18.9 ENT I Plastic Reconstruction

OTORHINOLARYNGOLOGY I EVALS 18
PLASTIC RECONSTRUCTION TRANS 9

Dr. Julie Ann Uy-Regalado, DPBO, FPSO-HNS
PART 1: COMMON CONGENITAL ABNORMALITIES

TOPIC OUTLINE
INTRODUCTION
PART 1: COMMON CONGENITAL III. Classifications of Injury
● Common Congenital Abnormalities:
ABNORMALITIES A. Contusions
→ Cleft Lip, +/- Cleft Palate
I. Cleft Lip +/- Cleft Palate B. Abrasion
→ Microtia, +/- Aural Atresia
A. Introduction C. Accidental Tattoo
B. Embryology
C. Etiology
D. Puncture Wounds
E. Avulsions
💡
📢
Case Scenario 1: Incomplete Cleft Lip | Video lecture
D. Classification F. Lacerations
E. Management IV. Other Matters to Consider
F. Poor Dental Condition A. Forehead Injury
G. Summary of the Timing of B. Eyelid Injury
Interventions C. Eyebrow Injury
H. Summary of Cleft Lip D. Lip Injury
Management E. Nose Injury
II. Microtia, +/- Aural Atresia F. Ear Injury
A. Classification
PART 3: SCAR REVISION AND Figure 1. Private patient with incomplete cleft lip.
B. Epidemiology
RECONSTRUCTION OF FACIAL ● An infant with this type of cleft was delivered by you during your
C. Etiology
DEFECTS tour of duty. As a primary care physician, you are expected to
D. Management
I. Scar reassure the parents of the child by addressing their usual
III. Saddle Nose Deformity
A. Scar Formation primary concern, which is feeding, and to outline a basic plan
A. Causes
II. Basic Concepts of management for the child such as timing of the surgery and
B. Pathophysiology
A. Skin Tension Lines the need for multi-disciplinary care.
C. Management
B. Cosmetic Units ● Referred at birth
IV. Facial Nerve Paralysis
C. Sites for Skin Incision → Address feeding concern
A. Facial Nerve Function
III. Scar Revision → Advise timing of surgery
B. Etiology
A. Intro to Scar Revision → Advise need for multi-disciplinary care
C. Approach to Diagnosis
B. Timing of the Scar Revision
💡
D. Bell’s Palsy
C. Scar Revision Surgery
📢
Case Scenario 2: Bilateral Cleft Lip & Palate | Video lecture
PART 2: SOFT TISSUE INJURIES D. Other Management Options
OF THE FACE IV. Reconstruction of Facial
I. Diagnostic Assessment Defects
II. Examination of the Wound A. Skin Graft
A. Bony Injury B. Skin Flap
B. Nerve Injury V. Clinical Application
C. Duct Injury A. Defect Reconstruction
D. Vessel Injury B. Medical Photography
E. Muscle Injury
F. Tendon Injury Figure 2. Infant with bilateral cleft lip & palate.
● Given a more challenging clinical scenario such as this, an
📢 - Lecturer’s notes/Audio Inputs
LEGEND
infant with bilateral cleft lip and palate described as having:
📖 - From Book (cite sources)
IMPORTANT TERMINOLOGIES
📝 - From Old Transes 📌

Disclaimers/Transer’s notes → Protrusive premaxilla/prolabium
🚩 - Important 💡
- Undiscussed Sections
- Nice to Know
→ Deficient to (almost) non-existent columella
→ Collapsed palatal shelves
Some parts of the trans were rearranged for better flow of discussion. 📝
→ 2021: The premaxilla and prolabium can be of variable size.
OBJECTIVES
● 📢 You are expected to do the same thing
● Diagnose common congenital and acquired deformities of the

I. CLEFT LIP +/- CLEFT PALATE
face
● Formulate a basic management Problems Associated with Cleft Lip and Palate
● Discuss the basic principles of common surgical and ● Feeding ● Ear
non-surgical procedures to enhance the face ● Dental ● Speech Difficulties
● Nasal Deformity & Aesthetic ● Other associated anomalies
Group 8A Page 1 of 30
OTORHINOLARYNGOLOGY I Plastic Reconstruction
💡
📢
Nice to Know | Video lecture
● Familiarize yourselves with these problems because you are ●
C. ETIOLOGY
📢 First patient would actually be the parents.
expected to administer initial management for some of these → Most of the time their first question would be what caused
problems as a primary care physician. it?
● As you can see these problems cover a wide area of discipline. ● When asked what caused the cleft, you would say the etiology
Therefore, you must–T/N: Audio was cut off at around the 2:02 could be due to genetics and could be non-syndromic or
timestamp. syndromic.
→ Non-syndromic: not part of a syndrome.
📢 Management: Multidisciplinary (Team) Approach ▪ The causes for this are multifactorial.
● 📢
Parents would then ask what are my next child’s chances
of a cleft deformity? (Refer to the probabilities listed below).
● 🚩📢 Just know if 1 parent has cleft deformity plus one child
the next child will have a higher chance of deformity.
Genetics (Non-syndromic)
● Multi-factorial
● Probabilities for cleft lip +/- cleft palate
→ One parent: 2%
→ One sibling: 4%
→ Two siblings: 9%
→ One parent + one sibling: 15%
● Probabilities for cleft palate
Figure 3. Multidisciplinary team approach for cleft lip +/- cleft palate. → One parent: 7%
● The management is a team approach with the → One sibling: 2%
otolaryngologist playing a key role. → Two siblings: 1%
● Other members of the team would include those listed above. → One parent + one sibling: 17%
● This approach recognizes that no single discipline possesses Genetics (Syndromic)
all of the expertise needed for the proper management of the ● 📢 Cleft deformity can also be part of a syndrome in 15-60% of
many problems of patients with cleft deformities. cases, which is high.
● Ideally, multidisciplinary care should begin when an infant is → More than 200 of identified syndromes include clefts in them
identified as having the deformity. ● (+) Cleft palate
● Sadly, the situation of cleft care in the Philippines is that only → Apert’s Syndrome
university hospitals are able to provide comprehensive cleft → Stickler’s Syndrome
care services. → Treacher’s Syndrome
● For general hospitals, there is a shortage of specialists causing ● (+) Cleft lip with or without Cleft palate
patients with cleft deformity not to receive comprehensive care. → Van der Woude’s Syndrome
→ Waardenberg’s Syndrome
A. INTRODUCTION
● 🚩📢 Remember that when you see a patient with a cleft lip, with
● CLEFT: A congenital abnormal space or gap generally in the or without palate, you need to rule out if the child has a
upper lip, alveolus, or palate. syndrome.
● Prevalence rate: 0.46 per 1000 live births (Philippine Cleft → 📢 Management would include addressing the other
registry, 2008). problems that are part of the syndrome.
→ 3rd most common birth defect in the Philippines after
Non-genetics
multiple congenital anomalies and ankyloglossia (Consensus
● The risks of cleft deformities are also observed to be increased
by Philippine Birth Defect Registry Project)
in the following:
→ Males > Females
→ Left > Right side of the face → Maternal Diabetes → Exposure to:
→ Increased Paternal Age ▪ Ethanol
B. EMBRYOLOGY: SHORT REVIEW
● 📢 Embryologically, it is a failure of fusion of embryonal facial → Reduced Folic Acid
Concentration
▪ Rubella virus
▪ Thalidomide
clefts.
→ Amniotic Band Syndrome ▪ Aminopterin
● LIP → PALATE
📢
→ The lip fuses ahead of the palate .
D. CLASSIFICATION
● INCISIVE FORAMEN ● Clefting of the lip and palate have a variety of forms and
📢
→ Divides the palate into the primary and secondary palate combinations.
▪ Cleft of Primary Palate: ANTERIOR to the incisive ● The THALLWITZ CLASSIFICATION (or LAHSAL
foramen Classification) is recommended for the diagnosis.
▪ Cleft of Secondary Palate: POSTERIOR to the incisive
foramen
1. COMBINED OR ISOLATED
Figure 7. (Left) Isolated cleft lip; (Center) Combined cleft lip and palate;
(Right) Isolated cleft palate.
2. UNILATERAL OR BILATERAL
Figure 8. (Upper Left) Left unilateral cleft lip; (Upper Right) Bilateral cleft lip;
(Lower Left) Bilateral cleft lip and palate; (Lower Right) Bilateral cleft lip with
full palate.
Figure 4. Thallwitz Classification a.k.a. LAHSAL CLASSIFICATION
3. COMPLETE OR INCOMPLETE
(Right Lip, Right Alveolus, Hard palate, Soft palate, Left Alveolus, Left Lip).
● 📢 Need to be able to describe if it is:
→ combined cleft lip and palate, an isolated cleft lip, or an
isolated cleft palate;
→ bilateral or unilateral;
→ complete or incomplete.
▪ complete: cleft crosses the nasal sill
▪ incomplete: cleft does not cross the nasal sill
💡 Lips and Nose Subunits | Short Review by Dr. Uy-Regalado
Figure 9. Incomplete and complete cleft
4. UNILATERAL CLEFT LIP AND CLEFT PALATE

Unilateral Cleft Lip
Figure 5. (Left) Ala and Columella of the nose; (Right, red line) Vermillion
border of the lip.
Figure 11. Left unilateral cleft lip
● Nasal floor → Oral Cavity
📢
→ Nasal floor communicates with the oral cavity.
● Hypoplastic Maxilla
📢
→ Maxilla on the cleft side is hypoplastic.
● Displaced Columella
Figure 6. Normal lip and palate.
📢
→ Columella is displaced to the normal side.
Unilateral Cleft Lip and Palate
Figure 14. (Left) Microform cleft; (Right) Submucous cleft.

Figure 12. (Left) unilateral cleft lip and palate; (Right) aberrant insertion of
E. MANAGEMENT
🚩 PRE-SURGERY
the orbicularis oris.
● Displaced Nasal ala ●
→ 📢 Nasal ala on the cleft side is laterally, posteriorly, and → 📢 As a primary care physician, familiarize yourselves with all
inferiorly displaced. the recommended pre-surgical interventions
● Lower and more obtuse lower lateral cartilage ● PRIMARY SURGERY
● Aberrant Lip Muscle Insertion → initial interventions designed to correct the ASSOCIATED
→ 📢 Note that the orbicularis oris or lip muscle, which is DEFORMITIES
supposed to be the oral sphincter, is discontinuous on either ● SECONDARY SURGERY
side of the defect. → follow-up interventions designed to correct the RESIDUAL
→ Instead of making their way around the mouth, this muscle DEFORMITIES
inserts aberrantly into the ala and columella. ● All these [are done] to achieve the management goals of:
5. CLEFT PALATE → To restore function
→ To achieve acceptable facial aesthetics
● Normal Anatomy
→ 📢
Normally, soft palate muscles are supposed to function as 1. PRE-SURGERY: EARLY DIAGNOSIS
a sling from their origin in the temporal bone to their ● Prenatal diagnosis with the use of an ultrasound is part of the
aponeurosis across the midline as they elevate the soft management
palate towards the posterior pharyngeal wall. → PRENATAL ULTRASOUND has a 73% rate for detecting
▪ The soft palate muscles are involved in swallowing and fetal cleft lip
speech, as well as maintaining the integrity of the ● Isolated cleft palate (1.4%) is difficult to diagnose via
eustachian tube. ultrasound due to technical limitations.
● Aberrant insertion of soft palate muscles. ● 📢 In a country like the Philippines wherein there is poor
→ 📢
In a palatal cleft, these soft palate muscles insert on the prenatal care, this is rarely done. The deformity is usually
posterior margin of the remaining hard palate, rather than the discovered at birth as a surprise. So often we miss the
midline raphe; hence, swallowing, speech, and integrity of advantages of prenatal diagnosis.
the eustachian tube are affected. ● Advantages
→ Psychological preparation and Education of parents
→ Opportunity to investigate other abnormalities
→ Possibility of fetal surgery
● Disadvantages:
→ Emotional disturbance
→ High maternal anxiety
→ Dysfunction
→ Termination of pregnancy
2. PRE-SURGERY: INFANT FEEDING PRACTICES (2000)
Figure 13. (Left) Normal anatomy of the palate; (Right) Aberrant muscle ● Infant and Young Child Feeding (IYCF) Practices
insertion of soft palate muscles.
● All newborns with Cleft Lip +/- Cleft Palate are encouraged to
6. OTHER TYPES OF CLEFT be breastfed
● MICROFORM CLEFT → 📢
Since the year 2000, the nurse specialist in the
→ May appear like a dent on the red part of the lip or like a multidisciplinary team has promoted breastfeeding.
scar from the lip up to the nostril. ● Education about the benefits of breastfeeding
→ The muscle tissue underneath the cleft can be affected and ● Evaluation of sucking swallowing ability by the nurse
may require surgery. specialist
● SUBMUCOUS CLEFT ● Demonstration and assistance of holding, positioning,
→ Bony defects of the palate but are covered with oral mucosa, latch-on, and rhythmic squeezing of the breast during
presenting only as a bifid uvula. breastfeeding by the nurse specialist
→ A bifid uvula is usually asymptomatic because the uvular
muscles have minimal contribution to the normal speech.
Feeding Difficulties ● Generally, infants with cleft lip, cleft palate, or both as their sole
● Feeding difficulties either in breastfeeding or use of regular health problem swallow normally, but suck abnormally.
bottle are expected from infants with cleft deformities ● Unlike in infants with PIERRE ROBIN SEQUENCE, wherein
● The purpose of the palate is to separate the mouth from the both sucking and swallowing are problematic aside from the
nose associated airway problem.
● Normally, the soft palate at the back of the throat moves up to → Other modes of feeding may be considered for these
close off the passage to the nose during feeding. This creates a patients after evaluation.
closed system. The sucking motion creates a negative pressure Feeding Techniques
which pulls the milk out of the breast or bottle ● Note that none of these bottles and nipples are available in
● A cleft lip may hinder sucking as the oral sphincter muscle regular stores
is discontinuous ● All of these work without the baby needing to create intraoral
● Cleft Lip + Cleft Palate / Cleft Palate suction in order to pull milk out of the nipple.
→ No closed system 1. SOFT BOTTLES
▪ 📢 A cleft palate prevents the infant from creating a closed ● Specific bottles particularly soft squeezable bottles that can be
system in his/her mouth, and makes it difficult for the milk squished in coordination with the baby’s sucking effort
to be pulled out.
→ Inability to generate a negative pressure
→ Lack of suction
▪ 📢 The infant may look like he/she is sucking, but they are
only using up precious calories in a futile attempt to gain
adequate nutrition.
Figure 16. (Left) Baby fed using a customized feeding bottle; (Right)
Specially designed feeding bottles for cleft palate.
2. MODIFIED NIPPLES
● Modified nipples with one way valve that keeps the nipple full of
milk
3. UPRIGHT POSITION
● A special fiddle technique in an upright sitting position can be
Figure 15. Feeding difficulty with cleft deformities. considered.
Feeding Consideration Serious Feeding Problems

Table 1. Assessment of sucking feeding techniques for infants with cleft lip ● Serious problems with sucking will occur in 3 cleft-related
and palate. (See Appendix A.) anatomic deficits:
→ Bilateral Cleft Lip and Palate
▪ 📢with severe anterior projection of the premaxilla that
precludes stabilizing the nipple
→ Wide Palatal Clefts
▪ 📢offer no backboard for tongue movements
→ Retroplaced Tongue
▪ 📢does not stoke the nipple effectively
● PIERRE ROBIN SEQUENCE
→ involves Wide Palatal Clefts and a Retroplaced Tongue
→ there is difficulty coordinating sucking and swallowing with
associated breathing difficulty.
● Breastfeeding in an infant with an isolated cleft in the soft

palate and isolated cleft lip works well.
● In infants with broad wide cleft lip, some problem solving may
be needed to ensure that the infant can get a tight seal around
the breast or nipples
● Breastfeeding may be a little more difficult for an infant with
cleft in the lip and alveolus, the bony palate or
combination. Figure 17. (Left) Wide palatal cleft; (Right) Bilateral Cleft Lip
● The cleft will generally preclude the generation of any
negative pressure unless the deficit can be plugged.
3. PRE-SURGERY: AIRWAY
● However, in infants with functionally small air leaks, they ● Major airway obstruction is uncommon among patient with cleft
may produce partial and intermittent negative pressure – ● If present, it is observed during feeding and sleeping
allowing sucking to be possible. Breastfeeding sometimes ● Intermittent episodes of airway obstruction
succeeds. → usually improve by placing the infant in PRONE POSITION
● Persistent airway obstruction

→ require OPERATIVE AIRWAY EVALUATION
→ escalate care to an ENT specialist.
● Persistent and serious airway problems are expected in cleft
palate patients with structural or functional anomalies
→ observed in patients with PIERRE ROBIN SEQUENCE:
▪ Micrognathia (mandibular hypoplasia)
▪ U-shaped Cleft Palate
▪ Glossoptosis (posterior tongue position)
− with resultant upper airway obstruction
− airway distress may develop from the tongue becoming
lodged in the palatal cleft.
Figure 20. Naso-Alveolar Moulding
5. PRIMARY SURGERY PROCEDURES

Table 2. Primary surgery procedures and its timing
PROCEDURES TIMING
Cheiloplasty As early as 3 months
Figure 18. Infants with airway problems
Alveoplasty (soft tissue only) Can be done with primary
4. PRE-SURGERY: PRESURGICAL ORTHODONTICS cheiloplasty or
● Would require referral to a specialist dentist or ENT for fitting until the ideal age of bone
and fabrication of either an obturator or naso-alveolar mold. grafting is
DENTAL OBTURATOR/PASSIVE MAXILLARY OBTURATOR Primary rhinoplasty Can be done primary
● An intraoral prosthetic device that fills the palatal cleft and cheiloplasty or until the ideal for
definitive rhinoplasty is reached
provides false roofing, which the child can suckle.
● It reduces feeding difficulties like insufficient suction, choking Palatoplasty 12 to 18 months
Ventilation tube insertion As indicated
🚩 A must know and a must do is to advice the timing of
and excessive air intake.
● An alternative with disadvantages ●
→ This is offered for high risk patients or those that refuse surgical interventions to the parents
surgery. CHEILOPLASTY
→ Disadvantage: The child needs to wear a prosthesis, and it ● Primary closure of the lips is undertaken between 2-4 months
needs to be modified as the child grows. of age.
● Follow the RULE OF 10
→ 10 weeks of life
→ 10 g of hemoglobin per deciliter of blood
→ 10 lbs. in body weight
● 📢it is at this time that infants are better able to tolerate surgery
under general anesthesia
PALATOPLASTY
Figure 19. Dental obturator ● The cleft palate is done at age 12-18 months.
● Timing of repair corresponds to the emergence of early
NASO-ALVEOLAR MOULDING DEVICE (NAM)
🚩
● infant speech
● To improve surgical results
● Note: since cleft repair is an elective procedure, if any
● An orthopedic device taped across the cleft externally
medical condition jeopardizes the health of an infant, the cleft
→ to bring the deep and alveolus segments closer together or
surgery is postponed until medical risks are minimal.
move the premaxilla to a more normal position to facilitate
MILLARD PROCEDURE
📢
good repair during cleft surgery.
● As a primary care physician, you are expected to refer the ● PRIMARY CLEFT RHINOPLASTY
child for NAM fitting as early as 2 weeks of age to an ENT ● It consists of designing skin flaps, a rotation, a columellar, and
specialist. an advancement flap
● Closure of a cleft lip involves meticulous repair of the skin,
muscle, and mucosa of the lip
● 🚩 Note: correction of the cleft lip nasal deformity is usually
done at the same time by an experienced surgeon
→ Better eustachian tube function

→ There is also better hygiene when the oral and nasal partition
is competent and,
→ Improve psychological stage for both parents and the infant
● Disadvantages:
→ Difficulty of surgery because of the small aperture and the
associated maxillary growth restriction due to scarring
● This results to an impaired midface growth wherein there is:
→ Maxillary deficiency
→ Mandibular prognathism
→ Malocclusion
Figure 21. Millard Procedure
6. PRIMARY SURGERY: CHEILOPLASTY

Figure 23. Concave profile of the face
● What is currently being advocated is a 2 STAGED SURGERY
OF THE PALATE to prevent this midface growth impairment
→ 📢 In a country where in the healthcare system is still
underdeveloped, this is impractical
2 STAGED SURGERY OF THE PALATE
● Soft palate closed; Hard palate remains open
→ Soft palate is closed between 18-24 mos. leaving the hard
palate open
→ this produces a functional velopharyngeal mechanism before
speech skills develop
● Hard palate closed in the preschool years
→ 📢 Later on, the hard palate is closed in the preschool years
around the age of 4-5 yrs old, when all the deciduous teeth
Figure 22. Cheiloplasty have erupted
● The lip is corrected as early as is medically possible because ● Palatal obturators used prior to palatal closure
it performs a favorable molding action on the distorted alveolus. → 📢 Note that some teams have even waited until maxillary
● It assist the child in feeding and it provides psychological growth is completed at around age 11 using only maxillary
benefit mostly to the parents palatal obturators prior to palatal closure
● Facial growth is less affected
7. PRIMARY SURGERY: PALATOPLASTY
● Closure of the palate is a complex surgical procedure
→ 📢 The rationale behind doing this is to allow maxillary
growth to proceed unimpeded before scarring from surgeries
● There are also several surgical techniques all tending
induced, hence facial growth is less affected
towards less scarring and tension
→ However, feeding, speech, socialization may suffer
● It involves reorientation and closure of the layers of the hard
Palatoplasty Complications:
and soft palate
● After undergoing palatoplasty, complication may also be
● One surgical concept to know is the concept of early palatal
observe such as:
closure vs staged palatal closure
● Failure of a part or all of the repair to heal resulting in an
EARLY PALATAL CLOSURE
ORONASAL FISTULA - 16.67%
● It means that both hard and soft palate are CLOSED AT THE 📢
→ with the surgeon being the strongest predictor
SAME TIME → it permits air or fluid to move between the oral and nasal
● Advantages: cavity resulting in snort or nasal regurgitation
→ Better palatal and pharyngeal muscle development ● HYPERNASALITY - 18.6%
→ Ease of feeding → a speech disorder in our vernacular as “NGONGO” or
→ Better development of intonation skills rhinolalia aperta
→ due to velopharyngeal insufficiency wherein there is 9. SECONDARY SURGERY PROCEDURES

inadequate function of the soft palate resulting in nasal air ● 🚩 A must know is also the timing of this secondary surgical
leakage interventions
→ due to scarring, the palate is short and there is decreased Table 3. Secondary Surgery
mobility of the soft palate PROCEDURES TIMING
● Both aforementioned complications may require secondary or
Alveolar bone 7 to 9 years in consultation with the
corrective surgeries
grafting orthodontist
Palate re-repair / As indicated or whenever recommended
Velopharyngoplasty by a speech therapist
Definitive rhinoplasty As early as 14 for Females and 16 for
Males
Lip revision As indicated but not earlier than 6
months from previous surgery
Orthognathic surgery As early as 16 for Females and 18 for
Males
Figure 24. (Left) Oronasal fistula; (Right) Hypernasality ● Alveolar Bone Grafting
→ is done to close the bony defect in the maxilla at 7-9 years in
8. PRIMARY SURGERY: VENTILATION TUBE INSERTION
consultation with an orthodontist
● High incidence of middle ear (ME) disease
→ 📢due to the abnormal anatomy of the palate the incidence
● Velopharyngoplasty
→ Done to correct velopharyngeal insufficiency may improve
of recurrent middle ear disease in children with cleft palate is
🚩
speech quality
very high at 90-95%
→ 📢note that the incidence of ear disease in cleft lip only is
→ Note: the intensive interdisciplinary cooperation of all
specialist, especially the speech therapist is necessary
similar to normal population
● Definitive Rhinoplasty
● Conductive Hearing Loss
→ hearing loss secondary to middle ear disease
→ 📢 must be done as early as 14 years of age once facial
→ 📢this can adversely influence speech and language with

features are fully developed
● Lip Revision
potential consequences on cognitive development and
psychological adjustment
→ 📢 Children may need lip and other revision surgeries to
correct nasal deformities or vermillion discontinuities
● Orthodontic and Orthognathic Surgery
→ 📢to address the dentition and the maxillary retrusion
10. SECONDARY SURGERY: ALVEOLAR BONE GRAFTING
Figure 25. OME: Otitis Media with Effusion; VT TUBE: Ventilation tube
insertion Figure 26. Alveolar bone grafting
● Insertion of a VENTILATION TUBE is the standard treatment ● Alveolar bone grafting surgery consists of harvesting bone
for otitis media with effusion usually performed at the time of the usually from the iliac crest
palate repair ● This collected bone is then placed in the alveolar cleft as seen
● Repeated ventilation tube placement on Fig. 24
→ 📢 50% of these children would require repeated ventilation ● Advantages:
→ Assists in the closure of the buccoalveolar oronasal fistula
🚩
tube placement
● Note: the frequency of ear diseases DECREASE as the → Provides bony support for unerupted teeth and teeth
child with cleft palate ages, owing to the change in the adjacent to the cleft
orientation of the eustachian tube from horizontal to being → Forms a continuous alveolar ridge to facilitate orthodontic
more vertical correction of malocclusion
● Audiologic monitoring → Supports the nasal floor and the base of the ala to improve
→ 📢 Because of the unpredictable course of middle ear nasal aesthetics
disease in young children with cleft palate, audiologic
monitoring or on going hearing assessment in
recommended
F. POOR DENTAL CONDITION

● 📢 Children with clefts are more prone to a larger than average
number of cavities and often have missing extra malformed
or displaced teeth requiring dental and orthodontic treatments
→ Abnormal morphology
→ Hypo/hyperdontia
● 📢 As a primary care practitioner, just reinforce PROPER
DENTAL CARE AND HYGIENE
G. SUMMARY OF THE TIMING OF INTERVENTIONS
Figure 28. Microtia
● Referred at birth
→ Address primary concern
→ Outline a basic plan of management
● 🚩 Aural atresia is present in 80% of patients

→ A great majority of patients with microtia have an associated
aural atresia.
● AURAL ATRESIA is defined as failure of the development of
external auditory canal, which has varied clinical presentations.
● 📢 The external auditory canal could be:
→ patent but blind ending
Figure 27. Timing of interventions → completely absent with associated abnormal development
● The ideal cleft care is sequenced and step-laddered, and or even absence of middle ear structures
patients is managed until adulthood
🚩
● This results in conductive hearing loss on the affected side
● Hence, the final results of a surgical repair of a cleft can only be ● Note: the inner ear function is usually normal on the
judged conclusively when the individual growth is complete at affected side
around 10-20 years later → Meaning the bone conduction is normal in 95% of the cases.
H. SUMMARY OF CLEFT MANAGEMENT → This is because the inner ear has a different embryological
● Early assessment and intervention origin from the outer and middle ear.
→ Imperative and ideally should begin in the prenatal and
newborn period
● Multidisciplinary team approach is necessary
● Continuity and coordination of care
→ Necessary because outcomes are measured throughout the
child’s life and team care is linked to improve outcomes
● Proper timing of interventions
→ Critical because of the interaction of facial growth, dental
occlusion, and speech
● Proper early management
→ Leads to better outcomes and fewer surgeries
II. MICROTIA
💡
📢
Case Scenario 3: Microtia | Video lecture
● Given this patient with left ear deformity, which we call microtia,
brought about by an abnormal development of the pinna.
● As a primary care physician, you are expected to reassure the Figure 29. (Upper) Normal ear; (Lower) MIcrotia with aural atresia
parents of the child by addressing their primary concern A. CLASSIFICATION
which is the possibility of hearing impairment
● Outline a basic plan of management for this child
→ e.g. the need for diagnostic tests, hearing aid amplification,
surgical intervention
● Emphasize also the need for multidisciplinary care and most
especially their referral to an ENT specialist
Figure 30. Classification of microtia (See Appendix B.)
● 🚩 Note: there is a positive correlation between the degree of D. MANAGEMENT

microtia and the severity if aural atresia as well as the degree of ● Goals: to maximize the opportunity for good hearing and
middle ear deformity achieve optimal cosmesis
GRADE 1 ● Investigate for:
● The ear is misshapen but all anatomic subunits are present. → Hearing status: Age appropriate hearing tests
● It is smaller than normal, but the ear has mostly normal ▪ Otoacoustic Emission (OAE) and Auditory Brainstem
anatomy. Response (ABR) to document hearing function in the
normal ear and the degree type of hearing loss in the
GRADE 2
🚩
affected ear.
● The ear lacks anatomic subunits.
▪ Unilateral atresia and the associated hearing loss may
● Part of the ear looks normal, usually the lower half.
have an impact in child’s development, and the child’s
● The ear canal may be normal, small, or completely closed
progress and hearing should be closely monitored.
GRADE 3 → Associated malformation
● What we call the “peanut ear”. ▪ Renal ultrasound
● There is a small remnant of skin with fibroadipose lobule, ▪ Cervical xray
located inferiorly and cartilage remnant superiorly.
🚩
▪ Panoramic view of the mandible for malocclusion
● There is no canal ● CT scan is not immediately indicated. It is requested prior to
GRADE 4 atresia repair surgery to evaluate ear canal and middle ear
🚩
● ”Anotia” structures.
● Wherein there is complete absence of both the external ear and ● If microtia is the only developmental anomaly, the initial
the ear canal. workup consists only of evaluation of hearing status
● This is the most severe form. 1. CONSIDERATIONS
B. EPIDEMIOLOGY Unilateral Microtia
● Prevalence rate of microtia in different populations: ● Affected ear can still hear by some degree because the inner
→ 0.8-4.2 per 100,000 in births in different populations ear is normal, therefore, bone conduction is normal
▪ Philippines: 22.4/10,000 births in a study conducted ● Unaffected ear is usually normal, so speech development is
between 2011 to 2014
🚩
usually at par with age
🚩
● 10% Bilateral ● As long as microtia is unilateral, these children are likely to
→ Note: Mostly a unilateral phenomenon in 90% of cases have normal speech.
● Right ear > Left ear
● Males > Females
2. MANAGEMENT FOR HEARING RESTORATION
● Associated with a syndrome or other congenital ● Educational support
malformations ● Conventional hearing aids
→ 40% of patients are known to have a syndrome or have ● Bone conduction hearing aids
associated congenital malformations mostly of the face, ● Bone anchored hearing aids and other implantable devices
followed by the kidneys, vertebra, and the heart. Bone Conduction Hearing Aids
C. ETIOLOGY ● Not needed:
● The key causative factors are disturbances in the regulation → Children with unilateral microtia and aural atresia with
of neural crest cell proliferation and/or migration. normal hearing of the contralateral ear are expected to
● 15% has a genetic or environmental cause, which are similar develop speech normally.
contributory factors to other congenital malformations: ● Needed permanently or pending surgery:
→ Fetal Alcohol Syndrome → Children with bilateral microtia and aural atresia must be
→ Maternal Diabetic Embryopathy fitted shortly after birth if speech is to develop.
→ Thalidomide and Isoretinoin exposure
● Another cause is vascular disruption or reduced blood flow
leading to ischemia and poor growth or tissue necrosis, which
could be brought about by intra-uterine ischemia
● No consistent inheritance pattern
→ The incidence of familial cases of microtia ranges from
3%-34%
→ About 5% of cases have an immediate family member with
ear deformity as well
→ Parents with two affected children have a higher risk of
recurrence as high as 15% in the subsequent pregnancy.
Figure 31. Bone Conduction hearing aids
Table 4. Options for microtia management III. SADDLE NOSE DEFORMITY

TYPE
Observation No risk
ADVANTAGES DISADVANTAGES
Appearance 💡
📢
Case Scenario 4: Saddle Nose Deformity | Video lecture
Prosthetic
Adhesive ● Appearance ● Less secure
retained attachment
● Ongoing prosthetic
care
● Daily maintenance use
Implant ● Appearance Multiple procedures
retained ● Secure retention ● Requires removal of
remnant and soft
tissue
● Ongoing prosthetic Figure 32. A 21 year-old male, complaining of a deformed nose
care ● History of present illness revealed that 6 years prior to consult
● Daily maintenance his nose was hit during a basketball game. He remembered that
● Use restrictions his nose became swollen, black, and painful 3 days after the
Reconstruction accident.
Rib cartilage ● Autogeneous tissue ● Inconsistent ● He sought consult in the emergency room and was given
(autogenous) ● Minimal maintenance appearance unrecalled medicine which he took, but never sought consult to
● Becomes senate ● Donor sites an ENT specialist as advised.
● Atresia repair (PINNA ● Multiple surgeries ● Over the years, he noted progressive flattening over an area on
RECONSTRUCTION) ● Reconstruction
his nasal bridge, up until it became like soin Fig 32.
performed betw. 6-10
● Presently he does not complain of any pain, any persistent
years of age
nasal obstruction.
Medpor ● Loss donor site ● Foreign body
● On physical examination, it showed dipping of the external
morbidity ● More challenging to
● Less variability in integrate with atresia structures, between the nasal bone and nasal tip with upward
carving repair tilting of the nasal tip.
● Reconstruction ● In this case, you can see a loss of dorsal septal cartilage, which
performed at earlier is called saddle nose deformity. This can collapse the nasal
age valves, so there could be complaints of nasal obstruction.
● Observation: no reconstruction, no prosthesis Luckily for this patient, he does not complain of persistent nasal
→ May not the best option once the child’s concept of body obstruction.
image beings to evolve at 4-5 years of age.
→ The child begins to be disturbed usually by age 7 ● SADDLE NOSE DEFORMITY: A marked depression or
→ Molded prosthesis or reconstructive surgery may need to be collapse along the mid portions of the nasal bridge resembling
considered the look of a saddle when looking at the nose from the side
● Reconstruction of the ear with rib cartilage view.
→ Staged procedure: multiple surgeries are required
→ A challenging surgery
→ Usually performed at 6-8 years of age with unilateral
microtia because the pinna is 85-90% of its adult size by this
age.
▪ The patient is usually large enough that rib size is
sufficient to harvest an adequate rib graft.
→ Surgery may be done earlier if the child has adequate rib
size and postponed if not.
→ With regards to the associated aural atresia, the
reconstruction of the pinna deformity must be done first
before the atresia repair to preserve the skin and blood Figure 33. Saddle Nose Deformity
vessels for a better outcome of pinna reconstruction.
A. CAUSES OF A SADDLE NOSE
● Depressed nasal bone fracture
📢
→ The most common cause is NASAL TRAUMA.
● Others: Iatrogenic, TB, Leprosy, or Syphilis
→ 📢 Other causes include, excessive removal of the nasal
septum during, submucous resection surgery, or destruction
of septal cartilage by hematoma or abscess, TB, leprosy or
syphilis
B. PATHOPHYSIOLOGY OF A SADDLE NOSE D/T

TRAUMA
💡
📢
Case Scenario 4: Management | Video lecture
Figure 34. Pathophysiology of saddle nose due to trauma Figure 36. Open rhinoplasty technique sing a pre-formed customized
● 📢 Due to the shearing of the submucosal blood vessels brought silicone implant.
● There is marked improvement in terms of the previously
about by the trauma, a hematoma can form in the nasal septum.
collapsed nasal bridge with better nasal tip support.
● In this case a silicone implant was used due to financial
constraints.
● Chances of rejection were thoroughly explained, he wanted to
see first if it would suffice before considering other more
invasive and more expensive surgery.
● This translated into a bridge and a nasal tip which now look
much more natural and more harmonious with his face.
📢 If you will do a complete PE of the nose on all patients with

Figure 35. Bilateral swelling of the nasal septum with nasal blockage.
●
nasal trauma, you will not miss this, as this would present as
bilateral swelling of the nasal septum with nasal blockage.
● 📢If a diagnosis of septal hematoma was missed. and therefore
was not drained immediately, septal cartilage necrosis would
happen then a septal abscess will form.
● This would compromise the septal cartilage leading to
decreased dorsal nasal structural support, manifested as saddle
nose.
C. MANAGEMENT: SADDLE NOSE
🚩 The challenge for patients with nasal bone fracture
● To rule out septal hematoma
→ 📢
because it can lead to a saddle nose deformity, which has
aesthetic and functional repercussions. Figure 37. The same patient after a year. (Right) The rib carved to
● To emphasize the importance of being seen by an ENT augment his nasal dorsum.
specialist. ● Rib harvesting was eventually performed because his silicone
● Surgical correction for patients: implant was rejected.
→ w/o nasal obstruction: ONLAY GRAFTING
→ w/ nasal obstruction: SPREADER GRAFTS or RIB IV. FACIAL NERVE PARALYSIS
HARVEST to reconstruct the nasal valves ● 📢 Facial paralysis is devastating not only cosmetically but also
● AUGMENTATION RHINOPLASTY functionally.
→ The depressed nasal dorsum can be filled with either:
▪ Cartilage: nasal septum or concha 💡
📢
Case Scenario 5: Facial paralysis | Video lecture
▪ Bone: iliac crest or rib

▪ Synthetic implant: Silicon (likely to be extruded)
→ Autografts are preferred over allografts
Figure 38. Facial nerve paralysis
C. APPROACH TO DIAGNOSIS
● A 28-year-old female complaining of sudden onset of
● History is of vital importance
unilateral paralysis of her entire left side of the face noted
→ the time, course, duration of paralysis may help predict the
upon waking up.
likelihood of recovery.
● PE showed inability to smile, close the eye, or raise the
→ Previous trauma, surgery, or infection may help in arriving
eyebrow on the left side. Whistling is also not possible.
with a diagnosis
● There is loss of muscular tone.
● Physical examination would include looking for:
● There is obliteration of the nasolabial fold, and drooping of the
→ Tenderness over the mastoid or preauricular area
corner of the mouth on the left side.
→ Vesicles of the pinna or external auditory canal
● Furthermore, she complained of dry eyes & loss of taste
→ Signs and symptoms of otitis media
● Our patient has total paralysis, so she is graded at 6/6 on
🚩
→ Presence of other cranial nerve deficits.
consult meaning there is loss of tone, no movement of the
→ Note: The face should be examined at rest and
forehead, eye, and mouth.
movement using the House-Brackmann scoring.
● Evaluation would also include topodiagnostic tests and nerve
A. FACIAL NERVE FUNCTION
excitability tests
📢
● Contraction of the muscles of the face
→ can confirm the presence of nerve damage and determine its
→ particularly muscles for facial expressions
severity.
→ The face plays an integral part in our everyday lives–we use
● Imaging like CT, MRI may be needed to rule out other presence
it when we smile and other non-verbal communication
of pressure at the facial nerves such as tumor or skull-base
● Production of tears from the lacrimal gland
fractures.
● Conveying the sense of taste.
● Sense of touch at the auricular concha. 1. HOUSE-BRACKMANN FACIAL NERVE GRADING
B. ETIOLOGY: FACIAL NERVE PARALYSIS SYSTEM
T/N underlined etiologies were highlighted in the video lecture 13:20. See Appendix C.
● Congenital ● Is used to objectively describe the degree of facial nerve
→ Mobius syndrome paralysis.
→ Myotonic dystrophy ● This is a standard category to assess facial nerve function.
● Neurologic ● Many of these symptoms will change overtime as a result of
→ Guillian-Barre spontaneous recovery of nerve function or as a result of
→ Myasthenia Gravis different therapeutic modalities.
→ Stroke 2. TOPODIAGNOSTIC TEST
→ Multiple sclerosis ● Done to localize the site of lesion on the course of the facial
● Toxins/Trauma nerve.
→ Head trauma ● The facial nerve has a very long course that has an intracranial
→ Temporal bone trauma and extracranial component.
→ Birth trauma
● Infectious/Idiopathic
→ Melkerson-Rosenthal syndrome
→ Ramsay-Hunt
→ Otitis media/Mastoiditis/Meningitis
→ Lyme Disease
→ Necrotizing Otitis externa
→ HIV, TB, EBV syphilis
→ Tetanus
📢
→ BELL’S PALSY (Idiopathic) most common
● Tumor
→ Parotid
▪ 📢Tumor invading the parotid gland, or paralysis could be
iatrogenic after a parotid or mastoid surgery
→ Acoustic neuroma Figure 39. The ENT specialist usually performs these tests: Schimer test,
stapedial reflex test, taste test, and submandibular gland flow test.
→ Glioma
→ Meningioma 3. UMN VS. LMN
→ Facial neuroma SUPRANUCLEAR LESION (UMN)
● Endocrine
● Paralysis of the lower part of the face.
→ DM
→ Pregnancy
→ 📢usually as a part of hemiplegia
→ only the lower part of the opposite/contralateral side of
→ Hypertension
the face is paralyzed.
● Partial paralysis of upper part of the face
→ 📢 the upper part with the frontalis and orbicularis oculi ● Common in middle aged people
escape paralysis due to bilateral representation in the → It can occur in any age
cerebral cortex. → More common in middle aged people.
→ The upper part of the face is innervated bilaterally by the ● R = L, but usually UNILATERAL
upper motor neuron, while the inferior half has only → Bilateral paralysis occurs in 0.3% only.
contralateral innervation. ● History
📢
📢
● This is seen mostly in intracranial lesions like stroke. → (+) Past Medical History and (+) Family History.
● Normal taste and saliva secretion → Most patients would have a history of previous facial
● Stapedius not paralyzed paralysis and a family history of Bell’s palsy can be elicited
INFRANUCLEAR LESION (LMN) in 8% of cases.
● Complete paralysis of 1 side of the face (same/ipsilateral 2. COURSES & PROGNOSIS: BELL’S PALSY
side) T/N: Audio was cut-off at 17:49
● 📢 The fibers carrying lower motor neurons, supplying half the ● Incomplete: excellent (95-100%)
face are all within the facial nerve. ● Complete: poorer
● This is seen in BELL’S PALSY. → Recovery takes longer
→ The face becomes asymmetrical and is drawn up to the → (+) Residual palsy and or synkinesis
normal side, the whole affected side is motionless. ● Factors associated with poor outcome:
→ Hyperacusis
→ Decreased hearing
→ >60 years
→ Diabetes Mellitus; Hypertension
→ Severe aura, facial, or radicular pain
3. MANAGEMENT: BELL’S PALSY
● Most significant complication: PSYCHOLOGICAL TRAUMA
→ i.e. The social isolation most patients often succumb to.
● Most serious complication: CORNEAL DAMAGE
→ due to insufficient lid closure and abnormal tearing
mechanism
● Eye care: The eye should be protected from dehydration,
drying, and abrasions.
→ Eye patch
→ Lubricating eye drops and eye ointment
● Primary care physicians are expected to be able to advise these
initial interventions prior to ENT referral of the patient.
● Medical management: STEROIDS +/- ANTIVIRAL
→ Prednisone 1mg/kg/day for 7-10 days
→ Acyclovir 400mg 5 times a day
▪ Alternatives: Famciclovir e Valaciclovir 500mg BID
Figure 40. UMN vs LMN
● Adjunctive treatments:
D. BELL’S PALSY → INFRARED
● Was ascribed to Sir Charles Bell who in 1821 demonstrated the → Galvanism
separation of motor and sensory innervation of the face. → Daily massage of the face
📢
● Bell’s palsy is a diagnosis by exclusion
→ Before you label everyone with facial paralysis as having
PART 2: SOFT TISSUE INJURIES OF THE FACE
Bell’s palsy, as the primary care physician you need to rule I. DIAGNOSTIC ASSESSMENT
out supranuclear or upper motor neuron lesions first.
● The following criteria should be met.
💡
📢
Case Scenario 1: Bony injury | Video lecture
→ Paralysis or paresis of all muscle groups of one side of

the face
→ Sudden onset
→ Absence of signs CNS disease
→ Absence of signs of Ear disease
1. EPIDEMIOLOGY: BELL’S PALSY
● Sex Predilection F > M
● Common in pregnancy
Figure 1. 21 year old male who sustained multiple hacking wounds mostly
→ It is more 3.3x more common in pregnancy. over the face and other parts of the body.
→ Occurs during the 3rd trimester
● Observe ABCs of trauma

→ Diagnostic assessment of an individual with trauma to the
face must start with an evaluation of the patient’s airway,
breathing, and circulation.
→ Head trauma and cervical spine injury should also be
considered based on the mechanism of injury, and
appropriate precaution should be taken.
Figure 2. Facial nerve injury repair
● Implement Resuscitative measures
● Perform diagnostic tests as needed C. DUCT INJURY
→ Once stabilized, another survey must be performed. ● There are two ducts in the head and neck region that if injured
● Examine the wound will cause dysfunction.
→ Irrigate and clean the wound with plain NSS and remove all → LACRIMAL DUCTS
the blood to examine the wound. → PAROTID DUCTS
→ Residual debris may leave [a] tattoo on the dermis → scrub
🚩
to remove them
→ Note: It is imperative to remove all foreign bodies at initial
treatment or repair.
→ Assess depth of the wound, layers, and structures affected
● Perform definitive management
→ Must be carried out promptly.
II. EXAMINATION OF THE WOUND
A. BONY INJURY
● Detected by observation
● Observe for:
Figure 3. Lacrimal and parotid ducts
→ hyposthesia: decreased sensation of the cheek ● These ducts will need to be cannulated to determine whether
▪ most commonly injured is the infraorbital nerve, which they are intact and functioning.
occurs with fractures of the infraorbital rim
→ asymmetry or deformity
→ Change in function:
💡
📢
Case Scenario 1 | Video lecture
▪ trismus: mandibular fracture

▪ diplopia: orbital floor fracture
● Likewise detected by doing palpation and requesting for
radiographic evaluation
● Need to be reduced and stabilized before repairing the soft
tissue injuries.
B. NERVE INJURY
● The facial nerve is at particular risk in lacerations at the region
of the parotid gland.
→ All level of CNVII must be assessed and documented.
● If injured, motor deficits will be present and repair of the nerve
must be performed.
1. FACIAL NERVE REPAIR
● Repair transection done immediately within 72 hours
→ Delayed repair will be difficult or nearly impossible to do as Figure 4. Encircled: Injury to the lateral brow and upper lid
the distal severed ends will contract. ● The lacrimal gland system over the lateral brow and upper lid
● Repair is done using appropriate instruments and expertise is suspected to be injured.
in micro-anastomotic surgery. → Keep in mind to refer the patient to an ophthalmologist.
● Nerve anastomosis: ● If injured, repair is via DACRYOCYSTORHINOSTOMY
→ done under a microscope under a non-absorbable 10-0 → Best carried out 3-6 weeks after the initial injury.
suture in 3-4 position circumferentially under minimal tension
to prevent fibrosis. 1. PAROTID DUCT INJURY
● Considered if CN VII buccal branch paralysis (inability to
blow) is present with an overlying laceration.
→ because the parotid duct travels agent to the buccal branch
of the facial nerve
● Should be repaired at the time of wound closure to prevent
fistula to the skin or to the mucous membranes of the mouth
● The tube is left for a two week period

● If a portion of the duct is missing, leave the tube for 6 weeks
and often the endothelium will breach the gap.
● If the duct is not easily repaired, re-route it directly to the oral
cavity or ligate it.
2. PAROTID PARENCHYMA INJURY
● Will only create a draining sinus to the skin, which heals
spontaneously most of the time.
● You do not need to worry about this, but you need to call a
specialist if the duct is injured.
D. VESSEL INJURY
● Only injury to the INTERNAL CAROTID ARTERY,
VERTEBRAL ARTERY, and INTRACRANIAL VESSELS cause
dysfunction as there are plenty of vascular anastomosis in this
Figure 5. Relationship of the facial nerve and the parotid gland region.
● TRAGOLABIAL LINE: The Stensen’s/Parotid duct courses ● LIGATE: if the vessel is big enough to be named
along the middle third of a line drawn from the notch of the → e.g. External carotid artery, facial artery, and angular artery
above the tragus to a point midway between the oral ● CAUTERIZE: smaller vessels
commissure and the alar rim (dotted line on Fig 5)
E. MUSCLE INJURY
● At the anterior border of the masseter muscle, the duct makes a
● must be detected at the time of wound examination
sharp right angle and pierces through the buccinator muscle to
● must be realigned as precisely as one can to regain normal
enter the buccal mucosa.
function
SILASTIC TUBE
F. TENDON INJURY
● The parotid duct emptied into the mouth opposite the maxillary
● The most important tendon in the face: MEDIAL AND
or upper second molar to drain the secretions of the gland into
LATERAL CANTHI
the mouth.
● Injury will present as widening of the distance between the
● Through this opening in the mouth, a silastic tube can be
pair of eyes, and this must be repaired.
inserted and can be visualized into the wound exiting the distal
● This is commonly seen in: nasoethmoorbital fracture, nasal
ends of the transected duct.
bone, and Le fort fractures.
● To investigate for injuries, the duct can be irrigated with saline
through the tube that is inserted intraorally.
→ The appearance of saline in the wound indicates that the
duct is injured.
● The proximal end of the duct can be identified in the wound
expression secretions of saliva.
Figure 8. Telecanthus
💡
📢
Case Scenario 1: Management | Video lecture
● The patient at the operating room ready for definitive
management.
● Knowing that this is a contaminated wound, [we] tried our best
to clean the wound after induction of anesthesia.
● Antibiotic treatment was also started.
● While cleaning and removing debris and blood, the extent of the
Figure 6. insertion of silastic tube injury was assessed to be the following:
→ Multiple Facial Lacerations
▪ Over the forehead
▪ Over the lateral brow and upper lid area going to the
lower lid and left nasal ala
▪ Laceration of the scalp and left parietal area
▪ Through-and-through laceration on the left malar and
parotid area
→ Parotid gland parenchyma injury
▪ No parotid duct and lacrimal system injury
Figure 7. Repair of parotid duct over a silastic stent with interrupted sutures ▪ Parotid duct is still attached and intact
using Loupe or microscopic magnification.
● Cleansing and observation is usually sufficient

→ Fracture of the ramus of the mandible
→ some hematomas will spontaneously resolve
→ Was not able to assess for full motor deficits
→ Other hematomas will require surgical intervention (e.g.in the
▪ But based on the presentation of the wound, the
ear and the nasal septum)
zygomatic and buccal branches of the facial nerve are
suspected to have been transected.
Figure 11. Contusion
B. ABRASION
● Are partial thickness disruptions of the epidermis as a result
Figure 9. Patient before repair of sudden forcible friction
● 🚩 Remember to address bony injury first before the soft ● This wound should be gently cleansed of all debris.
injuries. → failure to remove debris can lead to tattooing of the skin and
● Reduction was done via intraosseous wiring of the a poor cosmetic result.
mandibular fracture and complex layered closure of soft ● Local and regional anesthetic may be required to make the
tissue injuries in different regions of the face with special patient more comfortable and to achieve adequate cleaning.
considerations to the unique features of each area. ● Lubrication of the wound using an antibiotic ointment and
● At this time, [we] did not have the proper instruments, nor the covering it with a sterile bandage may encourage healing.
expertise to undertake repair of nerve transection or
micro-anastomotic surgery.
● [We] contemplated on repairing with nylon 8-0, which was the
best that could be found at that time, but [we] could not find the
distal ends of the nerve and [we] needed to prioritize other
pressing medical and surgical concerns, as he also has hacking
wounds in different parts of his body, particularly in the
abdomen and the chest.
● This patient will need facial reanimation surgery later on.
● This is the patient after meticulous repair and suturing. Aside Figure 12. Abrasion
from facial reanimation surgery, this patient is also a candidate C. ACCIDENTAL TATTOO
for scar revision. ● Happens when embedded particles in the dermis are not
removed promptly.
→ If left for more than 24-48 hours fixation can occur.
● Removal of the embedded particles:
→ Scrub with a stiff bristle brush.
→ Grease or oil may be removed using ether or acetone
Figure 10. Patient after surgery
III. CLASSIFICATIONS OF INJURY

● Contusion ● Puncture Wounds
● Abrasion ● Simple Laceration
● Accidental Tattoo ● Avulsion (flap)
Figure 13. Accidental tattoo in a patient
● Retained Foreign Bodies ● Avulsion (complete)
A. CONTUSIONS D. PUNCTURE WOUNDS
● Are not common in the face.
● Bruising injury caused by blunt trauma
● Injury is possibly in deeper structures.
● May present with or without hematoma
● Often swell due to hematomas.
● Management would include: F. LACERATIONS

→ removal of implanted foreign bodies ● A lacerated wound has a jagged edge (e.g. in a traumatic
→ evacuation of hematomas. shearing injury)
● 📢Puncture wounds are best excised for better healing. → On the other hand, an incision is a clean wound (e.g. what
a knife would make)
● Management would include:
→ Repairs should be undertaken only after underlying
structures have been assessed and all foreign bodies have
been removed.
→ 🚩 Note: the time lapsed between time of injury and repair
is important relative to:
▪ the risk of infection
▪ choice of repair technique
1. GENERAL PRINCIPLES ON THE REPAIR OF
Figure 14. Puncture wound
LACERATIONS
E. AVULSION ● Tissue that is devitalized must be excised regardless of its
● One of the most disfiguring injuries. location or how important it was.
● Avulsion could be a flap with undermining laceration or ● Although debridement should be conservative, it should be
complete with loss of tissue adequate.
1. AVULSION-FLAP (WITH UNDERMINING LACERATION) → 🚩 Note: ragged, severely contused wound edges should
● Management would include: be conservatively excised to provide perpendicular skin
→ Minimal debridement to preserve tissue. edges that would heal primarily with minimal scarring.
→ Removal of beveled wound margins. ● Closely parallel lacerations can be converted to a single wound
→ Application of pressure dressings or drains may be by excising the intervening skin bridge.
necessary to prevent hematomas. → This will facilitate repair and reduce scar formation.
● Displaced tissue should be returned to its original position.
IV. OTHER MATTERS TO CONSIDER IN THE MANAGEMENT
OF SOFT TISSUE INJURIES OF THE FACE
● Guidelines regarding closure of wounds and timing of closure
do not apply to the Head and Neck region as it does in
wounds on the trunk and extremities.
● Any wound in the head and neck region can be closed
primarily as long as you can debride the wound
satisfactorily and cross contamination is minimal.
Figure 15. Type of avulsion injury that presents as flap ● 📢 Dog bites, human bites, and wounds as old as 24 hours
2. AVULSION-COMPLETE (WITH LOSS OF TISSUE) can be closed provided that you can debride the wound
● Another type of avulsion wherein there is complete loss of satisfactorily and cross contamination is minimal.
tissue. → Because the risk of infection, although present, is very small
● Management would include: due to the high vascularity or abundant blood supply to the
→ Should be preferably repaired via direct primary closure. face and neck.
→ A flap or skin graft may be indicated. → If infection does occur, it can be recognized immediately and
→ 🚩 DO NOT LET IT HEAL BY SECONDARY treated effectively before any serious sequelae occur.
GRANULATION ● 🚩 Note: wounds that are left to heal via secondary or tertiary
intention, or wounds that are not closed, will leave unsightly
scars that are unacceptable to the face and to the patient.
● Risk of infection is small.
A. FOREHEAD INJURY
● Requires good deep closure.
● Simple interrupted sutures should be removed in 3-4 days to
prevent track marks.
→ 📢 This is not enough time for adequate healing and
attainment of bone strength.
● 🚩 Preferred suturing technique:
→ Subcuticular running suture (with prolene or nylon) +
Application of steri strips
→ Done so that you can leave the sutures longer and there will
Figure 16. Complete avulsion with loss of tissue. be no track marks
C. EYEBROW INJURY
● Preservation of the eyebrow as much as possible by not
shaving it
● Repair muscles to prevent depression
● Rule out fracture
D. LIP INJURY
● In suturing the lips, it is extremely important to do two things:
→ Realign the vermillion border by doing good approximation
of the lip margins
▪ 🚩 Note: A mere 1 mm step-off in the closure will be
noticeable.
▪ So as not to distort the normal lip anatomy caused by
excessive local anesthesia infiltration, NERVE BLOCKS
Figure 17. Example of a subcuticular injury may be considered for better cosmesis. It can minimize lip
distortion: Infraorbital and mental nerve
→ Reapproximate the orbicularis oris muscle to relieve
tension in this very mobile area
▪ 🚩 Remember to do layered closure of the muscle and
mucosa, or skin
▪ In the muscle, use absorbable (Dexon or Vicryl) sutures
▪ In the skin or mucosa, you can use either absorbable or
Figure 18. Subcuticular running suture non-absorbable sutures like nylon
B. EYELID INJURY
● Simple laceration of the eyelid without involvement of the lid
margins can be treated without concern for further eye injury
● Suture the skin only with small bites
● No need to reapproximate the orbicularis oculi because this
may lead to scar contracture and ability to close eye like in Fig
19.
Figure 21. Orbicularis oris Reapproximation
E. NOSE INJURY
● Soft tissue injuries in the nose are usually simple
● Remember to reduce the nasal bone fracture first if present
● Rule out septal hematomas.
● Realign nasal structures accurately, particularly the margins
and orifices when suturing, using either nylon 6-0,
nonabsorbable sutures in the skin, and absorbable sutures in
the nasal cavity.
Figure 19. Simple Eyelid laceration

● If the protective function of lid is compromised in any way,
serious ophthalmologic injury may result
→ Immediate referral to an ophthalmologist is indicated
Figure 22. Soft tissue injury to the nose
1. STENOSIS AND ATRESIA OF THE NARES

● Accidental or surgical trauma to the NASAL TIP OR
VESTIBULE can possibly lead to WEB FORMATION and
STENOSIS of the anterior nares.
Figure 20. Serious ophthalmologic injury
→ Infrequently seen but if present, is a challenging surgical → Bank cartilage

problem ▪ Take the skin off the cartilage and bank the cartilage
→ It causes nasal obstruction and aesthetic problems. underneath the skin of the abdomen until reconstruction
● Use of prosthetic NASAL STENT is indicated after suturing to can be performed.
prevent undesirable sequelae. → MICROVASCULAR ANASTOMOSES: highest success rate
▪ should be considered whenever a microvascular expert is
available.
→ 🚩 Remember to maintain the avulsed tissue in ICED
SALINE.
Figure 23. Silicon nasal stent
F. EAR INJURY
● 🚩 What makes the ear unique is that the skin is adherent to the Figure 24. Avulsed ear before repair vs after repair
cartilage and the cartilage derives its blood supply directly from
the skin.
● A direct blow or shearing force to the ear may result in tearing of
the blood vessels at the level of the perichondrium, which
results to a SUBPERICHONDRIAL HEMATOMA
● These injuries can result in a significant cosmetic deformity
called CAULIFLOWER EAR if missed or not treated
immediately.
● Treatment includes emergency incision and drainage of the
hematoma and pressure dressing. Figure 25. Suture size and timing of sutures removal
● 📢 Nowadays, we are seeing more and more patients ● Use SMALL CALIBER SUTURES in the head and neck region
developing cauliflower ear after seroma or abscess formation ● Remove sutures at an EARLIER TIME compared to other parts
with the increasing popularity of ear piercings in the cartilage. of the body.
→ Treatment is still incision and drainage with pressure ● This is done to avoid tracking and to improve cosmesis.
dressing and removal of the earring.
● 🚩 Note: If the wound is a linear laceration, suture only the
PART 3: SCAR REVISION AND RECONSTRUCTION
OF FACIAL DEFECTS
SKIN. The cartilage does not need to be sutured.
→ It is very difficult to suture cartilage together and the overlap
I. SCAR
● “Mark” remaining after the healing of a wound
may lead to a deformity.
● Final appearance influenced by:
→ Mechanism and location of injury
→ Initial management performed on the wound
→ Complications encountered during the healing process
A. SCAR FORMATION
● Result of the normal healing process
● Excessive scar formation may ensue, and the exact
mechanism for this abnormal response to injury is still poorly
understood, and for which treatment options are limited
● Abnormal scarring is classified as either HYPERTROPHIC
SCARRING or KELOID FORMATION.
Figure 24. Cauliflower ear

1. AVULSED EAR
● Management:
→ Reattach then place multiple incisions on both ear
surfaces → