UNIT IV - Aesthetic Plastic Surgery€¦ · Q.13 A 56 year old female presents with a biopsy proven...
Transcript of UNIT IV - Aesthetic Plastic Surgery€¦ · Q.13 A 56 year old female presents with a biopsy proven...
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UNIT IV HEAD & NECK
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29. SOFT TISSUE & SKELETAL INJURIES OF THE FACE.
Oct, 2012PI
Q10. A professional tennis player was hit by a tennis ball while playing a league match with bruising and swelling
over right orbital region. On examination of his eye, a subconjunctival hematoma with no posterior limit is noted.
a) What is your likely diagnosis?
b) How would you manage this injury?
MAR, 2011PI
Q.9 A 29 years old man presents to you with history of facial injuries which he sustained in a road traffic accident 2
weeks ago. He has complaints of diplopia, broad bridge of nose and depressed right cheek.
a) How will you evaluate this patient?
b) How would you manage the complaint of diplopia which was caused by blowout fracture of right side?
c) How would you manage the nasal deformity?
SEPT 2009
Q.2: A 30 year old man is involved in a motor bike accident and sustained a displaced fracture of the left zygoma
and depressed frontal bone and frontal sinus fracture. Movements of the left eye are restricted and the eye looks
smaller.
a) What consultation would you seek?
b) What is the best imaging method?
c) When the frontal bone fracture is being treated surgically by the neurosurgeon, what is the best way of treating
the frontal sinus fracture?
d) If not treated, what complications would arise from the frontal sinus fracture?
FEB 2007
Q.7:
a) How do you classify maxillary fractures according to the pattern of the fractures?
b) Give the emergency management.
c) Principles of definitive management.
MAR 2005, PII
Q.12 you are called to the emergency department to see a 21 years old man who has suffered facial injuries in a
road traffic accident. The casualty medical officer thinks he may have a zygomatic fracture.
a) List the clinical signs that would support such a diagnosis.
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b) What investigations would help in establishing the diagnosis and planning treatment?
c) Outline briefly the management plan.
SEP 2003PII
Q.14: A young man presents after a road traffic accident in the emergency room apparently bleeding from the
nose and the mouth and is getting suffocated.
a. How will you maintain the airway?
b. What are the different methods of arresting such bleeding?
MARCH 1998
Q.7: A young girl is involved in a head on collision in a car accident. She has suffered multiple injuries, including
lacerations, foreign body embedded in tissues, skin loss and fractures.
a) Discuss the injuries you would expect to see.
b) The management of this case.
c) Prevention of these drastic injuries.
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30. HEAD & NECK CANCER.
JULY 2017
Q2) A 40 year old lady has presented with a 2cm SCC of cheek mucosa. There is no neck involvement. Clinically you
don’t have facility for microvascular surgery.
a) What are the principles of excision?
b) Which pedicled flaps are of your choice, with justification, their importance and operative steps of flap
elevation.
JULY 2017
Q15) A 52 year old man presented with recurrent low grade fibrosarcoma of the right maxilla involving the anterior
wall and overlying skin. His right orbit is not involved, but the infratemporal fossa is reported to have the lesion on
CT scan.
a) What type of defect will be created after excision of this lesion?
b) Give 2 reconstructive options in this case for maxillary reconstruction.
c) How do you classify maxillary defects?
OCT 2013
Q13) A 55 year old man presents with a non-healing ulcer on the right cheek for 2 years. On examination there is a
6x4cm ulcer with induration on inner cheek mucosa and adherent to the retromolar area.
a) How would you evaluate this patient before undertaking excision and reconstruction? Enlist the investigations in
an order that you would like to perform.
b) With the description given of the lesion, what would be the likely defect after excision?
c) What are the reconstructive options, taking into consideration for the components essential for the
reconstruction?
Oct, 2012
Q.9 you are planning to operate on a 56 year old lady with an integral SCC that entails excision of the primary,
cervical lymph node dissection and microsurgical reconstruction of the intra oral defect.
a) Enumerate the major complications due to prolonged surgery that you should anticipate.
b) What steps would you take to prevent three of the major complications?
c) How does body temperature affect the microsurgical reconstruction?
MAR 2013
Q.13 A 56 year old female presents with a biopsy proven sebaceous carcinoma arising from the lateral canthal
region of the right eye and involving the whole lower eye lid.
a) What factors will you consider while planning the treatment?
b) If surgery is chosen, give your plan for complete management if this lesion
JUNE 2008
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Q.9 A 52 years old head mistress presents to you with a parotid swelling and facial nerve weakness of recent onset.
History reveals that she had a pleomorphic adenoma removed from the same site 20 years ago.
a) What is the likely cause of her problem and how will you assess her?
b) Give your treatment plan keeping in view her social obligations.
Q15) A 52 year old man presented with recurrent low grade fibrosarcoma of the right maxilla involving the anterior
wall and overlying skin. His right orbit is not involved, but the infratemporal fossa is reported to have the lesion on
CT scan.
a) What type of defect will be created after excision of this lesion?
b) Give 2 reconstructive options in this case for maxillary reconstruction.
c) How do you classify maxillary defects?
OCT 2013
Q13) A 55 year old man presents with a non-healing ulcer on the right cheek for 2 years. On examination there is a
6x4cm ulcer with induration on inner cheek mucosa and adherent to the retromolar area.
a) How would you evaluate this patient before undertaking excision and reconstruction? Enlist the investigations in
an order that you would like to perform.
b) With the description given of the lesion, what would be the likely defect after excision?
c) What are the reconstructive options, taking into consideration for the components essential for the
reconstruction?
Oct, 2012
Q.9 you are planning to operate on a 56 year old lady with an integral SCC that entails excision of the primary,
cervical lymph node dissection and microsurgical reconstruction of the intra oral defect.
a) Enumerate the major complications due to prolonged surgery that you should anticipate.
b) What steps would you take to prevent three of the major complications?
c) How does body temperature affect the microsurgical reconstruction?
MAR 2013
Q.13 A 56 year old female presents with a biopsy proven sebaceous carcinoma arising from the lateral canthal
region of the right eye and involving the whole lower eye lid.
a) What factors will you consider while planning the treatment?
b) If surgery is chosen, give your plan for complete management if this lesion
JUNE 2008
Q.9 A 52 years old head mistress presents to you with a parotid swelling and facial nerve weakness of recent onset.
History reveals that she had a pleomorphic adenoma removed from the same site 20 years ago.
a) What is the likely cause of her problem and how will you assess her?
b) Give your treatment plan keeping in view her social obligations.
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SEP 2000, PI
Q.5 A MIDDLE AGED WOMAN PRESENTS WITH AN INDOLENT ULCER 1.5 CM IN DIAMETER INVOLVING LEFT ANGLE
OF THE MOUTH AND BUCCAL MUCOSA. SHE IS A KNOWN PAN EATER FOR LAST 30 YEARS.
a) WHAT IS YOUR MOST LIKELY DIAGNOSIS?
b) DISCUSS ITS MANAGEMENT
MARCH 2000
Q.5: A 55 year old man presents with a hard palpable lymph node in the left cervical region of 2 months duration.
a) How will you assess this case?
b) How will you treat this case?
SEP 2003, PI
Q.6 List the important and specific complications of radical neck dissection?
