Ebook Operative oral and maxillofacial surgery (3/E): Part 2

Part 2 book “Operative oral and maxillofacial surgery” has contents: Submandibular, sublingual and minor salivary gland surgery, management of stones and strictures and interventional sialography, facial nerve dissection and formal parotid surgery, extracapsular dissection, mandibular fractures, orbital trauma,… and other contents.

Section    V SALIVARY GLAND AND THYROID SURGERY 44 Submandibular, sublingual and minor salivary gland surgery JOHN D LANGDON CONTENTS Principles and justification Surgical removal of stones in the distal submandibular duct Surgical removal of stones in the proximal submandibular duct Submandibular gland excision Sublingual gland excision for ranula or excision biopsy Sublingual gland excision for malignant tumour Surgery of the minor salivary glands Operation for excision of benign tumours Operation for low-grade malignant tumours Surgery for high-grade malignant tumours Suggested readings PRINCIPLES AND JUSTIFICATION The most frequent indications for excision of the submandibular 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 malignant 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 treatment For advanced malignant tumours with spread beyond the capsule, more radical clearance of the submandibular triangle is required, often in continuity with a neck dissection When a pre-operative diagnosis of a benign tumour can be reasonably and confidently established by computed tomography (CT) and ultrasound-guided fine needle aspiration 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 441 442 443 445 447 448 449 450 451 452 453 There are only two indications for the removal of the sublingual gland The first is in the management of a ranula and the other is when a tumour is present The sublingual 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 Investigations 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, making 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-stimulation emptying film will demonstrate residual function 441 442  Submandibular, sublingual and minor salivary gland surgery 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 lymphadenopathy 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 investigation 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 Biopsy 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 excision 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 ultrasound-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, furthermore 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 to be performed under local anaesthesia, 2% lignocaine hydrochloride with 1:80,000 epinephrine (adrenalin) ­ is used A lingual nerve block plus local infiltration suffices Care must be taken not to infiltrate too much solution 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 sublingual veins as this will result in a large haematoma Operation 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 backwards 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 stroking fashion gradually becoming deeper until the wall of the duct is opened The duct itself is seen as a pale grey structure with an overlying capillary network (Figure 44.2) It is often helpful to steady the duct with dissection forceps while incising longitudinally through its wall Often the calculus is seen through the duct wall and the overlying incision immediately releases it If the stone is large and there has been scarring and fibrosis, it may be adherent 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 SURGICAL REMOVAL OF STONES IN THE DISTAL SUBMANDIBULAR DUCT Wherever facilities are available, a first attempt at endoscopic 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 submandibular gland together with the stone from an external approach Anaesthesia In a co-operative patient, the operation is readily performed under local anaesthesia If co-operation is in doubt, a general anaesthetic should be used If the operation is Figure 44.1  Stay suture around the submandibular duct proximal to the site of the stone Surgical removal of stones in the proximal submandibular duct  443 Figure 44.2  A linear incision is made in the floor of the mouth to expose the submandibular duct Figure 44.4  The duct is irrigated both proximally and dis- Figure 44.3  The stone is exposed and released Figure 44.5  The floor of mouth mucosa is closed with one 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 membrane 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) tally to ensure that no ‘gravel’ remains or two sutures SURGICAL REMOVAL OF STONES IN THE PROXIMAL SUBMANDIBULAR DUCT Anaesthesia Access to the posterior floor of the mouth is difficult in the conscious patient and for this reason general anaesthesia is preferred Once the patient is on the operating 444  Submandibular, sublingual and minor salivary gland surgery Figure 44.7  Following retraction of the sublingual gland the lingual nerve can be identified deep to the submandibular duct A B 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 C Operation 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 identified, 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 submandibular 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 D Figure 44.8  Posteriorly the lingual nerve ascends towards the skull base crossing the duct as it enters the hilum of the submandibular gland (A) Facial artery; (B) lingual nerve and submandibular 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 Post-operative care 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 Submandibular gland excision  445 Figure 44.10  Incision marked out in a natural skin crease in the neck Figure 44.9  The hilum of the gland is incised to release the stone SUBMANDIBULAR GLAND EXCISION Anaesthesia 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 opposite 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 dental local anaesthetic containing 2% lignocaine hydrochloride and 1:80,000 epinephrine (adrenaline) This results in some vasoconstriction which limits capillary ooze and helps to define tissue planes The incision The incision should run within a natural skin crease in the neck at least cm below the lower border of the mandible in order to avoid damage to the mandibular branch of the facial nerve as it loops down below the lower border 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 submandibular triangle The incision is made with either a No 15 blade or with a fine diathermy needle or ceramic blade while the assistant 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 underlying muscle for approximately 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 incision, again using either a blade or diathermy 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 investing layer of the deep cervical fascia is next divided, preferably 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 angular 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 platysma and the fascia Great care must be taken to protect this branch Even with an incision as low as 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 capsule, the operation should proceed in the plane just superficial 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 446  Submandibular, sublingual and minor salivary gland surgery tumours that have extended beyond the capsule, a full ­submandibular clearance, usually as part of a neck dissection, 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 submandibular 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 submandibular 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 advantage 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 posteriorly to reveal the groove between the superficial and deep lobes of the submandibular gland The posterior border of the mylohyoid lies within this groove It is gently freed with scissors and then retracted forward 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 Figure 44.11  Division of the deep cervical fascia following skin incision and division of the platysma Figure 44.13 Surgery for a malignant submandibular tumour with cervical metastasis Figure 44.12 Exposure Figure 44.14  The lower pole of the submandibular gland is mobilized and retracted upwards of the submandibular gland revealing branches of the facial vessels Sublingual gland excision for ranula or excision biopsy  447 the gland through the underlying h ­ yoglossus 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 parasympathetic fibres tether the lingual nerve to the salivary gland Occasionally, the sublingual ganglion can be identified 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 remaining 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 vacuum drain inserted and closed in layers using a subcuticular suture to close the skin The wound edges may be reinforced with skin closure tapes Post-operative care The vacuum drain is removed when drainage has slowed, usually at 24 hours The subcuticular stitch is removed at about 10 days Complications Three cranial nerves are at risk during removal of the submandibular salivary gland: the mandibular branch of the facial nerve, the lingual nerve (a branch of the third division of the trigeminal nerve) and the hypoglossal nerve A neck incision at least cm below the lower border of the mandible and careful surgical technique will avoid damage 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 submandibular 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 