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18.9 ENT I Plastic Reconstruction
18.9 ENT I Plastic Reconstruction
D. Classification F. Lacerations
E. Management IV. Other Matters to Consider
F. Poor Dental Condition A. Forehead Injury
G. Summary of the Timing of B. Eyelid Injury
Interventions C. Eyebrow Injury
H. Summary of Cleft Lip D. Lip Injury
Management E. Nose Injury
II. Microtia, +/- Aural Atresia F. Ear Injury
A. Classification
PART 3: SCAR REVISION AND Figure 1. Private patient with incomplete cleft lip.
B. Epidemiology
RECONSTRUCTION OF FACIAL ● An infant with this type of cleft was delivered by you during your
C. Etiology
DEFECTS tour of duty. As a primary care physician, you are expected to
D. Management
I. Scar reassure the parents of the child by addressing their usual
III. Saddle Nose Deformity
A. Scar Formation primary concern, which is feeding, and to outline a basic plan
A. Causes
II. Basic Concepts of management for the child such as timing of the surgery and
B. Pathophysiology
A. Skin Tension Lines the need for multi-disciplinary care.
C. Management
B. Cosmetic Units ● Referred at birth
IV. Facial Nerve Paralysis
C. Sites for Skin Incision → Address feeding concern
A. Facial Nerve Function
III. Scar Revision → Advise timing of surgery
B. Etiology
A. Intro to Scar Revision → Advise need for multi-disciplinary care
C. Approach to Diagnosis
B. Timing of the Scar Revision
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D. Bell’s Palsy
C. Scar Revision Surgery
📢
Case Scenario 2: Bilateral Cleft Lip & Palate | Video lecture
PART 2: SOFT TISSUE INJURIES D. Other Management Options
OF THE FACE IV. Reconstruction of Facial
I. Diagnostic Assessment Defects
II. Examination of the Wound A. Skin Graft
A. Bony Injury B. Skin Flap
B. Nerve Injury V. Clinical Application
C. Duct Injury A. Defect Reconstruction
D. Vessel Injury B. Medical Photography
E. Muscle Injury
F. Tendon Injury Figure 2. Infant with bilateral cleft lip & palate.
● Given a more challenging clinical scenario such as this, an
📢 - Lecturer’s notes/Audio Inputs
LEGEND
infant with bilateral cleft lip and palate described as having:
📖 - From Book (cite sources)
IMPORTANT TERMINOLOGIES
OBJECTIVES
● 📢 You are expected to do the same thing
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OTORHINOLARYNGOLOGY I Plastic Reconstruction
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📢
Nice to Know | Video lecture
● Familiarize yourselves with these problems because you are ●
C. ETIOLOGY
📢 First patient would actually be the parents.
expected to administer initial management for some of these → Most of the time their first question would be what caused
problems as a primary care physician. it?
● As you can see these problems cover a wide area of discipline. ● When asked what caused the cleft, you would say the etiology
Therefore, you must–T/N: Audio was cut off at around the 2:02 could be due to genetics and could be non-syndromic or
timestamp. syndromic.
→ Non-syndromic: not part of a syndrome.
📢 Management: Multidisciplinary (Team) Approach ▪ The causes for this are multifactorial.
● 📢
Parents would then ask what are my next child’s chances
of a cleft deformity? (Refer to the probabilities listed below).
● 🚩📢 Just know if 1 parent has cleft deformity plus one child
the next child will have a higher chance of deformity.
Genetics (Non-syndromic)
● Multi-factorial
● Probabilities for cleft lip +/- cleft palate
→ One parent: 2%
→ One sibling: 4%
→ Two siblings: 9%
→ One parent + one sibling: 15%
● Probabilities for cleft palate
Figure 3. Multidisciplinary team approach for cleft lip +/- cleft palate. → One parent: 7%
● The management is a team approach with the → One sibling: 2%
otolaryngologist playing a key role. → Two siblings: 1%
● Other members of the team would include those listed above. → One parent + one sibling: 17%
● This approach recognizes that no single discipline possesses Genetics (Syndromic)
all of the expertise needed for the proper management of the ● 📢 Cleft deformity can also be part of a syndrome in 15-60% of
many problems of patients with cleft deformities. cases, which is high.
● Ideally, multidisciplinary care should begin when an infant is → More than 200 of identified syndromes include clefts in them
identified as having the deformity. ● (+) Cleft palate
● Sadly, the situation of cleft care in the Philippines is that only → Apert’s Syndrome
university hospitals are able to provide comprehensive cleft → Stickler’s Syndrome
care services. → Treacher’s Syndrome
● For general hospitals, there is a shortage of specialists causing ● (+) Cleft lip with or without Cleft palate
patients with cleft deformity not to receive comprehensive care. → Van der Woude’s Syndrome
→ Waardenberg’s Syndrome
A. INTRODUCTION
● 🚩📢 Remember that when you see a patient with a cleft lip, with
● CLEFT: A congenital abnormal space or gap generally in the or without palate, you need to rule out if the child has a
upper lip, alveolus, or palate. syndrome.
● Prevalence rate: 0.46 per 1000 live births (Philippine Cleft → 📢 Management would include addressing the other
registry, 2008). problems that are part of the syndrome.
→ 3rd most common birth defect in the Philippines after
Non-genetics
multiple congenital anomalies and ankyloglossia (Consensus
● The risks of cleft deformities are also observed to be increased
by Philippine Birth Defect Registry Project)
in the following:
→ Males > Females
→ Left > Right side of the face → Maternal Diabetes → Exposure to:
→ Increased Paternal Age ▪ Ethanol
B. EMBRYOLOGY: SHORT REVIEW
● 📢 Embryologically, it is a failure of fusion of embryonal facial → Reduced Folic Acid
Concentration
▪ Rubella virus
▪ Thalidomide
clefts.
