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--- resident:craniofacial [2019/10/15 19:43] – created melissa
+++ resident:craniofacial [2020/09/09 21:10] (current) – [Oral and Maxillary Facial Surgery] jonathan
@@ Line 1: / Line 1: @@
-====Surgical Approaches Review====
+===== Oral and Maxillary Facial Surgery =====
-● Submandibular\\
-● Retromandibular / transparotid\\
-● Preauricular \\
-● Transconjunctival / lateral canthotomy / transcaruncular \\
-● Subciliary / Subtarsal \\
-● Coronal \\
-● Upper bleph \\
-● Rhino/septoplasty \\
-● Gilles \\
-● Lefort \\
-● BSSO \\
-● Modified condylotomy \\
-● Anterior hip \\
-● Posterior hip \\
-● Tibia \\
-● Rib \\
-● Fibula \\
-● Tracheotomy \\
-**Submandibular:** \\
+Faculty:\\
+Dr. Glasgow - 301 237 1377
+Recommended Reading:\\
+[[https://www.amazon.com/Oral-Maxillofacial-Surgery-3-Set/dp/0323414990/ref=sr_1_4?dchild=1&keywords=Fonseca&qid=1599700059&sr=8-4|Oral Maxillofacial Surgery (Fonseca)]] - can get it on library genesis. The OMFS residents say this is where many pimp questions come from.\\
+[[https://surgeryreference.aofoundation.org/cmf/trauma|AO Foundation]] - Awesome for thinking about and going through approaches to trauma.\\
+===== Surgical Approaches Review =====
+====Submandibular====
 Incision: 2cm below inferior border of the mandible\\
 Layers: Skin, subcutaneous tissue, platysma, superficial layer of deep cervical fascia, pterygomasseteric sling, periosteum, mandible \\
@@ Line 26: / Line 18: @@
 Complications: marginal mandibular branch facial nerve damage, hematoma \\
-**Retromandibular / Transparotid:** \\
+====Retromandibular / Transparotid====
 - Hinds approach \\
 Incision: 0.5 cm below earlobe, continues inferiorly 3 - 3.5cm just behind posterior border of mandible.\\
@@ Line 33: / Line 25: @@
 Complications: salivary fistula (treatment with pressure dressing, scopolamine patch, pro banthine). \\
-**
+====Coronal Incision====
-Coronal Incision:** \\
 Layers: skin, subcutaneous tissue, galea, subgaleal (loose areolar tissue), pericranium Laterally the musculoaponeurotic layer becomes temporoparietal fascia \\
 Important structures: Superficial temporal artery (just superficial to temporoparietal fascia), supraorbital neurovascular bundle, temporal branch of facial nerve (just deep to or within temporoparietal fascia). \\
@@ Line 44: / Line 35: @@
 Complications: ptosis, epiphora, ocular injury \\
-**Preauricular:**\\
+====Upper eyelid / bleph====
+Incision: 10mm superior to upper lid margin and 6mm superior to lateral canthus (can extend as far laterally as needed for surgical access)\\
+Layers: skin, orbicularis oculi, periosteum (incised 2-3mm posterior to orbital rim) \\
+Important structures: Levator palpebrae superioris, Muller's muscle (superior tarsal muscle), lacrimal gland, orbital septum \\
+Complications: ptosis, epiphora, ocular injury \\
+====Preauricular====
 Incision: skin fold along entire aspect of the ear within 8mm of EAC. incise to the depth of the superficial layer of the temporalis fascia. \\
 Layers: Temporal region (skin, subcutaneous, temporoparietal fascia, superficial temporalis fascia, temporal fat pad, deep temporalis fascia). \\
@@ Line 52: / Line 50: @@
 The TMJ is a ginglymoarthrodial joint (rotation and translation) \\
-**Transconjunctival: (aka inferior fornix approach)** \\
+====Transconjunctival: (aka inferior fornix approach)====
 - Preseptal and retroseptal (retroseptal more direct and easier to perform) - Lateral canthotomy can be added for improved lateral exposure - Transcaruncular to access the medial wall \\
 Incision:
@@ Line 64: / Line 62: @@
 Complications: Entropion, ectropion \\
-**Rhinoplasty / septoplasty:** \\
+==== Subciliary / Subtarsal====
+====Rhinoplasty / septoplasty====
 Incision: \\
 Layers: \\
 Important structures: \\
 Complications: \\
-**Gilles:** \\
+====Gilles====
 Incision: \\
 Layers: \\
 Important structures: \\
 Complications: alopecia, temporalis pain \\
-**Lefort:** \\
+====Lefort====
 Incision: \\
 Layers: \\
 Important structures: \\
 Complications: \\
-**BSSO:** \\
+====BSSO====
 Incision: \\
 Layers: \\
 Important structures: \\