disposable titanium vascular clips are safer than diathermy in this situation Carelessness with these vessels results in extensive haematoma in the neck SUBLINGUAL GLAND EXCISION FOR RANULA OR EXCISION BIOPSY Figure 44.15  The submandibular gland is pulled downwards revealing the V-shaped lingual nerve prior to division of the parasympathetic nerve fibres The operation may be performed under general anaesthesia or local anaesthesia If a general anaesthetic is used, it is helpful to infiltrate the floor of the mouth with a local anaesthetic containing vasoconstrictor before any incision is made Incision For simple excision of the sublingual gland, a linear incision 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 incision should open the sac of the ranula to allow the mucinous contents to be aspirated Isolation of the submandibular duct Figure 44.16  The hypoglossal nerve lies in the floor of the gland bed The submandibular duct is now carefully identified and retracted medially Stay sutures passed through the margins of the mucosa are helpful to aid retraction (Figure 44.17) Using blunt dissection with scissors, the lingual nerve is identified 448  Submandibular, sublingual and minor salivary gland surgery Figure 44.19 Anatomical features displayed following removal of the sublingual gland Figure 44.17 Stay sutures retracting the sublingual mucosa The anterolateral part of the sublingual gland may be attached to the periosteum of the mandible by fibrous tissue 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 Complications Damage to the lingual nerve posteriorly or the submandibular duct medially is avoided by careful surgical technique Meticulous haemostasis is required to avoid a post-operative haematoma in the floor of the mouth SUBLINGUAL GLAND EXCISION FOR MALIGNANT TUMOUR Figure 44.18  Mobilization of the sublingual gland Mobilization of the sublingual gland 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 carefully in order not to damage the duct itself (Figure 44.18) Although only a rare site for a salivary gland neoplasm, the majority of such neoplasms will be malignant and therefore removal should encompass a clear margin of normal tissue of at least 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 The operation Because of the vascularity of the floor of the mouth, it is helpful to use a cutting diathermy for the soft-tissue incisions (Figure 44.20) Depending upon the position of the 914  Face transplantation (a) (b) (c) Figure 89.5  (a) The harvested face graft (b) Diagrammatic illustration of the components of the face transplant Front perspective (c) Diagrammatic illustration of the components of the face transplant Back perspective (Courtesy of the Cleveland Clinic.) The next crucial task is facial nerve neurorraphy Interpositional nerve grafts might be used to achieve tensionless neurorrhaphies Sensory nerve coaptations can then follow if feasible The facial allograft is then closed in layers from deep to superficial starting with the mucosal layers, muscle repair, subcutaneous layer and finally skin.1,10 Expected oedema has to be taken into account by avoiding tight skin closure (Figure 89.7a through c) POST-TRANSPLANT PHASE The composite vascularized facial allograft is monitored post-operatively in the ICU setting with hourly clinical examination for colour, temperature, oedema, fullness along with arterial and venous Doppler signals Normalization of haemodynamics, electrolytes, acid–base balance, oxygen saturation and carbohydrate levels is paramount Monitoring of circulatory, respiratory, neurological, renal and liver functions ensures timely pre-­emptive medical interventions to minimize adverse events Nutritional assessment and management is v­ aluable at this point to meet the hyper-catabolic response following this type of surgery The immunosuppressive regimen usually includes thymoglobulin for induction, and standard triple-­therapy including tacrolimus, mycophenolate mofetil and prednisone Rejection screening is accomplished according to a predefined protocol and includes punch biopsies from the skin and mucous membrane every 72 hours for the first weeks, then every week for the first months and then once a month for the first year An experienced pathologist evaluates the specimens by using a consistent rejection scale as the Banff classification Intense physical therapy, sensory re-education and speech therapy are started 48 hours after surgery and continued daily for 6–8 weeks and then decreased to three times per week Regular assessment of facial expression, swallowing, mastication and speech is essential to monitor progress Serial photography/videography in addition Outcome 915 (b) (a) (c) Figure 89.6  (a) 3D CT scan of the facial skeleton AP view after transplantation Note the adequate skeletal relationships of the hybrid skeleton (b) 3D CT scan of the facial skeleton left lateral view after transplantation Note the adequate skeletal relationships of the hybrid skeleton (c) 3D CT scan of the facial skeleton right lateral view after transplantation Note the adequate skeletal relationships of the hybrid skeleton (Courtesy of the Cleveland Clinic.) to nerve conduction and electromyographic studies serve for documentation and regular assessment Sensory testing (Tinel sign, Weber static two-point discrimination and Semmes–Weinstein monofilament technique) for supra-orbital, infra-orbital and mental nerve zones is performed regularly Psychological support daily for 6–8 weeks, and then three times per week is important to manage the psychosocial challenges following transplantation.1 OUTCOME Immunologic outcome Acute rejection is most common in the first year Reversal is usual with increasing steroid or tacrolimus dose, in addition to topical steroid or tacrolimus adjuncts (Figure 89.8a through c) No hyperacute rejection has been reported so far 916  Face transplantation (a) (b) (c) Figure 89.7  (a) Intra-operative left lateral view following inset of the facial transplant (b) Intra-operative right lateral view  ­following inset of the facial transplant (c) Diagrammatic illustration of face transplant after inset (Courtesy of the Cleveland Clinic.) Infections are common CMV donor/recipient mismatch predisposes to life-threatening infections and can trigger acute rejection Many transplant teams, therefore, avoid CMV mismatched trans­plantations Despite adequate prophylaxis for CMV (ganciclovir and valganciclovir), herpes simplex (acyclovir) and Pneumocystis jirovecii (trimethoprim-­ sulfamethoxazole), many patients developed opportunistic infections including CMV activation, herpes simplex, herpes zoster, EBV, Candida, rosacea, staphylococcal, Enterobacter and Pseudomonas aeruginosa infections Monoclonal B-cell lymphoma has been observed in one EBV mismatched patient, and tumour recurrence in an HIV-positive patient resulted in death.7 Functional outcome Sensory appreciation in the graft usually occurs even in absence of sensory neurorrhaphy but may be delayed up to months Motor recovery, however, is dependent upon facial nerve repair and may take up to months for lip closure, months for complete mouth occlusion and years for smile Improvements usually continue over time Thus, ability to eat, drink, speak, smell and smile has been reported in almost all patients Significant reduction in chronic pain following excision of scarred tissue and release of contractures has been reported as well Optimum outcomes require intensive physical, speech and psychological rehabilitation.7 References 917 (a) (c) (b) Figure 89.8  (a) Frontal view of patient years following face transplant Note the midface restoration and tracheostomy i­ndependence (b) Right lateral view of patient years following face transplantation Note the midface restoration and tracheostomy independence (c) Left lateral view of patient years following face transplantation Note the midface restoration and tracheostomy independence (Courtesy of the Cleveland Clinic.) Psychological outcomes MORTALITY Face transplantation has had a favourable psychological impact in the majority of patients with decreased depression, improved self-image, adequate social integration and work resumption.7 Three mortalities have been reported so far (mortality rate: 11.1%) Two patients were lost following acute rejection due to failure of compliance with immunosuppression (China) and secondary squamous cell carcinoma of the hypopharynx (Spain) One patient died following combined face and double-hand allotransplantation due to sepsis resulting from pseudomonal graft infection (France) (Table 89.3).12 COMPLICATIONS11,12 Table 89.3  Complications • Bleeding (requiring transfusions up to 66 units of packed red cells) • Jugular vein thrombosis • Insulin-dependent new-onset diabetes mellitus • Transient thrombocytosis • Acute renal failure • Thrombotic micro-angiopathy • Transient steroid induced confusion • Transient leukopenia • Post-transplantation monoclonal B-cell lymphoma • Cervical dysplasia • Severe rhabdomyolysis • Acute respiratory distress syndrome • Right diaphragmatic paralysis • Rosacea • Bacterial infection • CMV infection • Herpes virus infection • EBV • Molloscum contagiosum Abbreviations:  EBV, Epstein–Barr virus; CMV, cytomegalovirus REFERENCES Siemionow M and Gordon CR Institutional review board-based recommendations for medical institutions pursuing protocol approval for facial transplantation Plast Reconstr Surg 2010 Oct; 126(4): 1232–1239 Siemionow MZ, Papay F, Djohan R, Bernard S, Gordon CR, Alam DS