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Orbital floor fracture: (Blowout fracture)
o Orbital floor can be divided into three main categories
Orbital floor
Medial wall and
Zygomatic
o Anatomy:
o Classification:
Orbital wall fracture:
Blow out fracture
Pure blow out fracture
Impure blow out fracture
Blow in fracture
Isolated orbital wall fracrture:
Roof
Floor
Medial wall
Lateral wall
o Floor (antral) Blow out #: can be further sub-classified
Type I: limited elevation of effected eye due to
mechanical limitation
Type II: limited depression due to IR palsy or flap
tear
Type III: limited elevation and depression due to mechanical restriction and/ or IR palsy
or flap tear
o White eye or trapdoor fracture:
Patient has a blowout with entrapment, but without many signs, such as swelling,
ecchymosis or hemorrhage the eye is “white and quiet” even in the presence of a
fracture
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Mostly occurs in children or young adults when bones are more flexible and they “snap
back” and cause entrapment of tissue or muscle.
o Management:
History: (standard history)
Mechanism of facial trauma
Size of object (mechanism/velocity)
Physical exam:
ATLS protocol
Full evaluation of globe + surrounding structure
Standard eye examination (vision, 6 cardinal gazes)
Neurosurgical consultation (CSF leakage,
pneumocephalus)/ ophthalmologist
Orbital floor:
Periorbital edema and ecchymosis
Palpable bony “step-off” fracture
Infraorbital nerve injury hyperesthesia, dyesthesia or hyperalgesia
Herteel ophthalmometry may demonstrate either proptosis or enophthalmos
Limited vertical movement entrapment of inferior rectus muscle (also check for
Oculocardiac (reflex also known as Aschner phenomenon, Aschner reflex, or Aschner-Dagnini reflex,
is a decrease in pulse rate associated with traction applied to extraocular muscles and/or compression
of the eyeball)
Media wall:
Remains undetected
Periorbital edema and ecchymosis
Subconjunctival hemorrhage
Subcutaneous emphysema (ethmoid air cells damage)
Pseudo-Daune’s retraction syndrome (On attempted
abduction a narrowing of the palpebral fissure and retraction of the
globe was observed) Zygomatic:
Significant malar depression with step defect at infraorbital rim, frontozygomatic
suture, and zygomatic buttress of maxilla intraorally
Zygomatic # evoke pain on palpation in 70% of patients
Paresthesia in distribution of infraorbital, zygomatic or zygomaticotemporal nerves
can be seen
Mandible movement disruption
Imaging: CT scan (thin 2-3mm cuts) is the imaging study of choice
Treatment:
Medial wall:
o Avoid blowing nose for several weeks
o Nasal decongestive spray
o Prophylactic antibiotic
o Steroids
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Surgical:
o Currently, three general guidelines are commonly agreed on for surgical
intervention
o Diplopia
o Enophthalmosgreater than 2mm after 2 weeks of trauma
o A fracture involving one half or more of orbital floor; especially when
associated with media wall defect usually leads to functional/cosmetic
deformity.
Approach:
o Conjunctival approach
o Cutaneous exposure
o Through a transantral approach
o Endoscopic approach via transmaxillary and transnasal
Complication:
o Failure to diagnose in time result in
Fibrosis
Contractures and
Unsatisfactory union
o Loss of vision
o Traumatic optic neuropathy
o Diplopia
o Overcorrection or under correction of
enophthalmos
o Lower eyelid retraction
o Bleeding
o Infection
o Extrusion of orbital implant
o Infraorbital nerve damage
Principle of definitive management of facial fractures: in summary
o Treatment of facial fractures requires a multisystem
approach
o All bony and soft tissue injuries should be diagnosed and
o Reconstruction of all tissue layers should be performed- if possible
o Rigid fixation of most facial fractures
o More precise stability and fixation of fractures
o Well planned incisions minimize scarring
o Adequate exposure, precise reduction and stable fixation remains the hallmark treatment of
facial fractures
o But the main principles in middle face trauma are:
An accurate and complete injury evaluation
MDT approach with ENT surgeon, maxillofacial surgeon, neurosurgeon and
ophthalmology surgeon; the result has to be “as well as we get”
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Maxillary Fractures: (Le Fort Fracture)extend through the pterygoid plate
Type of Fracture Features Approach/Incision
Le fort I injury Le Fort II injury Le Fort III injury
Classically passes through the maxilla transversely, somewhere between the tooth roots and the infraorbital rims, with preservation of integrity of infraorbital rims. Extends through the infraorbital rim and nose and is sometime, reffered to as a pyramidal fracture. Involves the zygomatic arch, lateral orbital wall and nasofrontal region
Upper gingivobuccal sulcus incison Lower lid incision (commonly used) Moderate impact injuries combination of sulcus and lower lid incision Severe injuries coronal approach for exposure of nasofrontal and medial orbital region and zygomatic arch
Emergency management:
o After standard ATLS protocol
o Following immobilization of all these fractures
o The patient should be placed in maxillomandibular fixation, the zygmaticomaxillary and
nasomaxillary buttresses stabilized with plates
o The goals of treatment should be restoration of
function and appearance.
Facial subunits:
1. Forehead:
1a-central
1b-lateral
1c-brow
2. Nose:
2a-Dorsum
2b-lateral wall
2c-ala
2d-tip
2e-columella
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3. Eyelid:
3a-upper
3b-lower
3c-medial canthus
3d-lateral canthus
4. Cheek:
4a-infraorbital
4b-zygomatic
4c-buccal
4d-parotid-masseter
5. Upper lip:
5a-philturm
5b-lateral
5c-vermillion
6. Lower lip:
6a-central
6b-vermillion
7. Chin
8. Ear:
8a- Helix
8b- antihelix
8c- triangular fossa
8d- cavum/concha
8e-ear lobule
9. Neck
Principle of tumor (malignant) excision:
o Surgical resection is the most common method of treatment for skin cancer of the head & neck.
o The physician should keep four goals in mind:
1. Total removal or destruction of cancerous tissue
2. Maximal preservation of normal tissue
3. Preservation of function
4. Optimal cosmesis.
o The most important principle of treatment is complete tumor excision because if this goal is not
achieved, the other goals cannot be achieved.
o Adequate margins of resection are necessary to achieve clear margins
o For majority of BCC and SCC cases 4mm margins are sufficient (if less than 2cm tumor size)
o However, if tumor is 2 cm or greater or in high risk area, is invading fat or is not well demarcated
or recurrent tumor than 6-10mm margin of excision is required.
o Other treatment modality: (mostly destructive)
1. Radiotherapy
2. Topical 5-fluorouracil
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3. Lasers
4. Photodynamic therapy
5. Interferon
6. Retinoids
7. Curettage and electrodissection
8. Cryosurgery
Neck lymph node level:
Neck dissection classification:
1. Academy classification (1991):
a. Radical neck dissection (RND)
b. Modified RND
c. Selective neck dissection
i. Supra-omohyoid type
ii. Lateral type
iii. Posterolateral type
iv. Anterior compartment type
d. Extended radical neck dissection
2. Medina classification (1989):
a. Comprehensive neck dissection (RND and Mod. RND)
b. Type I (XI preserved)-most important thing (Nerve)
c. Type II (XI, IJV preserved)- 2nd most imp things is vein
d. Type III XI, IJV and Sternocleiodmastoid muscle)- all three things preserved
e. Selective ND
i. Indication:
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1. Cancer arising in head and neck region, who are consider at risk of mets
2. Who have no evidence of clinical mets
3. Spiro’s classification:
a. Radical (4-5 nodes levels involved)
i. Conventional RND
ii. Modified RND
iii. Extended RND
iv. M & ERND
b. Selective (3-nodes level resected)
i. Supra-omohyoid ND
ii. Jugular dissection (level II-IV)
iii. Any other 3 nodes levels resected
c. Limited (no more than 2 nodes level resected)
i. Paratracheal node dissection
ii. Mediastinal node dissection
iii. Any other 1 or 2 nodes levels
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Types of neck incision
Adnexal tumor:
o Adnexal skin tumors are rare neoplasms that develop from hair follicles, sebaceous glands and
sweat glands. In the majority of cases these tumors are benign, although metastases have been
reported in rare occasion.
