utilized.  If these are especially thick then triangular wedges are  removed along the medial osteotomy.   The lines of the lateral osteotomies are low to the face,  respecting Webster's triangle and directed towards the  highest thin part of the nasal bones. No infiltration, stab  incision or periosteal raising is carried out to prepare  the lateral osteotomies. The same 3-mm osteotome is    immediately engaged on the pyriform aperture just supe-  rior to the inferior turbinate's origin. The osteotome is  initially engaged in a plane perpendicular to the pyriform  aperture. Once a triangle of bone is preserved at Webster's  area, the osteotome is directed up the lateral bony wall  under finger control. Just below the level of the medial can-  thus, the cut is directed more anteriorly to meet the medial  osteotomy when required. The back fracture is completed  with rotation of the osteotome and finger pressure. The  inward fractures can be performed with greater accuracy  and precision transcutaneously at the lateral mid portion  of the osteotomy and through the glabella if necessary  with a 2-mm micro-osteotome and without stab incision.   The mobility of the nasal bones can be palpated through  the skin and controlled under direct vision. The dorsum is  palpated and visually checked to make sure that no irreg-  ularities or projections of bone or cartilage exist. Small  bony fragments can be resected with bone scissors and  cartilaginous protrusions can be trimmed by blade.   The concept of the open-structure rhinoplasty supports  reconstitution of disrupted support mechanisms by sutur-  ing and grafting which will resist the effects of scarring  and contracture of the soft-tissue envelope. The elevation  of the SSTE during rhinoplasty violates a minor support  mechanism. Therefore, the medial crura are generally  strengthened with a septal cartilage graft or the resected  osseocartilaginous hump, sandwiched between them as a  supporting strut. A pocket to receive the graft is dissected  between the medial crura towards, but not to, the nasal  spine. The strut not extending above the ASA is fixated  with through and through Vicryl™ 4.0 from the level of the  medial footplates. Care is taken not to distort or rotate the  nasal tip area by malpositioned sutures. The strut increases  support and stability and maintains symmetry of the nasal  tip. It can also serve as a foundation for a tip graft.   The medial crural/columellar strut complex is sutured  to the caudal septum. This will effectively reconstruct  the medial crural-septal ligaments sectioned when a TI  is used.   If tip narrowing and upwards TR is desired, cephalic  trim of the LLC is performed. Care is taken not to weaken  the lateral crura, by leaving a symmetrical strip of carti-  lage at least 6 mm in width. Over-resection can weaken the  lateral legs of the nasal tripod, resulting in external valve  collapse on inspiration and retraction of the nostril rim  from scar contracture on the LLCs. This is remedied dur-  ing surgery with alar batten grafts.   The recurvature of the ULC contributing to intercrural  width is resected together with the cephalic edge of the  LLC. The cartilage is removed while leaving the nasal skin  intact at all times.   Aesthetic adjustments to the position of rhinion to cre-  ate a more natural dorsum are often accomplished using  Skoog's technique of replacing the resected dorsal hump  after sculpting to the desired shape and size, into the dor-  sal pocket thereby avoiding irregular edges, asymmetry  and the ‘open roof deformity’.    Modification of the caudal aspect of the medial crura  can be carried out for such abnormalities as a hanging  columella deformity.   Opening up an obtuse NFA or widening the root of the  nose can be done by cartilaginous grafts.   Debulking of the undersurface of thick sebaceous tis-  sue of the nasal tip is accomplished under direct visualiza-  tion. Care is taken not to injure the dermis. The effects of  debulking the tip skin can be seen in the redraping of the  SSTE providing superior tip definition.   A widely arched dome may be narrowed and lowered by  excising triangles of LLC cartilage, leaving the skin intact.  The free ends of the lateral crura are reconstructed into a con-  tinuous strip by suturing the ends with 5/0 resorbable sutures  to maintain the strength of the tip tripod. Irregularities can  be trimmed. The interdomal ligament is restored by an inter-  domal mucosal apposition mattress suture, lying just below  the domes, acting to restore reattachments between the LLC  and the ASA, thus contributing to TS.   