et al First U.S near-total human face transplantation: A paradigm shift for massive complex injuries Plast Reconstr Surg 2010 Jan; 125(1): 111–122 Mohan R, Borsuk DE, Dorafshar AH, Wang HD, Bojovic B, Christy MR et al Aesthetic and functional facial transplantation: A classification system and treatment algorithm Plast Reconstr Surg 2014 Feb; 133(2): 386–397 Gharb BB, Rampazzo A, Kutz JE, Bright L, Doumit G and Harter TB Vascularization of the facial bones by the facial artery: Implications for full face allotransplantation Plast Reconstr Surg 2014 May; 133(5): 1153–1165 918  Face transplantation Alam DS, Papay F, Djohan R, Bernard S, Lohman R, Gordon CR et al The technical and anatomical aspects of the World’s first near-total human face and maxilla transplant Arch Facial Plast Surg 2009 Nov–Dec; 11(6): 369–377 Bojovic B, Dorafshar AH, Brown EN, Christy MR, Borsuk DE, Hui-Chou HG et al Total face, double jaw, and tongue transplant research procurement: An educational model Plast Reconstr Surg 2012 Oct; 130(4): 824–834 Khalifian S, Brazio PS, Mohan R, Shaffer C, Brandacher G, Barth RN et al Facial transplantation: The first years Lancet 2014 Apr 25: 384:2153– 2163 doi:10.1016/S0140-6736(13)62632-X Siemionow M, Gharb BB and Rampazzo A The face as a sensory organ Plast Reconstr Surg 2011 Feb; 127(2): 652–662 Siemionow M, Agaoglu G and Unal S A cadaver study in preparation for facial allograft transplantation in humans: Part II Mock facial transplantation Plast Reconstr Surg 2006 Mar; 117(3): 876–885 10 Alam DS, Papay F, Djohan R, Bernard S, Lohman R, Gordon CR et al The technical and anatomical aspects of the World’s first near-total human face and maxilla transplant Arch Facial Plast Surg 2009 Nov–Dec; 11(6): 369–377 11 Siemionow M and Ozturk C Face transplantation: Outcomes, concerns, controversies, and future directions J Craniofac Surg 2012 Jan; 23(1): 254–259 12 Siemionow M, Gharb BB and Rampazzo A Successes and lessons learned after more than a decade of upper extremity and face transplantation Curr Opin Organ Transplant 2013 Dec; 18(6): 633–639 Index A Abbe flap, 191–192, 539 Abdominal trauma, 521 ABG, see Alveolar bone grafting Abnormal head shape, 777 Abrasions, 538 Abscess, 22 Access surgery, 341 coronal scalp flap, see Coronal scalp flap maxillary swing, 345–348 nasal swing, 348–351 transmandibular approaches, see Transmandibular approaches transzygomatic approaches, 355–358 Acoustic shadowing, 17 Acrylic dental splint, 738, 810 Acute retrobulbar haemorrhage, 186–188 Adult dentition avulsion, 545–546 dentoalveolar fracture, 546 extrusion, 545 intrusion, 544–545 root fractures, 546 subluxation, 544 Adventitia scissors, 221 Afroze cleft lip repair, 668 Airway, breathing, circulation (ABC), 519 Alar base, 721, 731, 732, 892 Alar rim, 373–374, 891 AlloDerm®, 166 Allogenic bone grafts, 107, 111–112, 170 Allografts, 105 Alloplastic grafts, 105, 633, 731 Alveolar bone grafting (ABG) aim of, 703–704 assessment, 704 operating technique, 704–705 premaxillary osteotomy, 710–713 primary, 705 secondary, 706–710 Alveolar bone splitting/ spreading, 112–113 Alveolar cleft segments, 659 Alveolar osteotomy, 395 Alveolectomy, 395 AMSO, see Anterior maxillary segmental osteotomy Analgesics, 103 Anastomotic technique, 279–280 end-to-end, 221–222 end-to-side, 222 patent anastomosis, 221 patency test, 223–224 suture lines, assessment of, 223 Angioplasty balloon catheter, 460 Angle fractures, 554 Angle osteotomy, 354–355 Ankylosis, temporomandibular joint childhood, 639–640 costochondral graft harvest, 643–644 infancy, 639 reconstruction, 644–645 resection of ankylotic tissue, 640–641 surgery in adult, 640 Anterior cranial fossa, 794 Anterior crest, 278 Anterior ethmoidal artery, 186 Anterior hard palate, 659–660 Anterior jugular vein, 224–225 Anterior mandibular subapical osteotomy, 742–743 Anterior maxillary segmental osteotomy (AMSO), 735–737 Anterior nasal spine, 124, 657, 726, 771 Anterior rectus fascia, 240, 243 Anterior superior iliac spine (ASIS), 275, 276 Anterior tibial artery, 268, 271 Anterolateral thigh flap, 269 complications, 257–258 indications, 253 operation, 254–257 post-operative care, 257 preoperative, 253–254 principles and justification, 253 Antibiotic prophylaxis, 541, 621 Antibiotics, 103, 556 Aquamid, see Polyacrylamide hydrogel Arch bars, 527–528 Arerteriovenous fistula (AVF), 510 Artecoll/artefill, see Polymethylmethac­ rylate microspheres Arterial patency, 223 Arteriovenous malformation (AVM), 509–510 complications, 502, 505 treatment options, 501–502 Arthroscopy arthrocentesis, 618 lysis and lavage, 618–620 Articular disc, 629–631 Articular eminence, 628, 631–633 Articulated study casts, 100 ASIS, see Anterior superior iliac spine Atrophic mandible, 126 Auricular prosthesis, 157–159 Autogenous bone graft, 107, 143 Autogenous fat, 818 Autologous bone graft, 105, 705 AVF, see Arerteriovenous fistula AVM, see Arteriovenous malformation Avulsion injuries, 538–540, 547 B Bain retractor, 342 Balloon ductoplasty, 461 Barium swallow, 4, Barrel-staving osteotomies, 780, 781 Basal cell carcinomas (BCCs), 361, 368 BCLP, see Bilateral cleft lip and palate BFP, see Buccal fat pad Bifrontal craniotomy, 780, 788, 794 Bilateral cleft lip anatomy, 671 complications, 676–679 closure, 675–676 definitive primary repair of, 673 mobilization – open technique, 679–680 nasal cartilages, mobilization of, 675 premaxilla, 672–673 procedure, 673–675 rhinoplasty, 731–732 Bilateral cleft lip and palate (BCLP), 710 Bilateral coronal synostosis, 778, 781–782 Bilateral fractures, 564 Bilateral sagittal split osteotomy (BSSO), 745 Bilobed flap, 365 Binocular loupes, 229 Biologic healing adjuncts, 135–136 Biomet stock prosthesis, 647 Biopsy of soft tissue lesions, 28 of submandibular gland, 242 tissue, intra-operative assessment of, 30 Bipedicled longitudinal/ langenbeck flaps, 683–684 Bleeding, 495 Blepharoplasty incision, see Subciliary incision Blindness, 582 Blood pressure control, 387 Blow out fractures, 576, 577 Blunt dissection, 634, 675, 764 Blunt hook, 356, 357 Blunt scissors, 183, 342 BMP, see Bone morphogenetic protein Body of mandible, 36 Bone augmentation, in oral implantology donor sites, 108–110 general principles, 107–108 onlay graft, 110–11 maxillary sinus grafting, 111–112 alveolar bone splitting/ spreading, 112–113 bone regeneration, 113 transalveolar osteotome sinus lift, 113–115 Bone-borne distractor, 770, 773 Bone cuts, 346–348 Bone expansion, 124–125 Bone exposure, 232 Bone grafts, 104–105, 716, 792, 794 harvesting technique, 136, 278 Bone marrow, 173 Bone morphogenetic protein (BMP), 107 Bone plating, 232 Bone quantity assessment, 100–101 Bone regeneration, 113 Bone resection, 389 Bone wax, 278 Bony defect reconstruction, 728–729 Botulinum toxin type A, 824–825 horizontal lines of forehead, 827 injection technique and dosing, 825–826 technique of mixing, 825 Box osteotomies indications, 788 post-operative care, 793 techniques, 793–794 Brachioradialis, 227, 230, 232 Brain growth, inhibition of, 777 Branchial cleft cyst, 21, 95–96 Bridal wires, 551, 552 Brisk haemorrhage, 629 Brush biopsy, 30–31 BSSO, see Bilateral sagittal split osteotomy Buccal advancement flap, 189 Buccal bone cut, 746 Buccal fat pad (BFP), 190 Buccal mucoperiosteum, 739, 740 Buccal mucosal flap, 449 Bumps, 21–22 Bunny lines, 827 Buttress plate, 607, 608 919 920 Index C CAD/CAM technology, see Computer-aided design/computeraided manufacturing technology Calcifying odontogenic cyst (COC), 93–94 Cancellous bone, 111, 128, 705, 706 Capillary malformation, 496–497 Capsular dissection, 485 Carcinoma of lower lip, 379 Carotid angiogram, Cartilage grafts, 215–216 CAT scans, see Computerized axial tomography scans Caucasian–Western populations, 253 CBCT, see Cone beam computed tomography Cemento-enamel junction (CEJ), 62, 72 Central midface fractures, 565 Cephalic ratio, 779 Cephalic vein, 225 Cephalometric radiographs, 108 Cerebrospinal fluid (CSF), 520 fistulas, 597 Cervical spine injuries, 520 Cheek defect operations, see temple defect operations Cheek flaps, 370 Chest X-ray, 322 Chlorohexidine rinse, 113 Chronic shoulder weakness/ dysfunction, 237 Circumflex scapula artery (CSA), 236–237 Circumflex scapula vein (CSV), 236–237 Circumvestibular incision, 753 Cleft lip repair fisher cleft lip repair, 669 incomplete, 669–670 inferior triangle incision, 662 intranasal incision, 662–663 nasal floor reconstruction, 665 medial element incision, 661 muscle dissection, 663–664 millard cleft lip repair, 667 objectives of, 657–659 pfeiffer cleft lip repair, 668 septoplasty, 664–665 skin closure, 665–666 sterile mucosa incision, 663 tennison cleft lip repair, 668–669 Cleft palate repair anatomical considerations, 682–683 bipedicled longitudinal flaps, mucosal incisions of, 684 double opposing Z-plasty, 687–689 hard palate, closure of, 687 lateral release incisions, management of, 686–687 nasal mucosal layer, mucosal incisions of, 684–685 operative procedure, 683–684 oral mucosa, 685–686 overview of, 681–682 post-operative care, 689 pre-operative assessment, 683 principles, 682 Cleft rhinoplasty bilateral cleft lip, 731–732 lower lateral cartilage correction, 726–727 nasal bridge narrowing, 732 pre-school years, 724–726 primary cleft lip surgery, 722–724 redraping, 727–728 septal correction, 726 splinting and dressing, 728 techniques, 728–731 Clefts of the lip and/or palate (CLP), 657, 739, 740 Clinical chemistry, 31 Closed reduction techniques, 573 Closed rhinoplasty approach, 893–894 Closed treatment, mandibular fractures, 551 