Hyperplastic and Hamartomatous lesions
Benign neoplasms
Malignant neoplasms
Hair and hair follicle
Basaloid follicular hamartoma
Basaloid epidermal proliferation
Overlying dermal mesenchymal lesions
Hair and hair follicle
Trichofolliculoma
Desmoplastic trichoepithelioma
Trichoblastoma
Trichoblastic fibroma
Trichoadenoma
Hair and hair follicle
Trichilemmal carcinoma
Trichoblastic carcinoma
Malignant proliferating trichilemmal cyst
Pilomatrix carcinoma
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Trichofolliculoma
Sebaceous trichofolliculoma
Folliculosebaceous cystic hamartoma
Trichodiscoma/ fibrofolliculoma
Pilar sheath acanthoma Sebaceous glands
Sebaceous hyperplasia
Nevus sebaceous of Jadassohn
Proliferating trichilemmal cyst/pilar tumour
Trichilemmoma
Desmoplastic trichilemmoma
Pilomatricoma/proliferative pilomatricoma
Sebaceous glands
Sebaceous adenoma
Sebaceoma/sebaceous epithelioma
Sebaceous glands
Sebaceous carcinoma
Basal cell carcinoma with sebaceous differentiation
General features comparing Basal Cell carcinoma with Trichoblastoma:
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35. RECONSTRUCTION OF THE CHEEKS.
JAN 2008, PII
Q.11 A 45 years old female underwent a free Bi-paddled radial forearm Flap for a composite cheek defect after
resection for cancer After 12 hours the flap is a little blue with brisk capillary refill.
a) What is the likely cause of this problem and what measures will you take to salvage the flap?
In case the flap fails, give 3 reconstructive options, giving your reasons for selecting one of them
MAR 25, 2009 PI
Q.2 A new born female is discovered abandoned in a dustbin with an animal bite to her face resulting in a full
thickness loss of most of the left cheek unit and entire lower lip.
a) How would you manage this patient initially in the first few days?
b) When and how would you reconstruct the above mentioned defect?
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Cheek reconstruction: (acquired defects)
Reconstructive options for cheek defects:
1. Healing by secondary intention (useful for less than 1cm)
2. Primary closure
3. Skin graft (good result if less than 5mm, when greater than
5mmpermanent contour deformity)
4. Local flaps:
a. Advancement flap (V-Y)
b. Transposition flap (banner, bi-lobed, rhomboid)
c. Rotation flap (cervico-facial, cervico-pectoral)
5. Local composite flaps:
a. Pectoralis major flap
b. Trapezius flap
6. Tissue expansion
7. Microvascular reconstruction:
a. Radial forearm flap
b. Parascapular flap
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c. Rectus abdominus flap
d. Anterolateral thigh flap
e. Fibulo-osteocutaneous flap
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33. NASAL RECONSTRUCTION
April 23, 2014-P11
Q.18: A 75 year old gentleman with a round BCC of 2 cm diameter of right ala of his nose involving the alar
cartilage comes to you for surgery.
a) What Local flaps are available to you for reconstruction after excision of BCC?
b) Give surgical details of two of these procedures?
c) What are common donor sites for cartilage graft in this case?
MAR 2009; FEB 2007
Q.18; Q.3: A 22 year old actress is attacked by a deranged man with a knife and she sustains total nasal
amputation.
a) What are the principles of total nasal reconstruction?
b) Give three options for nasal reconstruction which would be suitable in this patient.
c) Give advantages and disadvantages of each method
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Nasal Reconstruction:
o The nasal base plateform: Gillies/ Millard Fat Flip Flap
o Nasal Lining:
a. The composite skin graft: (defect less than 1.5cm)
b. Local hingeover lining flap:
c. Prelaminated skin graft and cartilage for lining under forehead
d. Intranasal lining flap:
i. Small unilateral defect: residual vesctibular skin
ii. Larger unilateral defect: ipsilateral septal
iii. Ant. Based septal composite mucoperichondrial flap
e. Skin graft for lining: (prelimaneted with forehead flap)
f. Folded forehead flap for lining
g. Microvascular lining: i.e. radial forearm
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o Nasal support:
a. If underlying normal bone and cartilage remain intact support replacement may be
unnecessary
b. Alar defect septal, ear, rib cartilage graft
c. In extensive midline defect septum may be absent several methods are useful
i. Septal composite flappivoted anteriorly, lining and central support are
positioned simultaneously out of piriform aperture
ii. This creates basic platform on which to rest other grafts a dorsal graft,
columellar strut, alar batters and sidewall grafts
iii. The dorsum can also be supported with cantilever dorsal graft of rib or cranial
bone fixed with a wire, screw or plate to nasal bones.
o Nasal cover:
a. Small superficial defect: less than 0.5 cm
primary closure
b. Defect less than 1.5 cm composite chondrocutaneous graft
c. Upto 1.5cm geometric bi-lobed flap, dorsal roataion advancement, single stage
superiorly based nasolabial flap
d. Large deep defect: two stage nasolabial, forehead flap (2/3 stages), distant flap (arm
flap, abdominal tube, DP or cervical) and free flap (RFFF)
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37. RECONSTRUCTION OF THE MANDIBLE.
38. CRANIOFACIAL PROSTHETICS.
39. RECONSTRUCTION OF THE MAXILLA & SKULL BASE.
40. RECONSTRUCTION OF THE ORAL CAVITY, PHARYNX & ESOPHAGUS.
SEP2003PI
Q.4 Classify the lingual flap and describes briefly their likely uses?
MAR28, 2013PI
Q.5 A 23 year old female underwent right hemi-mandibulectomy and a neck dissection for a primary sarcoma of
the mandible 2 years ago. She had a post-operative radiation but no reconstruction was done. She now wants a
correction of her deformity.
a) What problems do you anticipate in the procedure and how can you avoid them?
b) Give 2 options for reconstruction and give reasons why you would choose a particular one for her?
MAR 25,2009PI
Q.8 A 23 Years old lady had a central mandibular defect measuring 11cm after firearm injury 6 months back. Her
soft tissue defect was repaired with a pedicle flap.
a) How will you prepare this patient for mandibular reconstruction?
b) How will you reconstruct this bony defect?
c) How will you check the viability of your transferred bone prior to any secondary procedure?
JAN 2008, PII
Q.13
a) How will you classify Maxillary defects?
b) A 50 years old man after resection of a Maxillary tumor came with a defect of right orbit maxillary area with
resection if right orbital contents and upper five walls of maxilla, sparing palate.
c) What are reconstructive options in this case? Which one will you choose and why?
JAN 2008, PI
Q.3 A 28 years old Pan-Masala user presents with a 4X6 cm ulcer over the left lateral order of the tongue. Biopsy
snows it to be a poorly differentiated squamous· cell carcinoma. He also has a 2X2 cm firm swelling in the left
submandibular region.
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a) How will you evaluate this patient?
b) Give your treatment plan keeping in view his age and histology of the tumor.
c) What would be your choice of reconstruction? Give reasons.
AUG 2007, PII
Q.15 Following a laryngectomy a patient starts having frequent coughing, foul smelling discharge from the wound
and wound dehiscence. There is also tachycardia & toxicity.
a) What is the likely diagnosis that has occurred? Give reasons
b) How will you evaluate the patient? Treatment plan.
March 20, 2012 PII
Q.15. Your ENT colleague is planning to a laryngopharyngectomy of squamous cell carcinoma in a 40 year old
obese female.
a) What factors will you consider while selecting a particular reconstructive procedure?
b) Give the advantages and disadvantages of three common forms of microsurgical reconstruction.
March 20, 2012 PI
Q.10: A 75 year old patient with well controlled diabetes was brought to you with extensive ulcerating lesion in sub
total destruction of her nose, upper lip, maxillary alveolus, left eye and cheek over a period of 7 years.
a) What is the most likely diagnosis?
b) How would you investigate this case?
c) How would you reconstruct the defect after resection?
MAR 17, 2010
Q.14 A young man received a shrapnel injury to the upper face during a terrorist bomb blast 2 hours ago The nose
upper lip, central upper alveolus and part of the hard palate are missing and the patient is bleeding profusely
a) What is the early management of this patient?
b) Outline the long term treatment plan.
c) Give in detail your plan for reconstructing his nose.