→ Amniotic Band Syndrome ▪ Aminopterin
● LIP → PALATE
📢
→ The lip fuses ahead of the palate .
D. CLASSIFICATION
● INCISIVE FORAMEN ● Clefting of the lip and palate have a variety of forms and
📢
→ Divides the palate into the primary and secondary palate combinations.
▪ Cleft of Primary Palate: ANTERIOR to the incisive ● The THALLWITZ CLASSIFICATION (or LAHSAL
foramen Classification) is recommended for the diagnosis.
▪ Cleft of Secondary Palate: POSTERIOR to the incisive
foramen
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1. COMBINED OR ISOLATED
Figure 7. (Left) Isolated cleft lip; (Center) Combined cleft lip and palate;
(Right) Isolated cleft palate.
2. UNILATERAL OR BILATERAL
Figure 8. (Upper Left) Left unilateral cleft lip; (Upper Right) Bilateral cleft lip;
(Lower Left) Bilateral cleft lip and palate; (Lower Right) Bilateral cleft lip with
full palate.
Figure 4. Thallwitz Classification a.k.a. LAHSAL CLASSIFICATION
3. COMPLETE OR INCOMPLETE
(Right Lip, Right Alveolus, Hard palate, Soft palate, Left Alveolus, Left Lip).
● 📢 Need to be able to describe if it is:
→ combined cleft lip and palate, an isolated cleft lip, or an
isolated cleft palate;
→ bilateral or unilateral;
→ complete or incomplete.
▪ complete: cleft crosses the nasal sill
▪ incomplete: cleft does not cross the nasal sill
Figure 5. (Left) Ala and Columella of the nose; (Right, red line) Vermillion
border of the lip.
Figure 11. Left unilateral cleft lip
● Nasal floor → Oral Cavity
📢
→ Nasal floor communicates with the oral cavity.
● Hypoplastic Maxilla
📢
→ Maxilla on the cleft side is hypoplastic.
● Displaced Columella
Figure 6. Normal lip and palate.
📢
→ Columella is displaced to the normal side.
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Feeding Difficulties ● Generally, infants with cleft lip, cleft palate, or both as their sole
● Feeding difficulties either in breastfeeding or use of regular health problem swallow normally, but suck abnormally.
bottle are expected from infants with cleft deformities ● Unlike in infants with PIERRE ROBIN SEQUENCE, wherein
● The purpose of the palate is to separate the mouth from the both sucking and swallowing are problematic aside from the
nose associated airway problem.
● Normally, the soft palate at the back of the throat moves up to → Other modes of feeding may be considered for these
close off the passage to the nose during feeding. This creates a patients after evaluation.
closed system. The sucking motion creates a negative pressure Feeding Techniques
which pulls the milk out of the breast or bottle ● Note that none of these bottles and nipples are available in
● A cleft lip may hinder sucking as the oral sphincter muscle regular stores
is discontinuous ● All of these work without the baby needing to create intraoral
● Cleft Lip + Cleft Palate / Cleft Palate suction in order to pull milk out of the nipple.
→ No closed system 1. SOFT BOTTLES
▪ 📢 A cleft palate prevents the infant from creating a closed ● Specific bottles particularly soft squeezable bottles that can be
system in his/her mouth, and makes it difficult for the milk squished in coordination with the baby’s sucking effort
to be pulled out.
→ Inability to generate a negative pressure
→ Lack of suction
▪ 📢 The infant may look like he/she is sucking, but they are
only using up precious calories in a futile attempt to gain
adequate nutrition.
Figure 16. (Left) Baby fed using a customized feeding bottle; (Right)
Specially designed feeding bottles for cleft palate.
2. MODIFIED NIPPLES
● Modified nipples with one way valve that keeps the nipple full of
milk
3. UPRIGHT POSITION
● A special fiddle technique in an upright sitting position can be
Figure 15. Feeding difficulty with cleft deformities. considered.
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● infant speech
● To improve surgical results
● Note: since cleft repair is an elective procedure, if any
● An orthopedic device taped across the cleft externally
medical condition jeopardizes the health of an infant, the cleft
→ to bring the deep and alveolus segments closer together or
surgery is postponed until medical risks are minimal.
move the premaxilla to a more normal position to facilitate
MILLARD PROCEDURE
📢
good repair during cleft surgery.