CLP, see Clefts of the lip and/or palate CNC, see Computerized numerical control COC, see Calcifying odontogenic cyst Colour flow Doppler, 18 Columella, 722 Composite osteocutaneous flap, 231–233 Computer-aided design/computeraided manufacturing (CAD/CAM) technology, 306–308 Computer-assisted reconstruction, of facial skeleton, 293 diagnosis, 293–294 of mandible, see Mandible, computer-assisted reconstruction of of midface, see Midface, computer-assisted reconstruction of planning and simulation, of facial reconstruction, 294–296 validation and quality control, 308, 310 Computerized axial tomography (CAT) scans, 140, 148 gunshot, 156 maxilla, 144 resultant defect, 155 tumour, 159 Computerized numerical control (CNC), 306, 307 Computer planning technology, 33–35 Conchal cartilage, augmentation rhinoplasty using, 893–894 Condylar fractures complications, 564 management of isolated unilateral, 561–563 treatment options and outcomes, 560–561 Condylar head, 629, 630 Condylar neck/base, fracture of, 560 Condyle, 394, 633–634, see also Condylar fractures Condylectomy, 641–642 Cone beam computed tomography (CBCT), 6–7, 59–60, 294, 298 Conjunctival melanoma, 400 Connective tissue grafts, 120, 123 Continuous positive airway pressure (CPAP) therapy, 807, 808 Contrast studies, 4–5 Contusions, 537 Copious irrigation, 764 Core biopsy, 22, 25 Core data set, 337–339 Coronal incision, 789 Coronal scalp flap indications, 341 midface procedures, 344 surgical technique, 341–344 Coronoidectomy, 642, 651 Corticocancellous block bone graft, 119, 134 with Le Fort I down-graft osteotomy, 129–130 Corticosteroids, 494 Cosmetic replacement, 227 Cosmetic tattooing, 374 Costochondral cartilage graft, 643–644, 731, 803 ear, 215 nasal septum, 215–216 Cover screw placement, 102 CPAP therapy, see Continuous positive airway pressure therapy Cranial growth, 779 Craniofacial implantology, 139 angulated, 139–142 auricular, 157–158 gunshot reconstruction, 153–157 hemizygomatic implants, 142 nasal and naso-maxillary reconstruction, 152–153 pterygoid implant, 157 quadratic zygomatic implants, 142–146 reconstruction, advanced digital technology in, 158–162 zygoma, see Oncology reconstructive protocol Craniofacial malformations, Craniofacial repair, 433–436, 588 Craniofacial trauma classification, 585 frontal sinus management, 594–597 incision, 589–593 nasoethmoidal fractures, 597–600 surgical procedure, sequencing of, 588–589 Cranio-orbital deformity, 588 Cranio-orbital resection, 433, 436, 437 Craniosynostosis, aesthetic and psychosocial considerations, 778 bilateral coronal synostosis, 781–782 complications, 785 functional considerations, 777–778 metopic synostosis, 782–783 pre-operative preparation, 779–780 sagittal synostosis, 783–785 timing of surgery, 779 unilateral coronal synostosis, 780–781 Craniotomy, 592, 593 Cranium, 211–212 Crestal incision, 102 Cricothyroid muscle, 483 Cross-face nerve graft, 284–285 Crow’s feet, 826–827 Cryer’s elevator, 53–54 Crypt control, 85 CSA, see Circumflex scapula artery CSF, see Cerebrospinal fluid CSV, see Circumflex scapula vein Cupid’s bow deformity, 679 Curative surgery, principles of, 325–326 Curettage, 28 Cutting jigs, 34–35 D Dacrocystogram, Dautrey’s osteotomy, 632 DCIA, see Deep circumflex iliac artery Debridement, 633 Deciduous teeth extractions, 55 Deep circumflex iliac artery (DCIA), 275 Deep fascia, 227–229 Deep inferior epigastric musclesparing perforator (DIEP) flap, 239–242, 244 Defensive incision, 199 Dehiscence of wound, 676 Delaire cleft lip repair, 667 Delayed implant placement, 122 Dental avulsion, 545 Dental elevators, 48–49 Dental extraction, see Tooth extraction Dental implants/implantology, 14, 39 Dentigerous cyst, 89–90 Dentoalveolar fractures, 546 Dentoalveolar trauma adult dentition, 544–546 patient assessment, 543–544 primary dentition, 546–547 Dermoid cysts, 22, 94, 96–97 DICOM, see Digital Imaging and Communications in Medicine DIEP flap, see Deep inferior epigastric musclesparing perforator flap Diet, 103 Diffuse thyroid disease, 21 Diffusion weighted imaging (DWI), Digital Imaging and Communications in Medicine (DICOM), 297 Digital radiography units, Dilated submandibular duct, 19 Dimpled chin, 827 Diplopia, 524, 582 Direct skin closure, 203 Discectomy, 631 Discopexy, 620–622 Discrepancy in vessel size, 223 Disc repositioning, 631 Dissecting scissors, 221 Distal pedicle dissection, 231 identification of, 272 Distal submandibular duct, stone removal in, 442–443 Distant reconstructive options, 409–410 Distraction device activation, 766, 767, 774–775 Distraction osteogenesis (DO), 39–40, 267 anaesthesia considerations, 762 extraoral distraction device placement, 764–766 Index 921 intraoral distraction device placement, 762–764 post-operative care, 766 pre-operative assessment, 761 DO, see Distraction osteogenesis Donor bone, 34–35 Donor site closure, 237, 256–257, 372 detachment of flap and, 230 management, 232–233 and pedicle division, 278–279 selection, 219–220 Dormia basket catheter, 460 Dorsal hump, 727, 729 Dorsal nasal flap, 371 Dorsum, 721, 889–891 Double mandibular osteotomy, 354–355 Down-fracturing technique, 737–738 Ductal calculi, 459 Dufourmental flap, 364 DWI, see Diffusion weighted imaging Dye lasers, pulsed, 496 Dynamic lymphoscintigraphy, 422 E Ear injuries, 215, 539 ECD, see Extracapsular dissection Edentulous fractures, 556–557 18-fluorodeoxyglucose (18FDG), Electrohydraulic intracorporeal lithotripsy, 457 Elliptical incision, 203 Emergency surgical airway, 179 Emergency tracheostomy, 179 Eminectomy, 632 Eminence augmentation, 632–633 Endodontics surgery anaesthesia in, 84 complications, 87 flap design, 84–85 procedure, 85–87 success rates, 83 Endoscopically assisted reduction, 562–563 Endoscopic retrieval, 458–459 Endosseous implants, 134–135, 146 End-to-end anastomosis techniques, 221–222 End-to-side anastomosis techniques, 222 Enophthalmos, 582, 584 Enucleation, 402 Epidermoid cysts, 94–95 Epistaxis, 510–511, 538, 540 e-PTFE, see Gore-Tex Ethmoidal artery ligation, 185 EUA, see Examination under anaesthetic EVPOME grafts, see Ex vivo produced oral mucosa equivalent grafts Examination under anaesthetic (EUA), 321–322 Excimer lasers, 290 Excision biopsy, 26, 442 of benign tumours operation, 450–451 Exfoliative cytology, 30–31 Exposed implants threads, 105 Exposure of parotid stone, 466–467 Extensive deep lobe and parapharyngeal tumours, 473 transpharyngeal approach, 474–475 Extensor digitorum longus, 268 Extensor hallucis longus (EHL), 267–268 External carotid artery (ECA), 19, 186, 508 External mandibular fixation, 529 External maxillary distraction devices, 773 Extracapsular dissection (ECD) complications, 479–480 dissection, 478–479 facial nerve injury, 480 incision, 478 indications, 477–478 post-operative, 479 Extracorporeal shock wave, 455–457 Extraction forceps, 47 Extraoral distraction device advantages and disadvantages of, 762 placement, 764–766 Extraoral examination, 100 Extremity weakness, 520 Extrusion, 545, 547 Ex vivo produced oral mucosa equivalent (EVPOME) grafts, 165–169 Eyelid apparatus, 539–540 resection, 368–370 sparing technique, 406 Eye protection, laser and, 291–292 F Face/neck mass, 15 Facial aesthetics, 817 Facial artery, 446 Facial artery musculomucosal (FAMM) flap, 388, 389 Facial bipartition indications, 793 post-operative care, 794–796 techniques, 793–794 Facial bite wounds, 541 Facial/craniofacial trauma, 10 Facial infection, 10 Facial nerve dissection advanced malignant tumours, 473 papillotomy, 466 pre-operative investigations, 465–466 principles and justification, 465 surgical removal of parotid stones, 466–468 transpharyngeal approach to deep lobe, 474–475 Facial nerve injury, 284–285, 480, 652 Facial reanimation cross-face nerve graft, 284–285 indications, 283 muscle transfer, 285–287 post-operative care, 287–288 pre-operative planning, 283–284 Facial resection, 362 Facial skeleton radiographs, Facial soft-tissue injuries classifications of, 537–538 eyelid and nasolacrimal apparatus, 539–540 facial bite wounds, 541 initial evaluation, 538 principles of, 538–539 surface anatomy, 540–541 treatment for, 539 Facial vascular malformations, 10 FAMM flap, see Facial artery musculomucosal flap Fascia-only flaps, 227 Fasciocutaneous radial flap, 229–230 Fat harvesting techniques, 818–821 Fat transfer, 818–821 Fibroblastic phase, 537 Fibrocartilage, 615 Fibula grafts, 36 Fibular flap historical development, 267 in maxillofacial surgery, 269 surgical anatomy, 267–268 surgical planning for, 269–270 surgical technique, 270–273 vascular anatomy, 268–269 Fine-needle aspiration (FNA), 22 biopsy, 466 Fine needle aspiration cytology (FNAC), 25, 322 Fine resorbable sutures, 209 FISH, see Fluorescent in situ hybridization Fisher cleft lip repair, 669 Fishtail technique, 223 Flap design, 84–85 latissimus dorsi flap, 248–250 rectus abdominis, 242 and skin paddle elevation, 256 Flap detachment, and donor-site closure, 230 Flap harvesting, 236 Flapless surgical extraction, 54 Flap mobilization, 230 Flap necroses, 201 Flap outline, 236 Flexor carpi radialis, 227–231 Flexor hallucis longus (FHL), 268, 271–272 Fluorescent in situ hybridization (FISH), 29 FNA, see Fine-needle aspiration FNAC, see Fine needle aspiration cytology Foley catheter to nasal cavity, insertion of, 185–186 Forced duction test, 578 Forceps technique, 47–48 Forearm incision, 230 Forehead defect operations horizontal/‘H’ sliding flap, 363 rotational forehead flap, 363–364 V-Y advancement flap, 362–363 Fossa, 650–651 Fractional photothermolysis, 292 Free-flap