SEP 2005, PII
Q.20 A sixteen years old female presents with a suicidal shotgun wound of the lower face 3 hours after the
occurrence. This has resulted in loss of part of mandible, floor of mouth, and chin.
a) Outline initial assessment and treatment
b) Very briefly give one option for reconstruction and your reasons for choosing it.
AUG 2006, PII
Q.12. A 50 year old man had excision of major part of floor of mouth, partial mandibulectomy and radical neck
dissection. Enumerate the methods of reconstruction with pros and cons.
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Classification system for maxillary and Midfacial defects:
o Maxilla Anatomy:
It’s a pyramidal in shape having a base, an apex and four walls
Base: lateral wall of nasal cavity
Apex: directed laterally towards zygomatic process of maxilla
Anterior wall: facial surface of maxilla
Posterior wall: infratemporal surface of maxilla
Roof: floor of orbit
Floor: alveolar process of maxilla
o Cordeiro and Santamaira Classification
Type Features Reconstruction
Type I Limited Maxillary
Defects involve resection of one or two walls of the maxilla, excluding the palate
Scapular Parascapular ALT Rareedial forearm flap
Type II Subtotal maxillary IIa IIb
Defects include resection of the maxillary arch, palate and anterior and lateral wall with preservation of orbital floor Resection of less than 50% palate Resection of greater than 50% palate
Either a free flap or a combination of skin graft an obturator RFF If not free flap candidates that temporalis muscle flap Osteocutaneous radial free flap “sandwich”
Type III Total maxillary IIIa IIIb
Defects in middle resection of all six walls of maxilla Total maxillectomy with orbital preservation Total maxillectomy with orbital exentration
The rectus abd. Flap (single skin paddle) The temporalis muscle flap The fibula flap Rectus abd flap (3 skin paddle)
Type IV Orbitomaxillary
Defects include resection of orbital contents and the upper five walls of maxillar, sparing the palate
Rectus abd.flap in ideal (single islanded)
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Goals of maxillary reconstruction:
o Obliteration of the defect
o Restoration of essential
function of mid face
o Provision of adequate
structural support
o Aesthetic reconstruction of
external features
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Mandibular defect:
o Mandible is U-shaped bone o TMJ is a di-arthrodial joint o Types of defects: (Jewer Classification)
“C”-central defect including both
canines “L”-lateral segment, that exclude
condyle and don’t cross midline “H”- or hemi-mandibular- condyle is
resected together with lateral
mandible Eight permutations of these capital
letters including C, L, H, LC, HC, LCL, HCL and HH- are
most encountered for mandibular
defects o Mandibular defects may be congenital, acquired
(pathological or traumatic)
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A new classification for mandibular defects after
oncological resection
HCL (Boyd and colleagues classficiation):
o H-lateral defects of any length upto midline
including condyle
o C-defects involve central segment containing 4
incisors and 2 canines
o L-lateral defects excluding the condyle 3 lower
case letters describe soft tissue component
o- no skin or mucosa
s- skin
m- mucosa
sm-skin and mucosa and also some added
t-tongue
o Lateral defects can be reconstructed with a
straight segment of bone
o Central defect require osteotomies
o Anterior mandibular (C) defects require
absolute indication for reconstruction using vascularized bone
o Some center will reconstruct lateral (L) defects with vascularized bone, whereas other would
prefer to use soft tissues flaps with or without plates for reconstruction.
o Non-vascularized bone grafts (NVBGs) i.e. iliac crest, is another option for reconstruction of
small pure lateral mandibular defects.
Goals of mandible reconstruction:
o Restore form and function
o Restore bony contour of native mandible
o Restoration of mastication
Deglutition
Articulation
Maintenance of the airway
Condyle reoconstruction:
o Preserve condyle during resection
o Use as a non-vascularized bone graft
o Other options are:
Placing the flap into the fossa, interposing periosteum or temporalis muscle fascia.The
aim in this is to achieve a painless gap arthroplasty at the TMJ
Costochonral rib and Pure soft tissue reconstructio
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Commonly used free flaps for mandible reconstruction:
Free flap donor site Advantages Disadvantages
Fibula flap (gold standard) Based on peroneal a. Vascularized bone graft SizeTotal
native fibula length -12cm
Provide long segment of bone Multiple osteotomies without disrupting blood supply Ability to use a two team approach Good aesthetic and functional outcome
Limited height (double barrel fashion) Pain on ambulation Ankle instability Difficulty to closure donor site primarily (i.e. skin graft)
Iliac crest (2nd choice) Osteo-cutaneous flap Based on
DCIA Graft
length 6-16cm
Good bone height Donor site hidden under clothing Osteotomy can be done Ability to use a two team approach Primary closure of donor site
Poor color match of groin tissue Shaping the bone is difficult Bulky muscle, difficult to inset Risk of post op hernia Donor site pain limits gait and prevent early mobilization
Scapular free osteo-cutaneous flap Based on CSA Graft length ~14cm
Concealed donor site Large quantity of skin and soft tissues Support osseo-integrated implant
Lack segmental blood supply, doesn’t tolerate osteotomies Quality of bone is inferior to fibula and iliac crest Inability to use a two team approach Change of positioning during surgery Reduce range of motion of shoulder and difficulty lifting object
Radial forearm osteo-cutaneous flap Based on radial a Graft length ~14cm Prefabricated radial forearm flap
Large quantity of soft supple tissue Ability to use a two team approach Long pedicle
Short limited bone segment Doesn’t tolerate osteotomies Support osseo-integrated implant poorly Radius fracture risk (prevention: keel shaped osteotomy and prophylactic plating) Unsightly donor site as well as require volar splint + skin graft)
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Osseo-integrated implant:
o Osseo-integration is defined as a time dependent healing process whereby clinically
asymptomatic rigid fixation of alloplastic materials is achieved, and maintained, in bone during
functional loading (Zarb &Albrektsson)
o Dental rehab is an important part of mandible reconstruction
o Use of Osseo integrated implant allows stable anchorage for placement of implant-borne
dentures, even in the absence of an alveolar ridge , allowing restoration of speech and
mastication and enhancing dental cosmesis
o Implants can be placed at the time of primary reconstruction or secondary with a delayed
procedures
o Pre-requisites for placement of osse-integrated implants:
An adequate vertical bone height
A minimum of 1mm of healthy bone surrounding the implants is also required
o Stages of Osseointegration:
Incorporation by woven bone formation;
Adaptation of bone mass to load (lamellar and parallel-fibered
bone deposition);
Adaptation of bone structure to load (bone remodeling)
o Recent advances:
Tissue engineering approaches to repair bone defect
Scaffolds ranging from collagen sponges to autologous autoclaved
bone have been together with bone marrow, derived stromal cells
and growth factors such as bone morphogenetic protein (BMP)-2
to facilitate osteogenic differentiation of implanted cells
o Soft tissue flaps:
The most commonly reported soft tissue flap used in combination with the fibula is the
radial forearm, but the ALT, rectus abd and pect.major flaps can be used as well as
pedicled flap like trapezius and pect.osteomyocutaneous flap.
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Reconstruction of pharynx: (larygnopharyngoplasty)
o Microvascular free flaps are largely replaced regional pedicled flaps, such as the PMMC flap, due
to their lower fistula rates.
o Free flap option include the jejunal free and fasciocutaneous free flaps, such as ALT and RFF free
flaps.