● As a primary care physician, you are expected to refer the ● PRIMARY CLEFT RHINOPLASTY
child for NAM fitting as early as 2 weeks of age to an ENT ● It consists of designing skin flaps, a rotation, a columellar, and
specialist. an advancement flap
● Closure of a cleft lip involves meticulous repair of the skin,
muscle, and mucosa of the lip
● 🚩 Note: correction of the cleft lip nasal deformity is usually
done at the same time by an experienced surgeon
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speech quality
very high at 90-95%
→ 📢note that the incidence of ear disease in cleft lip only is
→ Note: the intensive interdisciplinary cooperation of all
specialist, especially the speech therapist is necessary
similar to normal population
● Definitive Rhinoplasty
● Conductive Hearing Loss
→ hearing loss secondary to middle ear disease
→ 📢 must be done as early as 14 years of age once facial
Figure 25. OME: Otitis Media with Effusion; VT TUBE: Ventilation tube
insertion Figure 26. Alveolar bone grafting
● Insertion of a VENTILATION TUBE is the standard treatment ● Alveolar bone grafting surgery consists of harvesting bone
for otitis media with effusion usually performed at the time of the usually from the iliac crest
palate repair ● This collected bone is then placed in the alveolar cleft as seen
● Repeated ventilation tube placement on Fig. 24
→ 📢 50% of these children would require repeated ventilation ● Advantages:
→ Assists in the closure of the buccoalveolar oronasal fistula
🚩
tube placement
● Note: the frequency of ear diseases DECREASE as the → Provides bony support for unerupted teeth and teeth
child with cleft palate ages, owing to the change in the adjacent to the cleft
orientation of the eustachian tube from horizontal to being → Forms a continuous alveolar ridge to facilitate orthodontic
more vertical correction of malocclusion
● Audiologic monitoring → Supports the nasal floor and the base of the ala to improve
→ 📢 Because of the unpredictable course of middle ear nasal aesthetics
disease in young children with cleft palate, audiologic
monitoring or on going hearing assessment in
recommended
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Case Scenario 3: Microtia | Video lecture
● Given this patient with left ear deformity, which we call microtia,
brought about by an abnormal development of the pinna.
● As a primary care physician, you are expected to reassure the Figure 29. (Upper) Normal ear; (Lower) MIcrotia with aural atresia
parents of the child by addressing their primary concern A. CLASSIFICATION
which is the possibility of hearing impairment
● Outline a basic plan of management for this child
→ e.g. the need for diagnostic tests, hearing aid amplification,
surgical intervention
● Emphasize also the need for multidisciplinary care and most
especially their referral to an ENT specialist
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affected ear.
● The ear lacks anatomic subunits.
▪ Unilateral atresia and the associated hearing loss may
● Part of the ear looks normal, usually the lower half.
have an impact in child’s development, and the child’s
● The ear canal may be normal, small, or completely closed
progress and hearing should be closely monitored.
GRADE 3 → Associated malformation
● What we call the “peanut ear”. ▪ Renal ultrasound
● There is a small remnant of skin with fibroadipose lobule, ▪ Cervical xray
located inferiorly and cartilage remnant superiorly.
🚩
▪ Panoramic view of the mandible for malocclusion
● There is no canal ● CT scan is not immediately indicated. It is requested prior to
GRADE 4 atresia repair surgery to evaluate ear canal and middle ear
🚩
● ”Anotia” structures.
● Wherein there is complete absence of both the external ear and ● If microtia is the only developmental anomaly, the initial
the ear canal. workup consists only of evaluation of hearing status
● This is the most severe form. 1. CONSIDERATIONS
B. EPIDEMIOLOGY Unilateral Microtia
● Prevalence rate of microtia in different populations: ● Affected ear can still hear by some degree because the inner
→ 0.8-4.2 per 100,000 in births in different populations ear is normal, therefore, bone conduction is normal
▪ Philippines: 22.4/10,000 births in a study conducted ● Unaffected ear is usually normal, so speech development is
between 2011 to 2014
🚩
usually at par with age
🚩
● 10% Bilateral ● As long as microtia is unilateral, these children are likely to
→ Note: Mostly a unilateral phenomenon in 90% of cases have normal speech.
● Right ear > Left ear
● Males > Females
2. MANAGEMENT FOR HEARING RESTORATION
● Associated with a syndrome or other congenital ● Educational support
malformations ● Conventional hearing aids
→ 40% of patients are known to have a syndrome or have ● Bone conduction hearing aids
associated congenital malformations mostly of the face, ● Bone anchored hearing aids and other implantable devices
followed by the kidneys, vertebra, and the heart. Bone Conduction Hearing Aids
C. ETIOLOGY ● Not needed:
● The key causative factors are disturbances in the regulation → Children with unilateral microtia and aural atresia with
of neural crest cell proliferation and/or migration. normal hearing of the contralateral ear are expected to
● 15% has a genetic or environmental cause, which are similar develop speech normally.
contributory factors to other congenital malformations: ● Needed permanently or pending surgery:
→ Fetal Alcohol Syndrome → Children with bilateral microtia and aural atresia must be
→ Maternal Diabetic Embryopathy fitted shortly after birth if speech is to develop.
→ Thalidomide and Isoretinoin exposure
● Another cause is vascular disruption or reduced blood flow
leading to ischemia and poor growth or tissue necrosis, which
could be brought about by intra-uterine ischemia
● No consistent inheritance pattern
→ The incidence of familial cases of microtia ranges from
3%-34%
→ About 5% of cases have an immediate family member with
ear deformity as well
→ Parents with two affected children have a higher risk of
recurrence as high as 15% in the subsequent pregnancy.
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Prosthetic
Adhesive ● Appearance ● Less secure
retained attachment
● Ongoing prosthetic
care
● Daily maintenance use
Implant ● Appearance Multiple procedures
retained ● Secure retention ● Requires removal of
remnant and soft
tissue
● Ongoing prosthetic Figure 32. A 21 year-old male, complaining of a deformed nose
care ● History of present illness revealed that 6 years prior to consult
● Daily maintenance his nose was hit during a basketball game. He remembered that
● Use restrictions his nose became swollen, black, and painful 3 days after the
Reconstruction accident.
Rib cartilage ● Autogeneous tissue ● Inconsistent ● He sought consult in the emergency room and was given
(autogenous) ● Minimal maintenance appearance unrecalled medicine which he took, but never sought consult to
● Becomes senate ● Donor sites an ENT specialist as advised.