monitoring, 224 Free skin grafting, 406 Free tissue transfer, reconstruct skull base and, 430 Frey’s syndrome, 480 Frontal bandeau, 592 Frontal sinus, 594–597 Fronto-temporal craniotomy, 356, 358 Full thickness (Wolfe graft), 204–206 cheek flaps, 370 extended temporal flaps, 369–370 eyelid flaps, 368–369 Furlow, 687–689 G Gadolinium, 7, 493 GAF, see Galea aponeurotica flap Gait problems, 281 Galea aponeurotica flap (GAF), 193–194 Gamma camera, 423 Gap arthroplasty, 634–635 Gas lasers, 290 Gastrointestinal anastomosis (GIA) linear stapler, 251 Gastrostomy, 329 GCS, see Glasgow coma scale Genial tubercles, 812–814 Genioplasty, see Horizontal sliding osteotomy Geniotomy, 811–812 GIA linear stapler, see Gastrointestinal anastomosis linear stapler Gillies lift, for zygomatic fracture, 606 Gingival margin, 84 Glabellar complex, 826, 827 Gland dissection, 484–487 Glandular odontogenic cyst, 93 Glasgow coma scale (GCS), 520 Gore-Tex, 731, 892–893 Gorlin cyst, see Calcifying odontogenic cyst Gracilis flap complications, 265 operation, 261–265 reconstructive use, 261 Gracilis muscle exposure, 262 Grafting materials, classification of, 107 Graft positioning, 287 Graft procurement, 284 Great vessels, dissection and clearance around, 417 Gunshot reconstruction, 153–157 H Haemangiomas, 21, 494, 510 Haematology, 31 Haematomas, 237, 480 Haematoxylin, of ex vivo produced oral mucosa equivalent, 167 Haemorrhage, 265, 651 during drilling, 105 maxillofacial, 184–186 Haemostasis, 478, 538, 636 Halo frame external distractor, 774 Handheld Doppler probe, 268, 276, 280 Hard palate, closure of, 687 Hemifacial microsomia diagnostic images, 800 extraoral approach, 802–804 model surgery, 801 patient examination, 799 surgical management, 801–802 Hemizygomatic implants, 142 Hess chart, 577, 578 High condylar shave, 633 High-grade malignant tumours surgery, 452 High Le Fort I osteotomy, 757 Hilar vessel, 18 Horizontal bone cut, 739, 742–743 Horizontal/‘H’ sliding flap, 363 Horizontal osteotomy, 748–750, 810, 811 Horseshoe incision, 125 Hounsfield units, of tissues, Human papillomavirus (HPV), 29 Hump reduction, 727 Hyaline cartilage, 615 Hyaluronic acid-based fillers, 822 922 Index Hyoid gland, 488 Hyoid suspension procedure, 813 Hypertrophic scar, 679 Hypervascular tumours, 510 Hypopharynx, 809 Hypotensive anaesthesia, 478, 640 I IANs, see Inferior alveolar nerves IDC, see Inferior dental canal IHC, see Immunohistochemistry Iliac crest grafts, 212–214 complications, 281 indications, 275–276 operation, 276–280 post-operative, 280 principles and justification, 275 Ilium, 36 IMF, see Intermaxillary fixation Immediate implant placement, 104, 121–122, 147 Immunohistochemistry (IHC), 28–29 Implantology assessment of bone quantity, 100–101 atrophic mandible, 126 bone expansion, 124 bone grafting, 104–105 Class II, 121–122 Class III, 122–124 Class IV maxilla (inadequate nasolabial support), 124–125 Class V maxilla, 125 complications of, 105 diagnosis and treatment planning, 99–100 immediate implants, 104 insertion, 102 osteotomy, 101 placement, surgical guide for, 118 post-operative care, 103–104 pre-implant surgery, 118–119 reconstruction, 130–132 soft-tissue procedures, 120–121 surgical procedures, 102–103 surgical technique, 125–126 Incisional biopsy, 25, 26 Incisional hernia, 281 Infantile haemangioma complications, 495 indications for treatment, 494 treatment options, 494–495 Infection, 652 Inferior alveolar nerves (IANs), 59, 65–68 in bone compromised patient, 135 management, 78–79, 389 Inferior dental canal (IDC), 60–61 Inferior joint space, 629 Inferior orbital fissure, 356–358 Inferior osteotomy, 791 Inferior turbinate hypertrophy, 901 Infiltrating tumours, 400 Inflammation, 19–20 Infraorbital nerve repair, 79–80 Infratemporal fossa, 359 Initial lag phase, 537 Injectable filler, 818, 824 Inlay corticocancellous block bone graft, 128–129 Insetting flap, 200 Instrument case, 221 Intense pulsed light (IPL), 292 Interdomal stitch, 679 Intermaxillary fixation (IMF), 738, 747–748 reduction and fixation using, 573 screws, 528–529 Internal jugular vein (IJV), 413, 416–418 Internal oblique muscle, 276–277, 280 Inter-osseous membrane, 268, 271 Interpositional graft, 633 Interventional radiology arteriovenous malformations, 509–510 classification, 507–508 epistaxis, 510–511 equipment, 508–509 haemangiomas, 510 imaging, 508 principles and procedures, 509 veno-lymphatic malformations, 511–515 Interventional sialography balloon ductoplasty, 461 case selection and patient preparation, 460 post-operative care, 461–462 salivary stone extraction, 460–461 Intracorporeal shock wave, 457–458 Intracranial hypertension, 777 Intra-cranial tumours, 400 Intra-glandular ducts, 19 Intra-lesional steroids, 494 Intra-nodal vessels, 18 Intraoral distraction device advantages and disadvantages of, 762 placement, 762–764 Intra-oral haemorrhage, 184 Intra-oral sites, 215 Intra-oral vestibular incision, 79 Intrusion detection, 544–545, 547 Ipsilateral arm, 250 Isolated arch fractures, 608 Isosulphan blue-dye technique, 422 J Jaw resection mandible and maxilla, 389–390 mandibular resection, for oral squamous cell carcinoma, 390–394 resecting maxilla, 394–396 Jeweller's/watchmaker's forceps, 220 Jewer classification, 36 Joint capsule entry, 627–629 Juvenile chronic sialadenitis, 20 K Karapandzic flap, 539 Kazanjian flap, 126 Kent prosthesis (VK I), 647 Keratocystic odontogenic tumour (KOT), 91–92 Kirshner rod (k-rod), 801–802 Kittner dissectors, 485–486 Kocker clamp, 489 Köle technique, 743 KOT, see Keratocystic odontogenic tumour k-rod, see Kirshner rod L Labial artery, 380 Labial gland biopsy, 26 Lacerations, 537–539 to eyelid, 540 of soft tissue, 522 Lacrimal gland lesions/ tumours, 400 Langenbeck–Ernst–Veau–Kriens repair, 683–684 Large skin defects, 241 Laryngotracheal disruption, 521 Laser lithotripsy, 458–459 physics of, 289 practical safety, 291–292 tissue interactions, 290–291 types of, 290 Lateral bony osteotomy, 754 Lateral canthopexy, 792 Lateral canthotomy, 187 trans-conjunctival incision with, 579 Lateral cephalometric film tracing, 807 Lateral crura, 679 Lateral joint capsule exposing, 627 Lateral mandibular defects, 198 Lateral orbitotomy, 366–367 Lateral osteotomy, 727, 792 Lateral release incisions, management of, 686–687 Lateral rhinotomy approach, 365–366 Latissimus dorsi flap design and utilization, 248–250 development of, 247 features, 247–248 harvesting technique, 250–251 neurovascular anatomy, 248 pre-operative assessment, 250 Le Fort fractures, 523, 566–568 Le Fort osteotomy, 757–759 indications, 751 interpositional corticocancellous block bone graft with, 129–130 operation, 753–757 planning fundamentals, 751–753 post-operative care, 758 Levator veli palatini, 682 Light sedation, 617 Lingual nerve (LN) repair, 76–78 Lining deformity correction, 727 Lip adhesion, 672 Lip cancer, resection and reconstruction indications, 379 one-third to two-thirds of, 381 post-operative care, 387 reconstruction, 384–386 tumours of palate, 383–384 tumours of tongue, 384 two-thirds to total, 381–382 Lip injuries, 539 Lipoma, 21 Lip reconstruction, mucocutaneous grafts for, 170 Liquid-based cytology (LBC), 25 Lithotripsy extracorporeal shock wave, 455–457 intracorporeal shock wave, 457–458 LLC, see Lower lateral cartilage LMs, see Lymphatic malformations Local anaesthesia, 442, 460, 683–684 Local flap closure, 203–204 Local reconstructive options, 406–407 Locking plates/screws, 530–532 Long thoracic nerve injury, 237 Loupes, 220 Lower eyelid incision, 578, 580 Lower lateral cartilage (LLC), 877–880, 886–888, 896 correction, 725 Lower limb arterial supply, 268, 269 Luebke–Oschenbein flap, 84, 85 Lumps, 21–22 Lung injury/pneumothorax, 237 Luxators, 49–50 Lymphatic malformations (LMs), 497–501 Lymphatic metastasis, 421 Lymph nodes, 19 Lymphomatous lymph nodes, 18 Lymphoscintigraphy, 422–423 Lymphovascular invasion, 338 Lynch incision, 366 M MacFee incision, 415 Magnetic resonance imaging (MRI), 7, 294, 466, 508 advantages and disadvantages of, with gadolinium, 493 Malar complex fracture, 523–524 ‘Malar’ hook, 605, 607 Malignant tumours, 451–452, 473 Mandible, 35, 101–102 body of, 36 bone compromised patient, 135 computer-assisted reconstruction of, 305–308 endosseous implants, discontinuity reconstruction, 134–135 fractures, 525 implant reconstruction, 132 onlay corticocancellous block bone graft reconstruction, 133 ramus of, 35 resection of, 389–390 standard technique, 305 Mandibular canine, 64 Mandibular condyles, 810 Mandibular fractures antibiotics, steroids and tetanus prophylaxis, 556 applied anatomy, 549–550 assessment of, 550–551 common fracture sites, 550 external fixation, 552–554 miniplate placement, 554–556 post-operative care, 557 special considerations, 556–557 timing of surgery, 551 treatment principles, 551–552 Mandibular molar, 64–66, 68 Mandibular osteomyelitis, 10 Mandibular premolar, 65–67 Mandibular ramus, 109–110 Mandibular repositioning devices, 807, 808 Index 923 Mandibular resection, for oral squamous cell carcinoma, 390–394 Mandibular swing, 351, 353 Mandibular symphysis complications, 109 pre-operative preparation, 108 procedure, 108–109 Mandibular teeth, 46, 48 Mandibular third molars (M3Ms), 69–71 coronectomy, 71–72 Marginal resection, 391–393 Maryland dissector, 316 Masseter flap, 194 Matted nodes, 338 Maturation phase, 537 Maxilla, 347–348, 359 anterior–posterior position, 751 fixation of, 756 head and neck surgery, 3D modelling for, 37–39 implant surgery in, 101 reconstruction, 127 resection of, 389–390 surgical procedures, 