Flap donor sites Advantages Disadvantages
Jejunal free flap Vascular arcade via superior
mesenteric a 20-30 cm length (upper
ligament of treitz)
Avoidance of an additional suture line when reconstructing circumferential defects Lower fistula rates
Need of laparotomy Post op ilieus Anastomostic leakage Bowel obstruction
ALT free flap Minima donor site morbidity Lower fistula rates Can be used two skin paddle
Thick/ bulky flap Difficult to inset
PMMC (pectoralis major myocutaneous) flap
Large skin territory Rich vascular supply Large are of rotation No microvascular anastomosis Less time
Cosmesis Excessive bulk Breasat distortion in females
Lingual/ tongue flaps:
o First by Gersuny Eiselberg popularized in 1901
o One of the most versatile organ for obtaining tissue for transfer within the oral cavity of pharynx
o Its abundant blood supply permits the use of anteriorly/posteriorly based flaps, central island
flap and dorsal flap to transfer tissue
o Based on one or more branches of contralateral lingual vessel
Flap variation First described by Likely uses
Lateral-posterior tongue flap
Lexer Klopp & shurtev Conley Papioannau & Farr Ganguli & Villoria Chambens Som & Nusibaum Sessions
Repair defect of retromandiblar tonsil Repair defect of soft palate & tonsillar fossa Utilization tongue for closure of skeletal intraoral defects, creation of pharyngostomies and to protect carotid artery Reconstruction of floor of mouth Defects of cheek and tonsil Closure of defects of tonsillar fossa, buccal mucosa and retromandibular trigone Reconstruction of floor of mouth after marginal mandibulectomy Recommended ipsilateral hypoglossal nerve ligation to avoid flap pull away
Anteriorly based (set-back) tongue flap
De santo Defect of base of tongue
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Hemitongue advancement flap
Hovey Reconstruction of defect in patient who had undergone partial resection of anterior mobile tongue
Central island pedicled flap
Druck & Lorton Anterior floor of mouth defect recon (myomucosal flap)
Laterally based posterior tongue
Calcaterra
For pharyngeal closure For recon of hypopharynx
Tongue as transfer flap (dorsal tongue)
Guerrero-santos Reported use of these flaps to carry tissue to palate and lip
Sliding tongue flap Sisson For resurfacing hypopharynx
Splitting tongue Hiranandani Split the tongue and inferiorly advancement upper portion to reconstruct the pharynx
Sliding posterior tongue
Love Described use of a sliding posterior tongue flap for reconstruction following subtotal resection of hypopharynx
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32. RECONSTRUCTION OF THE EYELIDS & CORRECTION OF PTOSIS.
APRIL 2016
Q5) A 14 year old boy presents with the inability to lift both upper eyelids, requiring him to tilt the head upwards
for visualization. It is present since birth.
a) How would you establish your diagnosis, giving clinical evaluation.
b) Give an algorithm for upper eyelid ptosis.
c) What are the main complications of ptosis surgery, and how would you avoid them.
APRIL 2015
Q2) A 10 year old boy presents in the OPD with complaints of inability to open his eyes completely since birth.
a) What is your diagnosis?
b) How will you assess this patient?
c) Enumerate the reconstructive options according to severity of the condition.
MAR 2006, PII
Q.15 Briefly describe the various steps in orbital socket reconstruction following ablative surgery for tumor
excision.
a) Name two choices for lining of the orbital socket and the advantages and disadvantages of both; state your
preference
b) Name the commonest cause of a contracted eye socket unable to retain eye prosthesis?
MARCH 2006
Q.3 Enumerate the factors is preoperative evaluation of a patient with unilateral upper eyelid ptosis
Describe the two most important factors in deciding the type of operation to correct ptosis.
JAN 2008, PI
Q.8
a) Give the classification of Ptosis
b) A 52 years old lady develops ptosis after Botox injections. How will you manage this case initially? What will you
do if Ptosis persists after six months?
SEPT 2009
Q.8: With regard to upper lid ptosis:
a) Briefly describe how you would measure levator function.
b) Give the grades of levator function along with the measurement range of each grade.
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c) When the degree of ptosis is more than 3mm and levator function is more than 4mm, what type of operation
you would advise and why?
SEPT 2009
Q.1: Describe the methods of surgical reconstruction of lower eyelid defects following excision of tumor if the
lower eyelid defect is:
a) 0 – 25%.
b) 25 – 50%.
c) 50 – 70%.
d) over 70%.
SEP 2004, PI
Q. 10 A girl of 16 years presents with left sided ptosis.
a. How will you assess this patient?
b. Briefly discuss the surgical option available
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Upper eyelid ptosis:
o Blepharoptosis or ptosis is an upper eyelid malposition in which the upper eyelid falls below the
normal level of 1-2mm below the upper limbus
o Casues: number of anatomic problems involving
Levator palpabrae superioris muscle or
Its aponeurosis and or
Muller’s muscle.
Ptosis may be congenital or acquired
Congenital:
o Myopathic ptosis
o Blepharophimosis syndrome
o Marcus Gunn jaw winking synkinesis
Acquired:
o Aponeurotic ptosis: (involutional)most common
o Senile ptosis, post-operative edema, trauma
o Neurogenic:
o Third nerve palsy
o Horner’s syndrome
o Myogenic:
o Myasthenia gravis
o Chronic progressive external ophthalmoplegia
o Senile
o Mechanical ptosis:
o Excess weight due to edema, tumor, large chalazion etc
o Conjunctival scarring
o Symblepharon of the upper lid
o Pseudo-ptosis:
o Due to surgical anophthalmos, microphthalmos and phthisis bulbi
o Due to hypotropia
o Due to dermatochalasis
o Examination and evaluation:
Shaking hand (for myotonic dystrophy)
Standard History
Proper Examination:
Systemic
Local:
o Standard eye examination (vision, 6 cardinal gazes)
o Levator excursion
o Palpebral fissure measurement
o Ptosis grade measurement
o MRD
o Marcus Gunn jaw winking synkinesis
o Cover/uncover test and also Shirmer’s test
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Surgical correction:
o Levator repair or resection with advancement
o Tarsoconjunctival mullerectomy (Fasanella-servat procedure)
o Frontalis sling
Autogenous (fascia lata and palmaris longus tendon)
Alloplastic (silicon)
Complications:
o Undercorrection:
Prevention & Tx: proper
planning, re-evaluation
and re-surgery
o Poor lid crease:
Prevention & Tx: proper
marking, suturing skin to
deep orbital septum and
levator aponeurosis and
back to skin
o Over-correction:
Prevention & Tx:
fastening, taking wound
closure nd cutting the
offending suture, and
should be treated with
massage
o Lagophthalmos
o Lid malposition
o Lid contour abnormalities
o Infection, hematoma, scarring,
contracture etc
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Reconstruction algorithm based on reconstruction zones:
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31. RECONSTRUCTION OF SCALP, CALVARIUM & FOREHEAD.
JAN 2008, PI
Q.9 A medical officer from a small local hospital rings you to inform that he has a 15 year old patient with total
scalp avulsion sustained in a rotating machine one hour back.
What instructions will you give regarding transport of the Scalp tissue and the patient to you?
What are the principles of microsurgical replantation of the scalp?
MARCH 2009
Q.19: A 30 year old woman is referred to you with a sinus on the scalp, draining pus. She has a history of surgery
for brain tumor followed by radiation treatment 3 months ago. How would you evaluate and treat this patient?
March 20, 2012 PII
Q.11. A Young girl of 16 years had road traffic accident 2 years back in which she sustained scalp and facial injuries.
She presents with a bald patch of about 10x8 cm in left parietal and temporal region.
a) Name the most suitable reconstructive option.
b) How would you plan her reconstruction?
c) Enumerate the complications and how would you avoid them?
SEP 2005, PI
Q.6 A 32 years old farmer was electrocuted by high voltage tension wires 3 weeks back. His main wound requiring
your expert, help is over the occiput, measuring 13x11 cm. The occipital bone is exposed and occupies 2/3rd of the
area of this wound.
a) Order three investigations prior to surgery in this patient.
b) Enlist three- surgical options to repair the defect.
c) Name the most important complication you should try to prevent.
d) Name the most important long term complication in this case.
SEP 2004, PI
Q.6 A sixty years old man sustains electrical injury to scalp with necrosis of skin and calvarial bone over the right
parieto-occipital region.
a. What vessels supply the scalp?
b. What are the principles for managing acute scalp wounds?
c. What options are available for reconstruction of scalp bone defect?
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Scalp:
Layers:
Blood and nerve supply:
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Reconstruction of scalp:
o Primary closure up to 3cm
o Secondary closure
o Skin graft
o Dermal regeneration templates
o Local flaps
Partial thickness pericranial and glaeal
Full thickness an axial flap (based on major vessel)
For defects of 3-6 cm amenable to FTSG
For defects of 6-9cm large scalp flap (i.e. bucket handle for ant scalp defect)
Whichever flap design is chosen, the main reconstructive principles are
Mobilize as much scalp tissue as available to cover the primary defect (flap +
wide undermining) and to minimize the size of the secondary defect (wide
undermining) and
Plan the location of the secondary defect so as to maximize cosmetic and
functional results.
o Tissue expansion
o Regional flaps (trapezius and LD flap)
o Free tissue transfer: for defect greater than 9 cm
Musculocutaneous: (LD, RA, serratus anterior) muscle atrophy with passage of time
Fasciocutaneous (ALT) and
Omental flap (often becomes thin over time and may not be suitable for long-term
durable coverage)
Option available for reconstruction of scalp bone defect:
o Autogenous bone defect:
Calvarium, rib, and iliac crest
o Alloplastic material:
Titanium
Poly(methyl methacrylate) (PMMA)
Hydroxyapatite (HA)
Transport of Scalp Tissue: o Wash amputated part with water to remove gross
contaminants
o Wrap amputated part in moist gauze
o Place wrapped amputated part in dry plastic bag
o Place bag with amputated part in another plastic
bag with ice
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Principles of microsurgical replantation of scalp tissue: common principle are:
o Microvascular replantation should be attempted even in cases of prolonged ischemia time
o Careful cleaning and preparation of the scalp will help avoid the inclusion of hair and debris on
the underside of the flap
o One artery is all that is necessary for successful reperfusion, and it should be maximally
mobilized to avoid vein graft and
o One should attempt to re-anastomose at least two veins, ideally one in the occiput, to avoid the
common complication of venous congestion
Osteomyelitis:
o Has traditionally been classified into 3-categories
Hematogenous osteomyelitis through blood stream
Osteomyelitis due to spread from a contiguous focus of infection without vascular
insufficiency
Osteomyelitisdue to contiguous infection with vascular insufficiency
o Pathogenesis:
Norma bone is highly resistant to infection
Bacteria possess a variety of virulence
i.e. Protein (adhesin) which facilitate attachment to bone and ability to form
biofilm (a slim layer that shield bacteria from antimicrobial agent)
Inflammatory responses leads to increase intra-osseous pressureischemic necrosis
dead bone (sequestrum)
o Clinical presentation:
Depending on categories of infection, location, organism and host
Fever, chills, pain and sign of inflammation
Purulent discharge from wound
Physical exam: diminished pulses, poor capillary refill
o Evaluation and diagnosis:
Bone biopsy is the gold standard.
Routine exam and blood tests
Microbiology (blood cultures, wound C/S, bone biopsy)
Radiology: (plain radiographs, CT scan, MRI, Bone scan (3-phases), WBC scan
o Microbiology and treatment:
Basic principle of treatment:
A combined medical and surgical approach is usually needed
Dead- tissue must be removed
Poorly vascularized tissue is unlikely to heal
Empiric therapy not guided by culture results is more likely to fail
With few exception infection is very difficult to eradicate from prosthetic
material.
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Tissue expansion:
o Represents an invaluable asset in scalp reconstruction, allowing replacing like with like
o As much as 50% of the scalp can be reconstructed by expanding the remaining scalp
o Limitations:
The wounds need to be free of infection
Tissue o be expanded should be healthy and well vascularized
Expanding previously radiated tissue is not advisable
o Counselling:
The patient needs to be well informed preoperatively screened in regards to social
support, medical compliance, status of the underlying disease and its treatment course
and the will to endure the length expansion period, the consequent physical deformity,
and multistage reconstruction
Expander complication rates may be as high as 25% and include infection, exposure,
extrusion and device failure
o Principle of tissue expansion:
Correction of burn deformities using tissue expansion is a multistage process
Not only patient selection is crucial, so is individualized preoperative planning
The expectation of the patient and those of surgeon should match
Patient acceptance of weekly or bi-weekly injection process and the progressive
deformity cause by the expander is essential
Issues related to insertion process are less controversial when compared with the
details as to how this should be done
Incision:
Type of incision is still an issue
Proponents of paralesional incision (I.e. incision at the junction of normal tissue
and the scarred area) believe that minimal undermining of tissue is required for
insertion of expander
Implant:
Portal placement:
Several investigation have documented
safely in use of external ports
In pediatric population the use of
external port can alleviate pain and
anxiety associated with weekly
injection
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Expansion rates:
Can vary greatly
After healing of incision or
Anywhere from 1 week to 21/2 week after placement
Face and scalp expander may be easily inflated 2-3 times/week
Longer interval 7-10 days for extremities
Injection fraction vary, but 10% of volume per week is required to complete
expansion within 3 months period.
Overfilling/overexpansion by up to 50% of the estimated amount is necessary
o Techniques in tissue expansion:
Intraoperative consideration:
In most cases, expanders are placed below the galea or at the fascial layer,
depending on location
Meticulous hemostasis is crucial
Irrigation of expander pouted with antibiotic solution is also a common practice
Checking expander for leakage is an important part of procedure
Injection of air with the submersion of expander in saline is reliable for
detecting leaks
Alternatively, the use of methylene blue helps to identify expander leaks prior
to insertion
Operative technique;
Once the expander has been successfully inflated and ready for removal,
advancement or rotation of the flap has usually been decided
Hudson feels that the best method for maximizing the use of expanded tissue in
both vertical and horizontal direction is to add back cuts to the sides as well as
base of flap
Scoring the capsule to increase flap advancement has been touted by several
authors.
o Classification of burn alopecia:
Type Feature
Type I Type II Type III Type IV
Single alopecia segment a. Less than 25% of hair bearing scalp b. 25-50% of hair bearing scalp c. 50-75% of hair bearing scalp d. 75% of hair bearing scalp
Multiple alopecia segments amenable to tissue expansion placement Patchy burn alopecia not amenable to tissue expansion Total alopecia
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o Complication: 1984, martin et al
Major complication (interrupt expansion process) Minor complication (resolve without interruption)
1.Infection 2.Expander exposure
Dehiscence of incision Erosion of envelope fold through skin Erosion of envelope or reservoir through
inadequate covering tissue Manipulated by psychiatric patient
3.Implant failure Removal of port connector Physician assembly may be faulty Injection port may lack proper back Envelope may be perforated by needle
4.Induced ischemia: Flaps may become ischemic when expanded Irradiated tissue may not survive elevation
1.Pain on expansion 2.Seroma and drainage after expander inflation 3.Dog-ear after advancement 4.Widening of scar with time
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34. RECONSTRUCTION OF ACQUIRED LIP DEFORMITIES.
JUNE 25,2008PI
Q.3 A 55 years old male patient presents with squamous cell carcinoma of the lower lip, 1.5 cm wide and just 0.5
cm medial to the right commissure. The cervical lymph nodes are not involved.
a) Give two options for reconstruction of the defect after excision of this tumor.
b) Give advantages and disadvantages of each option.
MAR 2004, PI
Q.3: A 40 years old "naswar" user presents with a midline growth of the lower lip. Apparent changes are extending
to the mucosa of the adjacent alveolus.
a. Give the essential factors for the evaluation of this lesion.
b. Outline the treatment plan
SEP 2004, PI
Q.2 A 70 year old man presents with squamous cell carcinoma of central portion of lower lip of 2 cm size and
palpable sub mental N1 lymph node.
a. How will you investigate this case?
b. How will you treat this case?