● Atresia repair (PINNA ● Multiple surgeries ● Over the years, he noted progressive flattening over an area on
RECONSTRUCTION) ● Reconstruction
his nasal bridge, up until it became like soin Fig 32.
performed betw. 6-10
● Presently he does not complain of any pain, any persistent
years of age
nasal obstruction.
Medpor ● Loss donor site ● Foreign body
● On physical examination, it showed dipping of the external
morbidity ● More challenging to
● Less variability in integrate with atresia structures, between the nasal bone and nasal tip with upward
carving repair tilting of the nasal tip.
● Reconstruction ● In this case, you can see a loss of dorsal septal cartilage, which
performed at earlier is called saddle nose deformity. This can collapse the nasal
age valves, so there could be complaints of nasal obstruction.
● Observation: no reconstruction, no prosthesis Luckily for this patient, he does not complain of persistent nasal
→ May not the best option once the child’s concept of body obstruction.
image beings to evolve at 4-5 years of age.
→ The child begins to be disturbed usually by age 7 ● SADDLE NOSE DEFORMITY: A marked depression or
→ Molded prosthesis or reconstructive surgery may need to be collapse along the mid portions of the nasal bridge resembling
considered the look of a saddle when looking at the nose from the side
● Reconstruction of the ear with rib cartilage view.
→ Staged procedure: multiple surgeries are required
→ A challenging surgery
→ Usually performed at 6-8 years of age with unilateral
microtia because the pinna is 85-90% of its adult size by this
age.
▪ The patient is usually large enough that rib size is
sufficient to harvest an adequate rib graft.
→ Surgery may be done earlier if the child has adequate rib
size and postponed if not.
→ With regards to the associated aural atresia, the
reconstruction of the pinna deformity must be done first
before the atresia repair to preserve the skin and blood Figure 33. Saddle Nose Deformity
vessels for a better outcome of pinna reconstruction.
A. CAUSES OF A SADDLE NOSE
● Depressed nasal bone fracture
📢
→ The most common cause is NASAL TRAUMA.
● Others: Iatrogenic, TB, Leprosy, or Syphilis
→ 📢 Other causes include, excessive removal of the nasal
septum during, submucous resection surgery, or destruction
of septal cartilage by hematoma or abscess, TB, leprosy or
syphilis
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Figure 34. Pathophysiology of saddle nose due to trauma Figure 36. Open rhinoplasty technique sing a pre-formed customized
● 📢 Due to the shearing of the submucosal blood vessels brought silicone implant.
● There is marked improvement in terms of the previously
about by the trauma, a hematoma can form in the nasal septum.
collapsed nasal bridge with better nasal tip support.
● In this case a silicone implant was used due to financial
constraints.
● Chances of rejection were thoroughly explained, he wanted to
see first if it would suffice before considering other more
invasive and more expensive surgery.
● This translated into a bridge and a nasal tip which now look
much more natural and more harmonious with his face.
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C. APPROACH TO DIAGNOSIS
● A 28-year-old female complaining of sudden onset of
● History is of vital importance
unilateral paralysis of her entire left side of the face noted
→ the time, course, duration of paralysis may help predict the
upon waking up.
likelihood of recovery.
● PE showed inability to smile, close the eye, or raise the
→ Previous trauma, surgery, or infection may help in arriving
eyebrow on the left side. Whistling is also not possible.
with a diagnosis
● There is loss of muscular tone.
● Physical examination would include looking for:
● There is obliteration of the nasolabial fold, and drooping of the
→ Tenderness over the mastoid or preauricular area
corner of the mouth on the left side.
→ Vesicles of the pinna or external auditory canal
● Furthermore, she complained of dry eyes & loss of taste
→ Signs and symptoms of otitis media
● Our patient has total paralysis, so she is graded at 6/6 on
🚩
→ Presence of other cranial nerve deficits.
consult meaning there is loss of tone, no movement of the
→ Note: The face should be examined at rest and
forehead, eye, and mouth.
movement using the House-Brackmann scoring.
● Evaluation would also include topodiagnostic tests and nerve
A. FACIAL NERVE FUNCTION
excitability tests
📢
● Contraction of the muscles of the face
→ can confirm the presence of nerve damage and determine its
→ particularly muscles for facial expressions
severity.
→ The face plays an integral part in our everyday lives–we use
● Imaging like CT, MRI may be needed to rule out other presence
it when we smile and other non-verbal communication
of pressure at the facial nerves such as tumor or skull-base
● Production of tears from the lacrimal gland
fractures.
● Conveying the sense of taste.
● Sense of touch at the auricular concha. 1. HOUSE-BRACKMANN FACIAL NERVE GRADING
B. ETIOLOGY: FACIAL NERVE PARALYSIS SYSTEM
T/N underlined etiologies were highlighted in the video lecture 13:20. See Appendix C.
● Congenital ● Is used to objectively describe the degree of facial nerve
→ Mobius syndrome paralysis.
→ Myotonic dystrophy ● This is a standard category to assess facial nerve function.
● Neurologic ● Many of these symptoms will change overtime as a result of
→ Guillian-Barre spontaneous recovery of nerve function or as a result of
→ Myasthenia Gravis different therapeutic modalities.
→ Stroke 2. TOPODIAGNOSTIC TEST
→ Multiple sclerosis ● Done to localize the site of lesion on the course of the facial
● Toxins/Trauma nerve.
→ Head trauma ● The facial nerve has a very long course that has an intracranial
→ Temporal bone trauma and extracranial component.