102–103 vertical position of, 751 Maxillary canine, 60–62 Maxillary discontinuity reconstruction, 130–132 Maxillary distraction osteogenesis advantages and disadvantages of, 769 complications from, 775 distraction device activation, removal, 774–775 operative technique, 770–773 post-operative care, 773–774 pre-operative assessment, 770 Maxillary impaction, 756 Maxillary incisor, 60 Maxillary molar, 63–64 Maxillary premolar, 62–63 Maxillary reconstruction, 280–281 Maxillary sinus grafting, 111–112 Maxillary splint placement, 794 Maxillary swing bone cuts, 346–348 incision, 346 Maxillary teeth, 47 Maxillary third molars, 72–73 Maxillary tuberosity, 110 Maxillary vestibular incision, 789, 794 Maxillectomy/orbital exenteration, 240, 396 Maxillofacial assessment, 521–522 Maxillofacial fixation techniques closed treatment fixation, 527–529 locking plates/screws, 530–532 non-locking plates/screws, 529–530 positioning screws/lag screws, 533–535 semi-rigid fixation, 532 transbuccal approach, 532–533 Maxillofacial fractures assessment, 523 fractures of mandible, 525 malar complex, 523–524 nasal skeletal fractures, 524–525 orbital walls fractures, 524 radiology, 525–526 Maxillofacial malignancy, 11–12 Maxillofacial surgery, and fibula flap, 269 Maxillofacial trauma, 179 Maxillo mandibular fixation (MMF), 527–529 Maximal incisal opening (MIO), 616 McCoomb nasal dissection, 664 Medial canthopexy, 792 Medial crura, of lower lateral cartilage, 675 Medial osteotomy, 727, 790 Medial resection, 794 Medial skin resection/ rearrangement, 792 Median forehead flaps, 407 Merocel™, 902 Metal-on-metal prostheses, 648 Meticulous haemostasis, 277, 325, 418, 447, 475, 480, 643 Metopic synostosis, 779, 782–783 Metzenbaum scissors, 174 Microsurgical couplers, 223 Microsurgical principles instrumentation, 220–221 optical systems, 220 Microvascular free flaps, 409–410 Microvascular grafting, 643 Microvascular instruments, 221 Microvascular surgery anastomotic technique, 221–224 indications, 219 microsurgical principles, 220–221 post-operative care, 224 recipient vessel selection, 224–225 Middle third fractures diagnosis, 565 treatment, 569–573 using examination with classification, 565–569 Middle vault, collapse of, 900 Midface, computer-assisted reconstruction of applications of, 299–301 fractures, 565, 569, 572 intra-operative imaging, 297–298 intra-operative navigation, 296–297 secondary reconstruction of, 301, 304 Midline incision, 342 Midline of mandible, 36 Mid-line osteotomy, 735, 737 Midtarsal incision, 579 Millard cleft lip repair, 667 Mineral trioxide aggregate (MTA), 86 Minor gland biopsy, 449–450 Minor salivary glands surgery, 449–450 MIO, see Maximal incisal opening MMF, see Maxillo mandibular fixation M3Ms, see Mandibular third molars Mobilization of ostotomies, 791, 792, 794 Mobilized maxilla, 126 Modified Dingman retractor, 76 Modified radical neck dissection (MRND), 413–414 Schobinger incision for, 415 variations, 418 Mohs’ surgery, 361–362 Molecular testing, 29 Motor nerve supply, 261–263 MRI, see Magnetic resonance imaging MRND, see Modified radical neck dissection MSCT, see Multislice computed tomography MTA, see Mineral trioxide aggregate Mucocele formation, 595, 597 Muco-cutaneous grafts, for lip reconstruction, 170 Mucoperiosteum, 736–739, 742 Mucosal grafting, 195 Multifactorial malignancy grading, 27–28 Multi-rooted teeth, 50–52, 54 Multislice computed tomography (MSCT), Muscle cuff preservation, 231–232 Muscle dissection, 663–664 Muscle flaps, 277, 409 Muscle graft insertion, 286–287 Muscle repair, 685 Muscle transfer, 285–287 Muscular component, 255 Musculoperiosteal perforators, 227, 231 Musculus uvulae, 682 Myocutaneous flap, 197, 242–244 Myofascial pain, 652–653 N Narrow nasal bridge, 732 Nasal airway obstruction, 900–901 Nasal and naso-maxillary reconstruction, 152–153 Nasal bone infracture, 729 Nasal cartilages, mobilization of, 675 Nasal cavity, 359 Nasal defects, 370–371 alar rim defects, 373 large nasal defects, 371–372 nasal dorsum defects, 371 nasal tip defects, 372–373 scalp reconstruction, 374–377 total nasal defects, 374 Nasal dilators, 807 Nasal dorsum defects, 371 Nasal mucosa, 679, 790 incisions of, 684–685 Nasal osteotomy, 365 Nasal packing, 185, 186 Nasal reconstruction, posttraumatic, 896 Nasal regions, 809 Nasal septum, 215–216 Nasal skeletal fractures, 524–525 Nasal subunits, 540–541 Nasal swing incision, 348–350 soft tissue lip split, 350–351 visor flap, 351 Nasal tip defects, 372–373 Nasal tip surgery, 729–731 Nasal trauma, 895 Nasendoscopy, 322 Nasoethmoidal fractures background, 597–598 complications, 600 exposure, 598–600 Nasolabial flaps, 372, 373 Nasolabial fold augmentation, 822 Nasolacrimal apparatus, see Eyelid Nasolacrymal duct, 402–403 Naso-orbital ethmoidal (NOE) injuries, 565 Neck dissection, 336–337, 383 anterior, 417 classification, 413–414 technique, 414–418 Neck infection, see Facial infection Neck levels, terminology of, 414 Neck metastasis, 325 Neck skin flap, 351 Needle cricothyroidotomy, 179–180 Needle holders, 221 Negative pressure wound dressing, 230 Neoadjuvant chemotherapy, 324 Nerve damage, 341 Nerve injuries inferior alveolar nerve repair, 78–79 infraorbital nerve repair, 79–80 lingual nerve repair, 76–78 operation for, 75–76 principles and justification of, 75 sural nerve graft, 80–81 Nerve stimulation, 802 Neural integrity monitor (NIM) tube, 484 Neuroma, 77, 79–81, 480 Neuromotor development, 777 Neurovascular anatomy, 248 Nevoid basal cell carcinoma syndrome, 92–93 NIM tube, see Neural integrity monitor tube NOE injuries, see Naso-orbital ethmoidal injuries Non-homogeneous leukoplakia, 27 Non-locking plates/screws, 529–530 Non-resorbable monofilament material, 210 Non-steroidal analgesics, 84 Nonsteroidal anti-inflammatory drugs (NSAIDs), 55 Non-syndromic craniosynostosis, 777 Non-vascularized block bone grafts, 210–215 discontinuity reconstruction with, 134–135 Non-witnessed nerve injury, 75 Nose, 540 NSAIDs, see Nonsteroidal antiinflammatory drugs Numbness, 281 O OAF, see Oro-antral fistula Oblique occlusal radiograph, 704, 706 Obstructive sleep apnoea evaluation, 806 indications for intervention, 805 mechanical devices, 807 non-surgical management, 806–807 surgery, 809–814 surgical management of, 808–809 Occipito-mental (OM), Occlusal plane inclination, 752 924 Index OCS, see Orbital compartment syndrome Ocular adnexa, 400 Ocular injury, 520–521 Ocular prosthetics, 410 Oculofacial prosthetics, 410 Odontogenic cysts, 28, 89 Odontogenic keratocyst (OKC), 90–92 Oedema, 103, 617 OFG, see Orofacial granulomatosis OKC, see Odontogenic keratocyst OMFS, see Oral and maxillofacial surgery Oncology reconstructive protocol implant placement, 147–149 interim obturator, 150 maintenance, 151 stereolithographic simulated surgery, 146–47 surgical obturator, 149 tumour resection, 147 Onlay corticocancellous block bone graft reconstruction, 127 of advance mandibular resorption, 133 Onlay graft, 110–111, 125, 632 Open reduction and internal fixation (ORIF), 552, 571 Open structural rhinoplasty (OSR) technique, 892–893 Operating microscope, 220, 221 OPG, see Orthopantomogram Oral and maxillofacial surgery (OMFS), 179 Oral cancer, 26–28 Oral cavity, 227, 359 Oral defects reconstruction, 384–386 Oral mucosa, 165, 210 Oral squamous cell carcinoma, mandibular resection for, 390–394 Orbicularis oculi, 827 Orbicularis oris, 665 Orbit, 359 Orbital anatomy, 399 Orbital apex syndrome, 576 Orbital compartment syndrome (OCS), 610 Orbital defects combined approaches, 366–368 lateral orbital masses, 366 lateral rhinotomy approach, 365–366 Orbital hypertelorism box osteotomies, see Box osteotomies defined, 787 facial bipartition, 793–796 pre-operative assessment, 787–788 revision rate for, 796 Orbital lymphoma, 399–400 Orbital plates, 581, 583 Orbital prosthetics, 410 Orbital reconstructive techniques, 406–410 Orbital trauma anatomy, 575–576 complications, 582, 588 investigations, 577 operative procedure, 578–581 Orbital tumours, 399 radiological diagnosis of, 400, 402 Orbital wall fractures, 300–301, 524 ORIF, see Open reduction and internal fixation Oro-antral fistula (OAF), 189–190 Orofacial granulomatosis (OFG), 26 Oronasal airway, 519 Oronasal fistula, 677 Oropharyngeal squamous carcinoma (OSCC), 29, 313 Oropharynx, 313 Orthognathic surgery, 14, 496–497 bilateral sagittal split osteotomy, 745 bone cuts, 746 fixation, 747–748 genioplasty, 748–750 high Le Fort I osteotomy, 757 incision, 745–746 Le Fort III osteotomy, 758–759 Le Fort II osteotomy, 757 Le Fort I osteotomy, see Le Fort osteotomy quadrangular Le Fort II osteotomy, 758 split, 746–747 Orthokeratinized odontogenic cyst, 92 Orthopantomogram (OPG), 11, 322, 390 Orthoptic assessment, orbital trauma, 577 OSCC, see Oropharyngeal squamous carcinoma OSR, see Open structural rhinoplasty Osseous orbit, extended exenteration with resection of, 404 Osteoarthritis, 615 Osteocutaneous flap, 231, 232 Osteophytes removal, 633 Osteotomies, 34, 272, 351, 896 inferior horizontal, 109 location, 771–772 planning, 232 posterior vertical, 110 sinus lift, 113–114 surgical goals, 794 technique, 232, 789 vertical, 112 P PACS, see Picture archiving and communication systems Paediatric condyle/ramus fractures, 563 Paediatric orbital fractures, 577 Palatal gland surgery, 450 Palatal incision, 346, 348 Palatal osteotomy, 739–740 Palatal rotation flap (PRF), 189–190 Palatal tumour excision, 384 Palatoglossus muscle, 683 Palatopharyngeus muscle, 682–683 Palliative surgery, 326 Panendoscopy, 314 Panfacial fractures, 563 Panoramic radiographs, 