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Lip:
A reconstructive
algorithm for full
thickness acquired
defects:
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Four pattern of lower lip excision for
Small full thickness lower lip defects.
Schematic of Abbe flap:
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Schematic of B/L karapendzic:
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Schematic of Modified Bernard flap:
Schematic of Estlander and Reverse estlander flap:
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Schematic of Vermillion reconstruction:
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36. FACIAL PARALYSIS.
April, 2016
Q.1) A 28 year old female developed a facial palsy after removal of an acoustic neuroma. How will you manage her
postoperatively, giving your reasons if she presents at:
a) 3 months.
b) 12 months.
c) 24 months.
OCT 2013
Q20) A 25 year old unmarried woman presents to you with right sided facial palsy following surgery for a CP angle
tumor 6 months back.
a) What are the possible options to reanimate this patient?
b) Which one would you choose, justifying your choice.
MAR 2004, PI
Q.9
What are the causes of post-operative facial nerve dysfunction?
Briefly describe Frey's syndrome and its management
AUG 2006, PI
Q.8 Enumerate the dynamic procedures for treatment of facial palsy (unilateral complete) with pros and cons of
each procedure
MAR 2005, PI
Q.5 A 25 year old unmarried woman presents to you with a right sided facial palsy following surgery for an acoustic
neuroma 6 months ago.
a) What are the possible means of correction of this deformity in this patient?
b)'Which one would you choose giving reasons for it?
SEPT 2010
Q.2:
a) Enumerate the causes of facial nerve dysfunction.
b) Enumerate various dynamic facial re-animation procedures.
c) Briefly describe Frey’s syndrome and its management.
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Facial nerve paralysis:
o Facial nerve: 7th cranial nerve and supplies 23 paired and one orbicularis oris muscle.
Segments:
Cisternal segment in CPA
Intracanalicular segment
Labyrinthine segment
Tympanic segment
Mastoid segment
Extracranial segment
Branches:
Geniculate ganglion: is location of 1st
three branches
Greater petrosal nerve
Lesser petrosal nerve
External petrosal nerve
In mastoid segment:
Nerve to stapedius
Sensory auricular nerve
Chorda tympani
Extracranial segment:
Posterior digastric
Stylohyoid
Posterior auricular nerve
Braches in parotid gland:
Temporal branch
Zygomatic branch
Buccal branch
Marginal mandibular
branch and
Cervical branch
Etiology of facial nerve palsy: May in
1981
Intra-cranial Intra-temporal Extra-temporal/Temporal
Vascular abnormalities Brain tumor-CPA Developmental abnormalities Agenesis of Facial nucleus Trauma Degenerative disorder of CNS
Developmental Infection Cholesteatoma Tumors of middle ear, mastoid Trauma (# temporal bone) Iatrogenic
Trauma Malignant tumor (parotid) Iatrogenic Bell’s pasly:-
Idiopathic Trauma, Infection & Tumor
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o Aims of reconstruction:
Restore symmetry and coordinated dynamic animation with normal appearance at repose &
Symmetry during voluntary and involuntary expression
Competent oral and ocular sphincter
Preservation of existing facial function and
Minimal loss of function in other donor motor nerves should be the goal
o Pre-op examination:
Standard history and proper physical examination are imperative for establishing a
management plan
Local exam must include all cranial nerves, any scar, evaluation of facial expression, blowing,
forceful eye closure, whistling, clenching, parotid gland and any scar or mark over mastoid
area for exclusion of birth trauma etc
To detect anatomical site of lesion, tests such as the schirmer test, stapedius reflex, taste
examination and salivary flow test
Investigation: electroneurography, needle electromyography (EMG), nerve conduction
studies, blink reflex and nerve excitability testing , CT scan and MRI
o Operative technique:
Direct repair
Nerve grafting
Cross facial nerve graft up to 6 months (post injury)
Nerve transfer
The “Babysitter principle” 6 months to 2 ½ year (post injury)
Direct neurotization: not later than 2 years after injury
Muscle transposition in long standing injury (i.e. temporalis muscle innervate other than
facial nerve)
Free muscle transfer (i.e. gracilis, pect.minor, LD, serratus anterior, split rectus abd,
corachobrachilias, internal oblique, and extensor digitorum brevis muscle)
o Reanimation of upper, middle and lower face:
Reanimation of eye:
Primary aim is to:
Limit ocular exposure
Protect the eye
Restore eye closure and blink and
Improve appearance
Temporary measures:
Eye protection with tapes or other
occlusive measure during sleep, protective glasses and routine eye lubrication
Permanent solution:
Static maneuver:
o Gold weight insertion or eye spring for patient with partial blink
o Lower eyelid position can be improved with canthoplasty, tendon graft for
suspension or lid shortening
Dynamic maneuver:
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o Primary repair of nerve (zygomatic branch)
o Direct neurotization via implantation of motor donor nerves via nerve
graft in orbicularis oculi muscleviable muscle fibers in eye sphincter
o Orbicularis oculi muscle: substitution are contralateral platysma and
frontalis muscle
o Mini-temporalis transposition: no synchronous blink
o Reamination of smile:
Use of regional msucles:
Partial or total transfer of masseter
Temporalis muscle
Free microneurovascular muscle transfer: involve
one or two stage
First two operation by CFNG and later free
microneruovascular muscle transfer gold
standard management for long standing
paralysis or developmental facial paralysis
(DFP) i.e. gracilis and pect.minor
One stage free tissue transfer:
Muscle recovery as early as 6 months after one stage procedure and successfully
treated children with hemifacial microsomia
Harii et al. give 2 explanation for rapid muscle re-
innervation
Retrograde blood flow
Single neurorrhaphy
o Reamination of lip depressor:
Lower lip paralysis traditionally managed with
Selective myectomy or
Neuroctomy on normal side
Botulinum toxin Type A
Dynamic restoration:
Mini-hypoglossal nerve transfer
Use of CFNGs
Direct neurotization
Regional msucles (ant.belly of diagastric or
lateral platysma muscle
Soft tissue rejuvenative technique:
Superficial musculoaponeuritic system
cervicofacial rhytidectomy, blepharoplasty,
browlift, and lower lid tightening can augment
aesthetic restoration.
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Forehead Flap: surgical technique and design consideration
o General consideration:
This operation is performed under local, sedation or preferably with general anesthesia
Prior to designing the flap , primary defect must be
evaluated
In case where a combined defect of cheek and
nose is present, evaluate and fix cheek 1st
o Guiding principles for design and elevation include: (Modifications provided by masters like Burget and Menick have
only increased the utility of this exceptional flap)
Maintaining an axial pattern whenever possible
Utilizing the pedicle ipsilateral to defect
Extending the flap at right angle across the
forehead with caution and only when extra length
is necessary
Utilizing a reasonably narrow pedicle
Early sub-periosteal dissection
o Flap variation:
Paramedian forehead flap (Indiana)
Median flap
Lateral forehead flap
o Flap elevation:
Pedicle is located about 2 cm lateral to midline
near medial eyebrow
Base of flap is designed 1.5cm wide to include
pedicle
Modification include a narrower pedicle, axial pattern ipsilateral rotation, sub-periosteal
dissection with periosteal scoring and skin grafting at flap elevation
Avoidance of transferring of hair is best
Great care and operative time is put into correct flap dimension for coverage
Careful consideration is made for correct orientation
Remember that flap can be pivotal at a point below level of eyebrow
Avoid trauma to flap
Widening infiltration the surgical field will help define the surgical plane, and minimize
blood loss
Flap elevation begin distally
It is elevated thickly at level galea or 1cm below eyebrow, the dissection is carried sub-
periosteally and continued over the orbital rim
This captures sub-periosteal perforater and provide for very safe flap
If there is significant tethering or shorteness of flap, the periosteum can be scored,
dissected free, or the flap can be raised above periosteum
Tip of flap, for initial 1.5-2cm, is raised with subcut plane with removal fo sub fat and
underlying frontalis muscle.