→ Birth trauma
● Infectious/Idiopathic
→ Melkerson-Rosenthal syndrome
→ Ramsay-Hunt
→ Otitis media/Mastoiditis/Meningitis
→ Lyme Disease
→ Necrotizing Otitis externa
→ HIV, TB, EBV syphilis
→ Tetanus
📢
→ BELL’S PALSY (Idiopathic) most common
● Tumor
→ Parotid
▪ 📢Tumor invading the parotid gland, or paralysis could be
iatrogenic after a parotid or mastoid surgery
→ Acoustic neuroma Figure 39. The ENT specialist usually performs these tests: Schimer test,
stapedial reflex test, taste test, and submandibular gland flow test.
→ Glioma
→ Meningioma 3. UMN VS. LMN
→ Facial neuroma SUPRANUCLEAR LESION (UMN)
● Endocrine
● Paralysis of the lower part of the face.
→ DM
→ Pregnancy
→ 📢usually as a part of hemiplegia
→ only the lower part of the opposite/contralateral side of
→ Hypertension
the face is paralyzed.
● Partial paralysis of upper part of the face
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→ 📢 the upper part with the frontalis and orbicularis oculi ● Common in middle aged people
escape paralysis due to bilateral representation in the → It can occur in any age
cerebral cortex. → More common in middle aged people.
→ The upper part of the face is innervated bilaterally by the ● R = L, but usually UNILATERAL
upper motor neuron, while the inferior half has only → Bilateral paralysis occurs in 0.3% only.
contralateral innervation. ● History
📢
📢
● This is seen mostly in intracranial lesions like stroke. → (+) Past Medical History and (+) Family History.
● Normal taste and saliva secretion → Most patients would have a history of previous facial
● Stapedius not paralyzed paralysis and a family history of Bell’s palsy can be elicited
INFRANUCLEAR LESION (LMN) in 8% of cases.
● Complete paralysis of 1 side of the face (same/ipsilateral 2. COURSES & PROGNOSIS: BELL’S PALSY
side) T/N: Audio was cut-off at 17:49
● 📢 The fibers carrying lower motor neurons, supplying half the ● Incomplete: excellent (95-100%)
face are all within the facial nerve. ● Complete: poorer
● This is seen in BELL’S PALSY. → Recovery takes longer
→ The face becomes asymmetrical and is drawn up to the → (+) Residual palsy and or synkinesis
normal side, the whole affected side is motionless. ● Factors associated with poor outcome:
→ Hyperacusis
→ Decreased hearing
→ >60 years
→ Diabetes Mellitus; Hypertension
→ Severe aura, facial, or radicular pain
3. MANAGEMENT: BELL’S PALSY
● Most significant complication: PSYCHOLOGICAL TRAUMA
→ i.e. The social isolation most patients often succumb to.
● Most serious complication: CORNEAL DAMAGE
→ due to insufficient lid closure and abnormal tearing
mechanism
● Eye care: The eye should be protected from dehydration,
drying, and abrasions.
→ Eye patch
→ Lubricating eye drops and eye ointment
● Primary care physicians are expected to be able to advise these
initial interventions prior to ENT referral of the patient.
● Medical management: STEROIDS +/- ANTIVIRAL
→ Prednisone 1mg/kg/day for 7-10 days
→ Acyclovir 400mg 5 times a day
▪ Alternatives: Famciclovir e Valaciclovir 500mg BID
Figure 40. UMN vs LMN
● Adjunctive treatments:
D. BELL’S PALSY → INFRARED
● Was ascribed to Sir Charles Bell who in 1821 demonstrated the → Galvanism
separation of motor and sensory innervation of the face. → Daily massage of the face
📢
● Bell’s palsy is a diagnosis by exclusion
→ Before you label everyone with facial paralysis as having
PART 2: SOFT TISSUE INJURIES OF THE FACE
Bell’s palsy, as the primary care physician you need to rule I. DIAGNOSTIC ASSESSMENT
out supranuclear or upper motor neuron lesions first.
● The following criteria should be met.
💡
📢
Case Scenario 1: Bony injury | Video lecture
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to remove them
→ Note: It is imperative to remove all foreign bodies at initial
treatment or repair.
→ Assess depth of the wound, layers, and structures affected
● Perform definitive management
→ Must be carried out promptly.
II. EXAMINATION OF THE WOUND
A. BONY INJURY
● Detected by observation
● Observe for:
Figure 3. Lacrimal and parotid ducts
→ hyposthesia: decreased sensation of the cheek ● These ducts will need to be cannulated to determine whether
▪ most commonly injured is the infraorbital nerve, which they are intact and functioning.
occurs with fractures of the infraorbital rim
→ asymmetry or deformity
→ Change in function:
💡
📢
Case Scenario 1 | Video lecture
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Figure 8. Telecanthus
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📢
Case Scenario 1: Management | Video lecture
● The patient at the operating room ready for definitive
management.
● Knowing that this is a contaminated wound, [we] tried our best
to clean the wound after induction of anesthesia.
● Antibiotic treatment was also started.
● While cleaning and removing debris and blood, the extent of the
Figure 6. insertion of silastic tube injury was assessed to be the following:
→ Multiple Facial Lacerations
▪ Over the forehead
▪ Over the lateral brow and upper lid area going to the
lower lid and left nasal ala
▪ Laceration of the scalp and left parietal area
▪ Through-and-through laceration on the left malar and
parotid area
→ Parotid gland parenchyma injury
▪ No parotid duct and lacrimal system injury
Figure 7. Repair of parotid duct over a silastic stent with interrupted sutures ▪ Parotid duct is still attached and intact
using Loupe or microscopic magnification.
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B. ABRASION
● Are partial thickness disruptions of the epidermis as a result
Figure 9. Patient before repair of sudden forcible friction
● 🚩 Remember to address bony injury first before the soft ● This wound should be gently cleansed of all debris.
injuries. → failure to remove debris can lead to tattooing of the skin and
● Reduction was done via intraosseous wiring of the a poor cosmetic result.
mandibular fracture and complex layered closure of soft ● Local and regional anesthetic may be required to make the
tissue injuries in different regions of the face with special patient more comfortable and to achieve adequate cleaning.
considerations to the unique features of each area. ● Lubrication of the wound using an antibiotic ointment and
● At this time, [we] did not have the proper instruments, nor the covering it with a sterile bandage may encourage healing.
expertise to undertake repair of nerve transection or
micro-anastomotic surgery.
● [We] contemplated on repairing with nylon 8-0, which was the
best that could be found at that time, but [we] could not find the
distal ends of the nerve and [we] needed to prioritize other
pressing medical and surgical concerns, as he also has hacking
wounds in different parts of his body, particularly in the
abdomen and the chest.
● This patient will need facial reanimation surgery later on.
● This is the patient after meticulous repair and suturing. Aside Figure 12. Abrasion
from facial reanimation surgery, this patient is also a candidate C. ACCIDENTAL TATTOO
for scar revision. ● Happens when embedded particles in the dermis are not
removed promptly.
→ If left for more than 24-48 hours fixation can occur.
● Removal of the embedded particles:
→ Scrub with a stiff bristle brush.
→ Grease or oil may be removed using ether or acetone
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C. EYEBROW INJURY
● Preservation of the eyebrow as much as possible by not
shaving it
● Repair muscles to prevent depression
● Rule out fracture
D. LIP INJURY
● In suturing the lips, it is extremely important to do two things:
→ Realign the vermillion border by doing good approximation
of the lip margins
▪ 🚩 Note: A mere 1 mm step-off in the closure will be
noticeable.
▪ So as not to distort the normal lip anatomy caused by
excessive local anesthesia infiltration, NERVE BLOCKS
Figure 17. Example of a subcuticular injury may be considered for better cosmesis. It can minimize lip
distortion: Infraorbital and mental nerve
→ Reapproximate the orbicularis oris muscle to relieve
tension in this very mobile area
▪ 🚩 Remember to do layered closure of the muscle and
mucosa, or skin
▪ In the muscle, use absorbable (Dexon or Vicryl) sutures
▪ In the skin or mucosa, you can use either absorbable or
Figure 18. Subcuticular running suture non-absorbable sutures like nylon
B. EYELID INJURY
● Simple laceration of the eyelid without involvement of the lid
margins can be treated without concern for further eye injury
● Suture the skin only with small bites
● No need to reapproximate the orbicularis oculi because this
may lead to scar contracture and ability to close eye like in Fig
19.
E. NOSE INJURY
● Soft tissue injuries in the nose are usually simple
● Remember to reduce the nasal bone fracture first if present
● Rule out septal hematomas.
● Realign nasal structures accurately, particularly the margins
and orifices when suturing, using either nylon 6-0,
nonabsorbable sutures in the skin, and absorbable sutures in
the nasal cavity.
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F. EAR INJURY
● 🚩 What makes the ear unique is that the skin is adherent to the Figure 24. Avulsed ear before repair vs after repair
cartilage and the cartilage derives its blood supply directly from
the skin.
● A direct blow or shearing force to the ear may result in tearing of
the blood vessels at the level of the perichondrium, which
results to a SUBPERICHONDRIAL HEMATOMA
● These injuries can result in a significant cosmetic deformity
called CAULIFLOWER EAR if missed or not treated
immediately.
● Treatment includes emergency incision and drainage of the
hematoma and pressure dressing. Figure 25. Suture size and timing of sutures removal
● 📢 Nowadays, we are seeing more and more patients ● Use SMALL CALIBER SUTURES in the head and neck region
developing cauliflower ear after seroma or abscess formation ● Remove sutures at an EARLIER TIME compared to other parts
with the increasing popularity of ear piercings in the cartilage. of the body.
→ Treatment is still incision and drainage with pressure ● This is done to avoid tracking and to improve cosmesis.
dressing and removal of the earring.
● 🚩 Note: If the wound is a linear laceration, suture only the
PART 3: SCAR REVISION AND RECONSTRUCTION
OF FACIAL DEFECTS
SKIN. The cartilage does not need to be sutured.
→ It is very difficult to suture cartilage together and the overlap
I. SCAR
● “Mark” remaining after the healing of a wound
may lead to a deformity.
● Final appearance influenced by:
→ Mechanism and location of injury
→ Initial management performed on the wound
→ Complications encountered during the healing process
A. SCAR FORMATION
● Result of the normal healing process
● Excessive scar formation may ensue, and the exact
mechanism for this abnormal response to injury is still poorly
understood, and for which treatment options are limited
● Abnormal scarring is classified as either HYPERTROPHIC
SCARRING or KELOID FORMATION.
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🚩
myofibroblasts those that cut across.
Scant mucin Mucinous stroma ● A scar that crosses the skin tension lines at a right angle or
perpendicular to it would have maximal contraction and
No myofibroblasts Myofibroblasts
would be unsightly.
● KELOIDS
→ less common and have a genetic component that limits to B. COSMETIC UNITS
less than 6% of the population.
▪ Primarily seen among black and Asian populations.