108, 109, 111 Papanicolaou staining, 30 Papillary carcinoma, 20–21 Papillotomy, 466 Paraesthesia, 105 Paranasal sinuses, extended exenteration with resection of, 404–406 Parascapular flaps, 237, see also Scapula flaps Parasymphyseal fractures, see Symphyseal fractures Parathyroid glands, 484 Parotid duct identification, 467 Parotid duct injury, 480 Parotid gland, 19, 480 Parotid stones lithotripsy, 457, 458 surgical removal of, 466–468 Partial condylectomy, 633–634 Partial necrosis, 281 Partial superficial parotidectomy, 470 Partial-thickness defects, 368 Particulate grafts, 119 Patency test, 223 Patent anastomosis, 221 Patient positioning, flap harvesting, 236 PDL cells, see Periodontal ligament cells Pectoralis major, 197–201 Pedicle dissection, 236–237, 255–256 distal, 231 division closure, 278–279 division of, 279 flaps, 409 identification of, 229 PEG, see Percutaneous endoscopic gastrostomy Percutaneous biopsy, 22 Percutaneous endoscopic gastrostomy (PEG), 329–333 absolute contraindications of, 329 Percutaneous tracheostomy, 182 Percutaneous venogram, Perforator flap, 253 Pericranial flap, 367, 590, 593, 792 Perineural invasion, 325 Periodontal ligament (PDL) cells, 545 Peri-orbita, 399 Periosteal elevator, 488 Periosteal retractor, 770, 772 Periosteal stripping, 393 Periotomes, 50 Peroneal artery, 268–269, 271–272 Peroneus longus, 271 Per oral, 350 PET, see Positron emission tomography PET-CT, see Positron emission tomography– computed tomography Pfeiffer cleft lip repair, 668 Pharynx, 809 Phrenic nerve, 416, 417 Physical therapy, 237 Picture archiving and communication systems (PACS), 5, 8, 297 Plain radiographs, 3–4 Pleomorphic adenomas, 20, 465 PMSO, see Posterior maxillary segmental osteotomy Pneumobalistic lithotripsy, 457 Polyacrylamide hydrogel, 823–824 Polymethylmethacrylate microspheres, 823 Polyvinyl alcohol (PVA), 509–510 Ponsky technique, 329 Positioning screws/lag screws, 533–535 Positron emission tomography (PET), Positron emission tomography– computed tomography (PET-CT), 8, 294 Posterior maxillary segmental osteotomy (PMSO), 738–741 Post-nasal packing, 185, 186 Post-traumatic rhinoplasty examination, 895–896 nasal airway obstruction, 900–901 septal deformity, 896, 899 septoplasty–turbinate surgery, 902 Pre-auricular incision, 626, 641, 801, 802 Pregnancy, 521 Pre-implant surgery, 118–19, 126 Premaxilla, 672, 718–719 adequate stability of, 705 fracture of, 676 osteotomy, 710–713 Pre-vertebral fascia, clearance down to, 416–417 PRF, see Palatal rotation flap Primary dentition, 546–547 Primary lacrimal sac lesions, 400 Primary tumour, 336 Proliferative verrucous leukoplakia, 26–27 Prophylactic antibiotics, 617 Prosthetic fit, 647 Prosthetic replacement, of temporomandibular joint ankylosis, 640, 643 Prosthodontic rehabilitation, 150 Proximal vascular pedicle, 272 Pterygoid implant, 157 Pterygoid plates, 347, 395 Pterygomaxillary osteotomy, 794 Pulsed dye laser, 496 Pulse width, laser, 291 Punch biopsy, 25 Punctate calcification, 21 Pupillary assessment, 520 Pushback procedure, 681 PVA, see Polyvinyl alcohol Q Quadrangular Le Fort II osteotomy, 757–758 Quadratic zygomatic implants, 143–146 R Radial artery, 227, 230–231 Radial forearm flap, 254 justification of, 227 operation, 229–233 pre-operative, 229 surgical anatomy, 227–229 Radiation protection, Radical maxillectomy, with orbital exenteration, 396 Radical neck dissection (RND), 413 variations, 418 Radiographic examination, 100 Radiotherapy neck dissection, 418–419 Ramus fractures, 554 of mandible, 35 resecting, 394 Index 925 RBH, see Retrobulbar haemorrhage Recipient artery selection, 224 Recipient site techniques alveolar bone splitting/ spreading, 112–113 bone regeneration, 113 maxillary sinus grafting, 111–112 onlay grafts, 110–111 preparation of, 285–287 transalveolar osteotome sinus lift, 113–115 Recipient vessel selection, 224–225 Recombinant human bone morphogenetic protein-2/acellular collagen sponge (rhBMP-2/ACS), 113 Reconstruction of skull base, 430 Reconstructive surgery cartilage grafts, 215–216 choice of suture material, 209–210 non-vascularized bone harvesting, 210–215 oral mucosal flaps, 210 skin, 203–204 skin grafting, see Skin grafting Rectus abdominis deep inferior epigastric muscle-sparing perforator flap, 245 harvest of, 244 indications/applications, 239–241 myocutaneous flap, 242–244 operative technique, 242 post-operative care, 244–245 relevant anatomy, 241–242 Rectus flaps, 241 Recurrent laryngeal nerve (RLN), 483 Regional flaps, 409 Regional reconstructive options, 407–409 Relative contraindications, of percutaneous endoscopic gastrostomy, 330 Relaxed skin tension lines (RSTLs), 361, 364 Restylane, 822 Resuscitation, 519 Retrobulbar haemorrhage (RBH), 294, 582, 584, 610 Retromandibular (trans-parotid) incision, 560, 561 Retromandibular vein, 19 rhBMP-2/ACS, see Recombinant human bone morphogenetic protein-2/acellular collagen sponge Rhinoplasty for Southeast Asian noses alar base, 892 augmentation rhinoplasty using conchal cartilage, 893–894 dorsum, 889–891 technique for open structural rhinoplasty, 892–893 tip, 891 Rhombic flaps, 364 Rib, 212 Rigid external distraction (RED) device, 774 Rigid fixation, 119, 620–621 Rim resection, 391–393 RLN, see Recurrent laryngeal nerve RND, see Radical neck dissection Root-end cavity, 86 Root-end resection, 85–86 Root fractures, 546 Roots, non-surgical removal of, 51 Root tips, retrieval of, 54–55 Rotational flaps, 365, 370, 374–375 Rotational forehead flap, 363–364 Routine blood investigations, 323 Rowe’s disimpaction forceps, 572 RSTLs, see Relaxed skin tension lines Russell technique, 329 S Sacks–Vine technique, 331 Saddle nose deformity, 896, 897 Sagittal split osteotomy, 802, 810 Sagittal synostosis, 778, 783–785 Salivary calculus, 19, 455 Salivary ductal obstruction, 459 Salivary duct strictures, 460–462 Salivary endoscope, 458 Salivary glands, 19–21 obstruction, 459 pathology, 14 tumour translocations, 29 Salivary lithotripter, 456 Salivary stone extraction, 460–461 Scalp, 540–541 reconstruction, 374–377 Scanning position, ultrasound imaging, 18 Scapula flaps donor site closure, 237 flap outline, 236 history of, 235 pedicle dissection, 236–237 surgical anatomy, 235–236 SCC, see Squamous cell carcinoma Schobinger incision, 415 Schweckendiek, 686–687 Sclerotherapy, 497 Secondary jaw reconstruction, of small continuity defects, 211 Second-stage surgery, in teeth implant, 104 Segmental resection, of mandible, 393–394 Segmental surgery of jaws anterior mandibular subapical osteotomy, 742–743 anterior maxillary segmental osteotomy, 735–737 Köle technique, 743 posterior maxillary segmental osteotomy, 738–740 pre-operative assessment, 735 Wassmund technique, 737 Seldinger technique, 182 Selective laser sintering (SLS), 172, 306, 307 Selective neck dissection (SND), 413, 414 Semi-rigid discopexy, 617, 620 Semi-rigid fixation, 532 Sentinel node biopsy, 337 background, 421 identification of, 424 lymphoscintigraphy, 422–423 marking of, 423 operation, 423–424 Septal cartilage graft harvesting, 729 Septal correction, 726 Septal deformity, 896, 898–899 Septal perforation, 899 Septocutaneous radial flap, 229, 230–231 Septoplasty, 658–659, 664–665 turbinate surgery, 902 Septum, 721 Sequelae prevention, of late infective, 588 Serology, 31 Seromas, 237, 281 Severe nasal haemorrhage, 185–186 Shallow nasal bridge, 731 Sharp dissection, 762 Short-time inversion recovery (STIR), Shoulder joint violation, 237 Shrapnel in arm, 156 Sialectasis, 20 Sialocoele, 480 Sialogram, 4, 441 Sialography, 466 Sialolithiasis, see Salivary calculus Sigmoid notch, 641–642 Signed consent form, 100 Silicone-induced granulomas, treatment of, 822 Silicone oil, 822 Single puncture technique, temporomandibular joint, 618 Single-rooted teeth, 50, 51 Sinogram/fistulogram, Sinus perforation, 114 Sistrunk procedure, 487–489 Sjogren’s syndrome, 20 Skeleton cysts, 13 Skeletonization, 729 Skin flap development of, 415, 626 elevation, 230 Skin grafting, 368 full thickness, 204–208 pedicled orofacial flaps, 194–195 split skin grafts, 208 technique, 208–209 Skin incision, 261, 270, 271 Skin paddle, 230, 242, 270–271 disadvantage of, 267 elevation, 236, 256 harvesting, 268, 273 Skin redraping, 727 Skull base tumours clinical presentation, 427–428 craniofacial resection with curative intent, 433 cranio-orbital resection with palliative intent, 433–436 key technical principles, 429–430 reconstruction, 240 sphenoid wing meningioma en plaque, 430–432 Skull fractures, 520 Sleek tape, 626 Sleep apnoea, 314–315 SLS, see Selective laser sintering Small curved anterior incision, 215 SND, see Selective neck dissection Snoring, see Obstructive sleep apnoea Soft-tissue augmentation, 818 SOHND, see Supra-omohyoid neck dissection Solid/crystal lasers, 290 South Wales cleft team technique, 666 inferior triangle incision, 662 medial element incision, 661 muscle dissection, 663–664 septoplasty, 664–665 skin closure, 665 Sphenoid wing meningioma en plaque, 430–432 Split skin grafts, 208 Split-thickness mucosal grafts, 120, 122 Split-thickness skin grafts (STSG), 194–195 Spontaneous granulation, 406 Spot size, laser, 291 Squamous cell carcinoma (SCC), 240, 338, 421 Static lymphoscintigraphy, 422 Stenson’s duct, 19 Stereolithographic model, 160, 163, see also Selective laser sintering Stereotactic radiosurgery, skull base tumours, 436 Sterile mucosa, 663 Sternocleidomastoid muscle (SCM), 416, 418 Steroid therapy, 495, 556 STIR, see Short-time inversion recovery STL, see Surface tessellation language Strap muscles, 488 STSG, see Split-thickness skin grafts Subciliary incision, 79, 578–579 Subcutaneous tissues, 227–228 Subfascial donor site, 230 Sublingual gland excision for malignant tumour, 448–449 for ranula, 447–448 Subluxation, dentition of, 544 Submandibular duct isolation of, 447–448 surgical removal of stones in, 442–445 Submandibular gland, 19 excision, 445–447 stone lithotripsy, 458 triangle, 417–418 Submental island flap, 384–385 Submental vessels, 385 Subperiosteal dissection, 344, 590, 762, 764 operative technique, 770 South Wales cleft team technique, for cleft lip repair, 664 Sub-platysmal flaps, 484–485 Subtotal orbital exenteration, 402 Subtotal/total glossectomy, 240–241 Sucker, 479 Suction drain, 230, 273 Superficial biopsies, 26 Superficial fascia, 484–485 Superficial lobe removal, 469–470 Superficial musculo-aponeurotic system flap (SMAS) flap, 471–472 Superficial parotidectomy closure, 471 identifying trunk of facial nerve, 469 indications, 468 removal of superficial lobe, 469–470 surgical anatomy, 468–469 926 Index total parotidectomy, 470–471 tumour spillage, 472 Superficial temporal facia incision, 591, 593 Superior joint space, 628 Superior/lateral orbitotomy, 357, 358 Superior orbital fissure syndrome, 575–576 Superior osteotomies, 790, 794 Superior pharyngeal constrictor muscle, 683 Supernumerary teeth, 66 Supplementary fixation, 213 Supraclavicular flap, 200 Suprafascial dissection, 230–231 Suprafascial donor site, 231 Supra-omohyoid neck dissection (SOHND), 413, 414, 418 Supraorbital neurovascular bundle, 344 Sural nerve graft, 80–81 Surface anatomy, see Nasal subunits Surface markings, 231 Surface tessellation language (STL), 293, 294–295, 306 Surgical biopsy assessment of fixed tissue samples, 29–30 limitations of, 30 oral cancer, 26–28 orofacial granulomatosis, 26 pathology request form, 29 punch, 25 vital staining, 28 Surgical cricothyroidotomy, 180–182 Surgical excision, 495 Surgical extraction, 45, 51–54 Surgical prosthetic procedure, 127 inlay corticocancellous block bone graft, 128–129 interpositional corticocancellous block bone graft, 129–130 Surgical tracheostomy, 182–184 Suspicious neck lumps, 321 Suture discopexy, 620, 622 Suture lines, 223 Suturing, 728 Symphyseal fractures, 554–556 Synovial adhesions, 615 Synthetic fillers, 821–822 T TCA, see Transverse cervical artery Template for surgery, 100 Temple defect operations bilobed flap, 365 rhombic flaps, 364 Temporalis fascia, 341, 343 closure, 593–594 and muscle flaps, 409 temporomandibular joint, 627, 628 Temporalis muscle, 341–342, 344, 355–356 Temporalis myofascial flap (TMF), 192–193 Temporomandibular joint (TMJ), 342, 343 ankylosis, see Ankylosis, temporomandibular joint arthrogram, arthroscopic arthrocentesis, 618 articular disc, 629–631 articular eminence, 631–633 closure, 636 complications, 623–624, 636, 651–653 condyle, 633–634 discopexy, 620–622 gap arthroplasty, 634–635 indications, 616, 649 indications for, 625 lysis and lavage, 619–621 operation, 626–629 overview of, 647–648 pathology, 15, 615–616 peri-operative considerations, 616–617 pre-operative preparation, 625–626 prosthetic choice, 649 replacement, 35–36 surgical technique, 650–651 Temporoparietal fascia, 341, 342, 344 Tennison cleft lip repair, 668–669 Tensile strength, soft tissue, 537 Tensor veli palatini, 682 Tetanus immune globulin (TIG), 522 Tetanus prophylaxis, 556 Third molars coronectomy, 71–72 mandibular third molars, 66–69 maxillary third molars, 72–73 unerupted mandibular third molars, 69–71 Thoraco-acromial process, 198 Thoracodorsal artery, 248 transverse/vertical limbs of, 249 Three-dimensional (3D) stereolithic modelling, 33–35 body of mandible, 36 distraction osteogenesis, 39–40 hardware issues, 36–37 mandible, see Mandible mandibular reconstruction, 35–36 maxilla, 37–39 Thrombocytopenia, 495 Thromboembolism, 508 Thrombosis, 265 Thyroglossal duct cyst, 22, 487 Thyroidectomy gland dissection, 484–487 post-operative management, 487 pre-operative considerations, 483 relevant anatomy, 483–484 setup, 484 sistrunk procedure, 487–489 thyroglossal duct cyst, 487 Thyroid gland, 483 Thyroid lobectomy, 483 Thyroid nodules, 21 Thyroid ultrasound, 20 Tibia, 214 Tibialis anterior muscle, 268 Tibialis posterior muscle, 268, 271–272 TIG, see Tetanus immune globulin Tissue engineering, 165 hard tissue reconstruction, 170–174 muco-cutaneous grafts, for lip reconstruction, 170 soft-tissue reconstruction, 165–170 Titanium mesh, 581, 582 TMF, see Temporalis myofascial flap TMJ, see Temporomandibular joint Tomograms, 108, 109 Tongue flap, 190–191 Tooth extraction complications, 56 dental elevators, 48–49 extraction forceps, 47 forceps technique, 47–48 in fracture site, 556 luxators, 49–50 non-surgical removal of roots, 51 periotomes, 50 post-extraction care, 55–56 pre-operative evaluation and preparation for, 45–46 retrieval of retained root tips, 54–55 transalveolar, surgical extraction, 51–54 TORS, see Transoral robotic surgery Total condylectomy, 634 Total nasal defects, 374 Total orbital exenteration, 402–404 Total parotidectomy, 470–471 TPA, see Trans-palatal arch Tracheostomy, 182 TRAM flap, see Transverse rectus abdominis myocutaneous flap Transalveolar extraction, 51–54 approach, 535–536 osteotome sinus lift, 113–115 Transfacial approaches, 344 Transmandibular approaches angle osteotomy and double mandibular osteotomy, 354–355 extended mandibular swing, 353–354 mandibular swing, 351 surgical technique, 351–353 Transoral approach, 532 Transoral robotic surgery (TORS), 313, 384 oropharynx, 313–314 sleep apnoea, 314–315 unknown primary, 314 Trans-palatal arch (TPA), 705 Transverse cervical artery (TCA), 224 Transverse rectus abdominis myocutaneous (TRAM) flap, 240, 242–243 Transverse upper gracilis (TUG), 261 Transzygomatic approaches lateral and superior orbitotomy, 357 surgical technique, 357–358 zygomatic osteotomy, 356–357 Traumatized children, 521 Trendellenberg position, 626 Tuberosity, 126 Tumours, 13, 20 excision, 384, 450 floor of mouth, 382–383 grade, 338 palate, 383–384 tongue, 384 Tumour spillage, 472 Twisted nose, 899–900 U ULC, see Upper lateral cartilage Ulceration, 495 Ultrasound imaging, 442, 460, 466 biopsy, 22 lumps and bumps, 21–22 lymph nodes, 18–19 principles of, 17–18 salivary glands, 19–20 thyroid, 20–21 Uncontrolled maxillofacial haemorrhage, 184–186 Unerupted teeth, surgical removal of coronectomy, 71–72 mandibular canine, 64 mandibular molar, 65–66, 68 mandibular premolar, 64–65 mandibular third molars, 66–69 maxillary canine, 60–62 maxillary incisor, 60 maxillary molar, 63–64 maxillary premolar, 62–63 post-extraction management, 73 pre-operative evaluation, 59–60 supernumerary teeth, 66 Unilateral cleft rhinoplasty, 728 Unilateral condylar fracture, 561–562 Unilateral coronal synostosis, 778, 780–781 Upper lateral cartilage (ULC), 895, 896, 898, 900 V Valsalva manoeuvre, 418 Vascular anomalies classification of, 493 clinical characteristics of, 494 Vascular invasion, 325 Vascularized block bone grafts, 134–135 Vascular malformations, 495–496 Vascular pedicles, 243, 268, 271, 272 dissection of, 262–264 identification of, 262 Velopharyngeal dysfunction (VPD), 682 Velopharyngeal insufficiency (VPI), 682 Veno-lymphatic malformations, 511–515 Venous anastomoses, 222 Venous malformation (VM), 497 ‘Venting PEG’, 329 Vermilion, 380, 381 Vermilionectomy, 380 Vertebro-vertebral fistula, 510 Vertical alveolar, 395 Vertical bone cuts, 742 Vertical incision, 739 full-thickness, 350–351 midline, 342 Vertical osteotomy, 810 Vesiculobullous/ulcerative lesions, 26 Vessel clamps, 221 Index 927 Vessel dilators, 221 Vestibular incision, 102, 770 Vestibular mucosa excision, 731 Vestibuloplasty, 167, 169 ‘V’ excision, 379, 380 Vincristine, 494 Virtual planning, 34–35, 39–40 Visor flap, 351, 352 Visual/auditory impairment, 778 Vital staining, 28 VM, see Venous malformation Volume-rendered lateral projection, V-Y advancement flap, 362–363 W Warthin’s tumour, 20 Wassmund technique, 735, 737 Waterproof tape, see Sleek tape Wavelength, laser, 289 Weber–Fergusson incision, 149, 150, 346–348 Webster–Bernard flap, 539 Wharton’s duct, 383 Whistling deformity, 679 Wilkes’ staging, of temporomandibular joint, 616 ‘W’ incision, 380 Witnessed nerve injury, 75 Wolfe graft, 204–206 Wound closure, 78, 80, 265 Wunderer technique, 736–737 X Xenografts, 105 Z Zygoma oncology reconstructive protocol, see Oncology reconstructive protocol Zygomatic arch/bone, 299 Zygomatic fractures applied anatomy, 603–604 external fixation, 608 reduction and repair, 605–608 retrobulbar haemorrhage/ orbital compartment syndrome, 610 Zygomatic implants, 139–142, 146 and gunshot reconstruction, 153–157 nasal and naso-maxillary reconstruction, 152–153 oncology reconstructive protocol, see Oncology reconstructive protocol quadratic, 142–146 Zygomaticomaxillary buttress, 110 Zygomatico-orbital complex fractures, 300 Zygomatic osteotomy, 356–357 Zygomaticus muscle exposure, 286 ... the hilum of the submandibular gland Int J Oral Maxillifac Surg 20 05; 34: 20 8 21 0 Seward GR Anatomic surgery for salivary gland calculi Oral Surg Oral Med Oral Pathol 1968; 25 : 670–678 Shaheen... Lundquist P Salivary calculi and chronic sialoadenitis of the submandibular gland: A radiographic and histologic study Oral Surg Oral Med Oral Pathol 1984; 58: 622 – 627 Kelly IMG and Dick R Technical... cases Cured (%) Partial success (%) Failure (%) Kater 1994 104 38.4 18.3 43.3 Katz 1998 20 0 63.0 34.0 3.0 Escudier 20 03 122 33.0 35.0 32. 0 Zenk 20 04 197 29 .0 71.0 0.0 Capaccio 20 04 Electromagnetic,