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o Flap inset:
If properly designed, insetting should be easiest part of case
Great care is taken to thin most distal ~1/8th of the flap
as this portion will never be re-evaluated
o Donor site closure:
Primary closure or left some area for secondary healing
or covered with skin graft
Important not to attempt to close the donor site at level
of rotation to prevent pinching and venous congestion
of the flap
o Post-op care:
Dressing
Can take shower- 3rd post op day
Removal of inset suture- 5-7th day
o Detachment: after 14-21 days
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Nasolabial flap:
o Introduction:
The nasolabial flap is a hardy flap that finds its use in the everyday reconstruction of
various defects in the head and neck. The flap may be superiorly or inferiorly based. The
choice between the two will depend on the location of the defect and the arc of
rotation needed to reach it with the least amount of tension. The use of the nasolabial
flap varies. In broad terms, it is commonly used as a superiorly based flap to reconstruct
nasal defects and oral defects located in the upper sulcus or palate. When it is raised as
an inferiorly based flap, it is used most commonly to address lower lip defects or
intraoral defects such as floor of mouth, lower gingival sulcus, and buccal mucosa
defects. The nasolabial flap has found a unique role as one of the go-to flaps in the
reconstruction of buccal defects such as those encountered after the excision of scar
bands and or fibrosis secondary to betel nut chewing. Prior to the establishment of
microvascular transfer as a routine option in the reconstruction of head and neck
defects, the nasolabial flap was very popular for the repair of floor of mouth defects
created after excision of squamous cell carcinomas.
The main advantages of using the nasolabial flap for reconstruction of external skin
defects are the color and texture match to the defect site. Because of the proximity of
the donor site to the defect site, the use of this flap allows for a near imperceptible
reconstruction for these two factors.
The main disadvantage of the nasolabial flap is the scar at the donor site. The location of
the scar renders its use less than favorable to many patients. In some cases, when the
flap is utilized in younger patients and only on one side, there is a potential for
postoperative facial asymmetry. Lastly, in cases where the flap is needed for the
reconstruction of floor of mouth defects, the remaining dentition needs to be evaluated
to see if it will traumatize the flap when the patient is chewing and the reconstruction is
carried out in stages.
o Anatomy
The regional anatomy relevant to the nasolabial flap extends from about 5 mm inferior
to the medial canthus and extends inferiorly towards the inferior border of the
mandible.
The bulk of tissue available for use in a nasolabial flap is found along the area of the
nasolabial fold as it extends lateral to the ala of the nose to a few millimeters below the
lateral aspect of the oral commissure. The common design of the nasolabial flap would
include the tissues in the nasolabial fold and lateral to it and as it extends inferiorly, it
would include a small quantity of tissue just medial to the fold but with a greater
quantity on the lateral aspect.
The vascular anatomy of the periorbital and perinasal region comes mainly from the
facial artery, angular artery, and the nasal arteries.
The facial artery travels in a superior oblique direction once it emerges above the
mandible. Along its path it gives off a number of branches, those being the inferior and
superior labial arteries, and the lateral nasal artery before it becomes confluent with the
angular artery.
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The angular artery is a branch of the ophthalmic artery that joins the facial artery as it
descends inferiorly along the superior lateral aspect of the nose.
In the superior aspect of the nose, the ophthalmic artery also gives off the dorsal nasal
artery.
All of these arteries give off perforators to the skin, which are responsible for the
perfusion to the nasolabial flap. The main perfusion to the flap comes from the
perpendicular vessels originating from the facial artery and angular artery.
The venous supply to the flap is based on the accompanying veins.
The nasolabial flap may be raised as an axial flap, a random flap, or as an island flap. An
inferiorly based nasolabial flap has been raised in patients where the ipsilateral facial
artery has been ligated either at the time of surgery or in a previous surgical encounter.
o Flap harvest:
Superiorly based flap:
o Once the decision has been made to raise a superiorly based flap, the next decision
is to determine its width and length, and therefore the reach of the flap.
o The flap should be designed so that the inferior tip of the flap narrows down to a
point. This design will allow for the closure of the donor site with the least amount
of undermining and excision of dog ear. Equally, the flap design should place the
final scar within the nasolabial groove. The placement of the scar within this region
will give the least conspicuous
evidence of the surgery.
o The flap is elevated from the distal tip
towards the base by first making an
incision deep to the dermis along the
marked width of the flap.
o The flap is elevated in a plane
superficial to the muscles.
o Care should be taken to identify and
avoid injury to the perpendicular branches of the facial artery as they penetrate the
muscle on their way to perfuse the overlying skin.
o The surrounding area is undermined to
improve the rotation of the flap without
causing distortion of the tissues around the
base of the flap.
o In cases where the flap is to be used along the
nasal sidewalls, the flap is rotated to insure
the reach is adequate and without tension.
o The flap is contoured to the defect and inset
by placing one to two deep sutures along the
base to recreate the groove and the rest of
the flap is inset in the usual fashion as per the
surgeon’s routine.
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Inferiorly based flap
o The inferiorly based flap is designed with the superior medial border of the flap
running in the nasolabial fold and widening to incorporate the desired width of the
flap laterally along the cheek.
o In the inferior region of the flap, around the upper lip and towards the commissure,
the medial incision should extend about 4 mm medial to the crease.
o The inferior width of the flap should be about 1.5 cm in order to capture enough of
the perforating vessels and to allow for adequate perfusion to the distal tip of the
flap.The incision is made superiorly.
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Flap monitoring: 24-72 hours most failure occurs within first 48 hours
o Clinical evaluation:
By an experienced microsurgeon is considered the gold standard for perfusion assessment
Important physical sign:
Quality of capillary filling,
Bleeding from cut edge,
Tissue turgor and
Temperature
Arterial inflow problem: pale, cool, digit with rapid refill
Venous insufficiency: rigid, blue with rapid refill
o Monitoring device:
Surface or pencil Doppler
Temperature probe
Laser Doppler probe
Quantitative fluorometer
Implantable Doppler
Near infra-red spectroscopy
Qualitative indocyanin green
o Causes of failure: Vascular occlusion (venous congestion is more common than arterial)
o Salvage rates: From 28%-90% (venous has higher salvage rate)
o Managing flap failure:
The first step in managing flap failure is early recognition of a compromised flap. Clinical
observation + pin prick, temperature and surface doppler, upon suspicion of vascular
compromise, shift the patient to OR for re-exploration. Surgical method should be the first
choice, with re-exploration initial attention should be directed at vascular pedicle. Causes
of extrinsic compression i.e. hematoma, pedicle kinking or misconfiguration are easily
identifiable and potentially correctable. The arterial system should be examined under
magnification for vascular spasm, for which topical papaverine may be used. Arterial can be
assessed by looking for pulsation of the distal pedicle or use of intraoperative Doppler.
Milking of venous system using microsurgical instruments may be used to assess venous
outflow. Identification of thrombus should prompt opening the anastomosis and
evacuation of clot with heparinized saline irrigation or a fogarty catheter prior to careful re-
anastomosis. Thrombolytic agents i.e. streptokinase, urokinase or tissue plasminogen
activator can be used if a thrombosis is identified, particularly in venous system.The venous
anastomosis should be taken down prior to flushing the flap with any of these thromblytic
agents in order to avoid systemic effect. Systemic antithrombotic therapy with IV heparin
may be considered in select salvage cases of arterial or venous thrombosis where flow is
re-established, particularly if thrombosis formation rapidly occurs at time of re-
anastomosis. The initial recipient vein and/or artery may not be appropriate in which case
another should be chosen.
o Non-surgical management of compromised flap: In selected cases venous congestion can be
managed with application of leeches. Partial flap loss may be managed with conservative
treatment such as debridement and secondary healing.