A septal cartilage graft sculpted into a three-dimensional  shield-like tip lobular graft with bevelled contours is placed  over the Stable nasal tip structure. This establishes the  desired projection, angle of the infratip region, a double  break and the bidomal shape. This graft is usually thick-  est at its dorsal aspect and gradually tapers to the ventral.  Resorbable 5/0 sutures can secure the graft to the under-  lying septal crural foundation. An elongated tip graft  extending along the greater part of the columella is used  to provide greater stability for increased projection. In gen-  eral, this graft is not fixated so, after initial wound closure,  it can be displaced to the desired position, creating a more  pleasing tip definition.   After careful inspection of the reconstructed skeleton,  the skin incisions are meticulously closed with 6/0 nylon  sutures. With Rees and Skoog we believe that no amount  of post-operative splinting, clamping or other forms of  pushing and pulling, nor healing, will provide a better  outcome.   The SSTE is taped to the nasal skeleton, especially in  the supratip region, thus eliminating dead space. An  additional adhesive strip is placed along the nasal tip for  support.   A plaster of Paris with forehead extension, avoiding any  movement, is used (Tessier). A generous amount of antibi-  otic ointment is placed in both nares.   A reinforced Silastic” sheet is used as a septal splint  at the right side where functional surgery has been per-  formed. Although through-and-through sutures readapt  the mucoperichondrial flaps, nasal packing is frequently  used. Unless contraindicated, intraoperative steroids and  antibiotics are given routinely. A gauze is taped over the  nostrils to function as a drip pad.   The patient receives facial ice packing and a position  of at least 45° is advised for up to 24 hours. Antibiotics  are given for 3-4 days till the packing is removed. Upon  follow-up in 7 days, the splint and the Silastic sheet (s) is  removed, as well as the sutures.   Dorsum 889  Tip 891  Alar rim 891  Alar base 892  Technique for open structural rhinoplasty (OSR) 892  Augmentation rhinoplasty using conchal cartilage via closed approach 893    Asia is a big continent and the characteristic noses can be  very different from the Middle East to Far East.   This chapter will concentrate its discussion on Southeast  Asian noses. The common features of Southeast Asian  noses are the following: bulbous tip, thick skin, low dor-  sum, weak cartilages, short and upturned tip and hanging  and wide ala.   Most noses need dorsal augmentation, lengthening, tip  projection, columellar show, hanging ala correction and  alar base plasty.    The nose can be divided into thirds. The dorsum com-  prises the nasal bones as the upper third and the dorsal  septum with the attached upper cartilages (UCs) as the  middle third (see Figure 86.1).   Most aesthetic deformities of the nasal bone are low  radix and wide nasal bone base. A low radix can be aug-  mented with soft-tissue material such as fascia or softened  cartilage or synthetic material, e.g. silicone or expanded  polytetrafluoroethylene (e-PTFE) (popularly known as  Gore-Tex). A wide nasal bone can be corrected with medial  and lateral osteotomies.   The junction of the upper and middle third of the nose is  the rhinion. It corresponds to the dorsal hump. A prominent  hump can be corrected by direct trimming of the UC with  the dorsal septum and humpectomy of the nasal bones using  a chisel or rasp. The majority of humps are cartilaginous.    Internal valve collapse is not common in low dorsum  noses because of the wider relationship of the septum  and the UCs. In the presence of a caudal deviation of the  septum, support grafts, e.g. spreader and septal extension  grafts (SEGs), can be used to straighten the deviation.  A deviated dorsal septum needs splitting the UC from  the septum and reinforcement with spreader graft (see  Figure 86.2).   The dorsum for most Southeast Asian noses is low and  almost always needs augmentation. Dorsal augmentation  is performed after tip projection surgery is completed. The  tip projection surgery often utilizes a support system of  SEGs. The augmented dorsum is used to blend the new tip  with the radix (see Figure 86.3). For noses that have a good  tip and need only dorsal augmentation, a silastic implant  either an I-shape or an L-shape can be used. It is inserted  via a closed approach (bilateral marginal incision). The  dissection is sub-SMAS (superficial muscular aponeurotic  system) at the UC and lower cartilage, and subperiosteal  at the nasal bones. The dissection should just be limited in  order to avoid mobility of the silicone implant. The under-  surface of the implant should be carved well in a concave  manner to allow full surface contact with nasal bones and  the UCs. Healing is via fibrous encapsulation. Most silicone  implants heal well; however, there are some that heal with  capsular contracture after several years needing revision  surgery. Silicone is also prone to calcification with time.   e-PTFE, popularly known as Gore-Tex, has gained pop-  ularity because of its better aesthetic outcome. It is initially  introduced in the market as sheets; however, recently many    ® Support graft  = Septal extension graft  (SEG) - open  = Extended spreader  graft - open  = Columellar strut graft  - closed or open    companies produced preformed e-PTFE of various shapes  and sizes. This implant is now preferred because it is more  natural looking and heals with tissue adhesion. Despite it  being less visible as an implant, there are times that it may  show under a thin skin. In order to make e-PTFE implant  better looking, the sides of the Gore-Tex should be cut  and carved well to avoid cornering appearance (see Figure  86.4). Make certain implant placement is midline and in  full contact with undersurface. Since e-PTFE is soft, it is  not used in tip support surgery. One dreadful complica-  tion of e-PTFE is infection. Infection can be avoided by  diligently observing the sterility, e.g. soaking the implant  in gentamicin solution when not in use and avoidance  of prolonged air exposure. Implant package should be  opened only when it is time for insertion. The caudal edges    of the implant should be cleared and away from the inci-  sion line since the incision wound can be the site of entry  of microorganisms (see Figure 86.5).   Cartilage may also be used in dorsal augmentation.  Cartilage source may be from the septum, ear or rib.  Mostly the source is from the ear. Scoring the cartilage in  the concave portions helps make the implant to bend to a  straight looking piece; however, sometimes warping can  still occur. Resorption and warping are high in cartilage  for dorsal augmentation.   Dermofat from the sacrococcygeal area may sometimes  be used as augmentation material. The advantage is the  natural look, however, resorption is high. This material  is usually reserved for secondary rhinoplasty of patients  with thin skin.    Figure 86.5 e-PTFE implant. Note the caudal edges of the  implant are within the line of incision.    Homograft materials such as cartilage and dermis are  gaining popularity nowadays because of least reaction;  however, the cost is prohibitive.    Most Asian tips are bulbous which is due to thick skin  or convex lower lateral cartilage (LLC), or a combina-  tion of both. The dome portion of the lower cartilage  may not be well formed too. The medial crura are usu-  ally much smaller and weak causing the inadequate tip  support.   Many simple procedures such as transdomal and inter-  domal suture techniques are good enough to define the  tip; however, most often, tip grafts such as shield and onlay  grafts are needed for a more defined tip. A too convex LLC  may need cephalic trimming, making sure that enough  5-8 mm of LLC is left behind for support and patency of  external nasal valve.    Figure 86.7 A piece of triangular tissue shaped like a ‘sail’  is excised from the inner lateral portion of the nasal vestibule.  The alar rim is rolled in and sutured to close the defect.    The whole shape of the lower cartilage can be changed  when the dome is pulled anteriorly and fixed to the ante-  rior angle of SEG for a total new dimension of tip projec-  tion. SEG is the usual support graft used for lengthening a  short nose and projecting a low tip (see Figure 86.6).   An additional procedure to improve the tip in a thick  skin is to perform defatting, especially at the supratip area.    The rims in some Asian noses are hanging and need lift-  ing procedure. A triangular tissue is excised at the inner  lateral portion of the nasal vestibule. The triangular tissue  is shaped like a sail of a sailboat with two irregular sides  and a base. The inferior side is the inner rim of the ala, and  the cephalic side is a skin groove in the vestibule which is  a depression marked by transition of thin and thick vibris-  sae. The alar rim is then sutured to the inner vestibular  skin like a flap (see Figure 86.7). The sail excision is usually  done as the first procedure in rhinoplasty in order to allow  the maximum flexibility of manoeuvring the ala from  marking, incision, excision and suturing. 
orthognathic-surgery-principles-and-practice Operative Oral and Maxillofacial Surgery, Third Edition_djvu.txt