→ Frequently associated with pruritus & pain clinically.
→ Most common sites of keloid formation in the head and
neck region are the:
▪ earlobes
▪ mandibular border
▪ posterior neck
II. BASIC CONCEPTS
A. SKIN TENSION LINES
● INTERLAY of the collagen and elastic tissue plus the tension by
the underlying muscle
● PERPENDICULAR to the muscles
● PARALLEL to the dermal collagen bundles
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📢
(RSTL)
consistent within a unit.
💡
● Sometimes, scars can be aesthetically unacceptable (e.g.
📢
Cosmetic Units: Illustrative Case | Video lecture post-traumatic scars)
→ Revision technique can be employed after performing a
🚩
detailed analysis of the scar.
● Note: Not all scars can be improved with scar revision
technique.
→ Scars that are already optimal or have good cosmesis can
be made worse with a poorly thought of attempt at revision.
● Patients should be carefully counseled to assure that their
🚩
expectations are realistic
● Reminders:
→ Perform a detailed analysis of the scar
Figure 6. Cosmetic units → Expectations must be realistic
▪ 📢 If a patient expects that scars are completely not
visible, they should be informed that it is not possible or
they are likely to be displeased with the outcome
→ “Camouflage”
▪ 📢 Successful scar revision is really all about disguising of
📢
the fact that a scar is present and will always be present
▪ It is technique is just to trick the observer's eye into
Figure 7. (Left) Cheek rotation flap; (Right) 3 weeks post op
overlooking or ignoring the scar’s presence.
● The postoperative appearance at the third week without any
B. TIMING OF THE SCAR REVISION
cosmetics already shows that the wound is healing flat ,
📢Scars shrink and become less noticeable as they age.
→ 📢 Scars usually take 12 months to mature but may continue
narrow and well camouflaged on the face. ●
📢
● Note: The shadows that are cast from the changes in ● Earlier (=2months) for obvious poor cosmetic outcome.
contour tend to hide the scars well. → May be performed as early as 2 months for those that will
obviously heal poorly and would result in poor cosmesis.
C. SITES FOR SKIN INCISION ▪ Particularly: scars that are perpendicular or outside the
● Most favorable sites for incision: skin tension line.
→ Inside an orifice (nose, mouth, and ear) ● Optional:
→ Dermabrasion at 6 to 9 weeks post-injury
📢
▪ useful in designing the incision during an elective surgery
− This is rarely useful in scar revision unless the ▪ 📢 Utilizing the high fibroblastic activity in the wound at this
surgeon can move a scar from an unfavorable site into time to aid in favorable wound healing.
an orifice or hairline.
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● Scars that are flat with the surrounding skin can always be ● Scar oriented:
covered by makeup, and are favorable. → across RSTL (unfavorable)
● Scars that are raised or depressed are associated with a → in the middle of a facial cosmetic unit (unfavorable)
shadow that no amount of makeup will disguise, and they are ● In this situation, you must accept the unfavorable location and
considered unfavorable. instead camouflage the scar by irregularizing it by using the
● Scars tend to be smoother and shinier than the surrounding aforementioned scar revision techniques.
skin, and this textural difference is unfavorable. ● These techniques are all designed to convert a linear scar to an
→ This textural difference is more pronounced in wide scars like irregular one.
that in a burn scar, which is usually wide, that revision is not ● This is done to trick the eye because a straight line is more
practical. obvious to our eyes.
→ Lasers may be better helped in the improvement of texture. ● Scar revision surgery provides an erratic scar that diffuses light
● Irregularity is the principle of camouflage patterns
2. Z-PLASTY
→ As a rule, irregular scars or non-linear scars are less
noticed by the eye and are more favorable. ● 📢a powerful scar revision technique
→ These are linear scars in linear borders of cosmetic units or ● The result not only irregularizes the scar, but also lengthens it
linear scars along relaxed skin tension lines. and alters the direction.
→ Therefore, linear scars cutting across relaxed skin ● Indications:
→ Lengthening
tension lines are considered unfavorable.
● The final factor to a scar’s detectability is color. ▪ 📢 for scars with some element of contracture or
→ To which the surgeon has the least control. shortening, distorts surrounding tissues, or even interferes
→ Redness of a healing scar is expected and can take months with the function of the surrounding tissues.
→ Reorientation
to fade.
→ Patients need to be advised that only time will fade the ▪ 📢for scars that run perpendicular to relaxed skin tension
noticeable redness. lines or across facial junctions.
📢
→Does not lie in or along favorable skin tension lines
● The treatment plan may be as simple as to make unfavorable
scars more favorable
→ May be via simple direct excision and closure or as
complicated as to do other techniques and adjuncts to scar
revisions
● Scar revision surgery basic techniques:
→ Z-plasty
→ W-plasty
→ Geometric broken line closure
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3. W-PLASTY
📢
→ Transposition increases scar length to 75%
▪ Undermining the 2 flaps created by incising the limbs
and transposing them theoretically increases the length of
scar by 75%
→ Angles less than 30° may result in flap tip necrosis
Figure 14. Il Running W-plasty
→ Those greater than 75° may result in redundant standing
● The running W-plasty is particularly useful around areas of
cutaneous cones
convex curvature, such as along the:
→ Mandibular border
→ Antihelical fold
→ Nasal dorsum
→ Occasionally a vertical forehead scar
▪ like in Fig 14, wherein consecutive small triangles of skin
are excised on each side of the scar, and the resultant
triangular flaps are opposed and sutured together
● Best applied to scars of >2cms
● As many of the component incisions as possible should be
placed parallel to relaxed skin tension lines
📢 With the Z plasty technique of scar revision, the surgeon
Figure 12. 60° Z-plasty
● ● The intermingling of small scars and normal tissue camouflages
must be aware that it requires 2 extra incisions and the site
subsequent scars to correct a single scar. ● The maximum segment length is 6 mm, meaning the broken
→ The surgeon must make sure that its use must significantly lines or edges of the flaps should not exceed 6mm in length.
improve the appearance of the scar. → Ideally, it should be only about 3-4mm in length
🚩
● Angles should not exceed more than 90°
● Advantage of W-plasty over Z-plasty: the scar does not
cause overall scar lengthening.