 Complications: \\
-**Modified Condylotomy:** \\
+====Modified Condylotomy====
 Incision: \\
 Layers: \\
 Important structures: \\
 Complications: \\
+====Anterior hip====
+Anatomy: \\
+- The anterior iliac crest is located between to AIS and tubercle of the ilium, which is 6 cm
+posterior to the AIS. - A maximum of 50cc of uncompressed cancellous bone can be harvested. - 10cc of uncompressed bone per 1 cm of defect. - Tensor fascia lata originates from the AIS laterally and is the most important structure
+related to gait disturbances. It inserts on lateral tibia. - External abdominal oblique attaches to AIS medially. - Inferior to anterior iliac crest is gluteus medius and minimus attach to lateral cortex. - Iliacus attaches to medial surface of iliac crest and is reflected during surgery. - Sartorius attaches to AIS and inserts into medial aspect of tibia. - Inguinal ligament attaches to AIS and inserts onto pubic tubercle. - Iliotibial band - Both the inguinal ligament and sartorius should not be encountered during the dissection. - Most commonly affected nerve is lateral cutaneous branch of the iliohypogastric (L1,L2) which runs over the tubercle of the ilium - Lateral cutaneous branch of the subcostal nerve (T12, L1) runs over the tip of the AIS and is slightly inferior to the iliohypogastric - Blood supply: perforating branches of the deep circumflex iliac artery and vein located on
+the medial ilium \\
+Incision/ layers: Retract the skin medially which facilitates the postoperative scar to the lateral to the iliac crest and avoid irritation from clothing. 4 - 6 cm incision is placed starting 2 cm posterior to the ASIS to avoid the lateral femoral cutaneous nerve and extending posteriorly toward the tubercle. The dissection is carried down through skin, (camper’s fascia) subcutaneous tissue, Scarpa’s fascia and through the aponeurosis between the external oblique and tensor fascia lata. The periosteum is sharply elevated off the crest of the ridge and the iliacus muscle is retracted medially in a subperiosteal plane. \\
+Important structures: \\
+Complications: \\
+- meralgia paresthetica is an injury to the lateral femoral cutaneous nerve resulting
+in dysesthesia and anesthesia to lateral thigh. - Bleeding: most common source of bleeding during harvest is the gluteal artery. - Avitene - microfibrillar collagen \\
+====Posterior hip====
+Incision: \\
+Layers: \\
+Important structures: \\
+Complications: \\
+● Defects larger than 5 cm should be reconstructed with microvascular reconstruction
+Tibia: \\
+- 25cc of cancellous bone - Can be performed in the office
+Anatomy: \\
+- Lateral approach to the tibia metaphysis. - Primary bony landmark in the proximal tibia is Gerdy’s tubercle. - Gerdy’s tubercle is a bony protuberance between the patellar ligament (midline) and the head of the fibula, which is palpable 90 degrees laterally. - No vital anatomic structures located over Gerdy’s tubercle. - Cutaneous branches of the lateral sural nerve in the area - Fibular nerve is well protected beneath the head of the fibula and does not enter surgical field. - No major nerve structures are located over Gerdy’s tubercle - Branches of the inferior genicular artery and recurrent tibial artery. Easily cauterized. - Iliotibial tract attaches from above
+Incision: 3-4 cm incision directly over Gerdy’s tubercle, carried thru skin, subcutaneous tissues (including iliotibial tract) and periosteum. The periosteum is elevated in preparation for making a cortical window through the cortical bony plate at Gerdy’s tubercle. \\
+Bone harvest: \\
+- A cortical window can be made with a surgical drill or osteotome and mallet. - An oval hole offers less stress in the cortical bone as opposed to square or rectangle. - Harvest the cancellous bone with a curette by going across the tibial plateau and down the shaft of the tibia. - Care must be taken going superiorly to avoid the joint space of the knee. - Close in layers with iliotibial tract being reapproximated. \\
+Important structures: \\
+- iliotibial tract is the only anatomic structure one encounter during the dissection.
+A dense fascial band that runs from the anterior iliac crest to lateral surface of the tibia. \\
+Complications: \\
+- Ok for weight bearing immediately after procedure. - Avoid contact sports or vigorous physical activity for 6 weeks. - Fracture of tibia plateau \\
+====Tibia====
+- 25cc of cancellous bone - Can be performed in the office \\
+Anatomy: \\
+- Lateral approach to the tibia metaphysis. - Primary bony landmark in the proximal tibia is Gerdy’s tubercle. - Gerdy’s tubercle is a bony protuberance between the patellar ligament (midline) and the
+head of the fibula, which is palpable 90 degrees laterally. - No vital anatomic structures located over Gerdy’s tubercle. - Cutaneous branches of the lateral sural nerve in the area - Fibular nerve is well protected beneath the head of the fibula and does not enter surgical field. - No major nerve structures are located over Gerdy’s tubercle \\
+- Branches of the inferior genicular artery and recurrent tibial artery. Easily cauterized. - Iliotibial tract attaches from above \\
+Incision: 3-4 cm incision directly over Gerdy’s tubercle, carried thru skin, subcutaneous tissues (including iliotibial tract) and periosteum. The periosteum is elevated in preparation for making a cortical window through the cortical bony plate at Gerdy’s tubercle. \\
+Bone harvest: \\
+- A cortical window can be made with a surgical drill or osteotome and mallet. - An oval hole offers less stress in the cortical bone as opposed to square or rectangle. - Harvest the cancellous bone with a curette by going across the tibial plateau and down the shaft of the tibia. - Care must be taken going superiorly to avoid the joint space of the knee. - Close in layers with iliotibial tract being reapproximated. \\
+Important structures: \\
+- iliotibial tract is the only anatomic structure one encounter during the dissection. \\
+A dense fascial band that runs from the anterior iliac crest to lateral surface of the tibia. \\
+Complications: \\
+- Ok for weight bearing immediately after procedure. - Avoid contact sports or vigorous physical activity for 6 weeks. - Fracture of tibia plateau \\
+====Rib====
+Incision: over the 5th or 7th rib \\
+Layers: \\
+Important structures: \\
+Complications: \\
+====Fibula====
+Incision: \\
+Layers: \\
+Important structures: \\
+Complications: \\
+====Radial Forearm====
+- Based on the radial artery - 10-12 cm with good diameter (2.5 cm) \\
+- Can harvest nerves with the flap (Sensory innervation is derived from the lateral
+antebrachial cutaneous nerves traveling with the cephalic vein - Should perform Allen’s Test before the procedure - The distal end of the skin paddle should be at least 1 cm from the flexor crease of the wrist - \\
+Incision: \\
+- Incision is made through skin in the outline of the planned flap. - lateral cutaneous nerve can be identified in close proximity to the cephalic vein and can be preserved for possible use with a sensate flap - Dissect along the cephalic vein distally, along its lateral aspect, toward distal aspect part of skin paddle - Dissect over the brachioradialis muscle and tendon - Superficial branches of the radial nerve should be identified at the distal aspect to maintain sensation to the dorsum of the hand - The communicating - Veins medial to the main trunk of the cephalic vein must be preserved the full length of the flap because these will provide the drainage route from the flap to the cephalic vein proximally - Dissection is carried down to the flexor carpi radialis muscle and palmaris longus tendon. - A subfascial dissection is performed, preserve the paratenon of the flexor carpi radialis
+tendon. \\
+Layers: \\
+Important structures: \\
+- Radial Artery - Cephalic vein - Vanae comitantes - Brachioradialis muscle - Cutaneous nerve (lateral antebrachial cutaneous nerve) - Radial Nerve - Flexor pollicis longus muscle (lies just deep to the radial nerve and artery) - Flexor carpi radialis muscle and palmaris longus tendon \\
+Complications: \\
+- First 48 hours most important - \\
+====Tracheotomy====
+Incision: Trace out Thyroid cartilage, cricoid cartilage and sternal notch. Horizontal line is drawn halfway in between the sternal notch and cricoid cartilage. Horizontal incision, Skin subcutaneous, platysma, avascular raphe between the strap muscles (sternohyoid and sternothyroid) May encounter anterior jugular veins laterally if your off midline, Pretracheal fascia, then trachea. Inverted U incision is known as Bjork. In between rings 2 and 3. Can place stay suture if desired. \\
+Al-Kayat & Bromley: 1979 \\
+Dingman and Grabb: \\