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🚩
any dimension
→ Note: Figures less than 3mm are difficult to close and
those larger than 7mm are too visible to provide effective Figure 18. Lasers
camouflage. D. OTHER SCAR MANAGEMENT OPTIONS
● Done to further improve the appearance of the scar short of
doing the other interventions previously mentioned.
● Massage
● Topical therapy: Vitamin E, oil, OTC and prescription scar
🚩
creams with moisturizer and steroids
● Important to protect from sun exposure for the first 12
months
● Silicone sheeting: Apply 12 hours/day for 6 months
Figure 16. Illustrative case for geometric broken line closure IV. RECONSTRUCTION OF FACIAL DEFECTS
💡
● Provided good cosmetic outcome
📢
● Although time consuming, this is the technique of choice for Clinical scenario: Reconstruction of Facial Defects | Video lecture
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● Given this patient with skin a skin lesion associated with significant ● 🚩 Note: the skin graft may either be a full or split thickness
destruction of the right nasal ala (Fig 19), what do you do? depending how much dermis is included.
● First, get the History of Present Illness. ● Split Thickness Skin Grafts contain varying thicknesses of
→ HPI revealed that the lesion started 10 years PTC as a small dermis
plaque, which later on progressed despite self-medication ● Full Thickness Skin Grafts contain an entire dermis.
with various creams and ointments.
→ Consult was done for 6 years with dermatology service B. SKIN FLAP
wherein biopsy was done, and she was advised complete ● Consists of skin and subcutaneous tissue
excision, which she refused to have done. ● Transferred into another location
📢
→ Progressive increase in size with bleeding episodes ● Still has its own blood supply
prompted present consult. → Transferred from one part of the body to another with a
● The lesion here is glaringly a skin malignancy. vascular pedicle or attachment to the body being maintained
📢
→ It can either be a melanoma or non-melanomatous skin for nourishment.
malignancy (BCC, SCC, Keratoacanthoma), premalignant ● Although the skin graft is often simpler, there are cases in
(low grade lesions), rare tumors. which a flap is required or more desirable.
● Hence, biopsy is necessary to identify the specific skin
malignancy. 💡
📢
Illustrative Case: Skin flap | Video lecture
● Proper planning of a flap is essential to the success of the
● Plan for a definitive management, which will require a
operation.
multidisciplinary team approach, involving the surgeon,
● All possible sites and orientation for the flap must be considered
dermatologist, pathologist, radiation oncologist and even a
so that the most suitable option is selected like in this case,
psychiatrist because surgical intervention in this case will be
where the flap designed is advanced to close the defect.
greatly disfiguring.
A. SKIN GRAFT
● Consists of epidermis and some portion of the dermis
● By definition, something completely removed from the body
→ completely devascularized or removed from its blood
supply and is then
● Transferred into another location
💡
📢
Illustrative Case: Skin graft | Video lecture
Figure 21. (A-B) A dorsal nasal flap is used to repair a distal nasal defect
brought about by a wide excision for a tumor.
Figure 20. (A) Skin defect on the nose after Mohs micrographic surgery for
basal cell carcinoma; (B) Skin graft; (C) Transferred skin graft onto the nose
● The wound edges seen in Fig 21 cannot be cannot be
approximated end to end.
→ This needs to be closed to avoid wound contraction or Figure 22. (C) Despite the long incision line required to create the flap, the
contracture since this is a full thickness wound. final aesthetic result is favorable; (D) One year post procedure
● In this case, a skin graft from the nearby skin overlying the
clavicle of approximately the same size is harvested.
● This skin graft is eventually transferred to close the defect on
the nose.
● Grafts of any kind require vascularization from the bed into
which they are placed for survival.
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Figure 23. (A) Defect on the nasal side wall Figure 26. Defect flap design
● BILOBED FLAP: Two lobes geometrically designed beside ● This is the defect created on the cheek and the nose. The flaps
each other on a pivot point. designed to close the defect are from the forehead and the
● The flaps are incised, undermined, and rotated like in Fig 23 cheek.
● The nasal ala and alar rim were likewise reconstructed using
cartilage derived from the concha.
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Figure 36. How to take medical photographs in front, lateral, side, back and
Figure 33. Stenotic right nostril close-up views
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8. The main difference between a skin graft and a skin flap is:
a. Blood supply
b. Nerve supply
c. Epidermal involvement
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Appendix A.
Assessment of Sucking and Feeding Techniques for Infants with Clefts of Lip and Palate
Appendix B.
Classification and grading of microtia
Appendix C.
House-Brackmann Facial nerve Grading System
I VI (TOTAL
II (MILD DYSFUNCTION) III (MOD.) IV (MOD. SEV) V (SEVERE)
(NORMAL) PALSY)
At rest Normal Normal symmetry and tone N. sym & tone N. sym. & tone Asymmetry Loss of tone
Motion
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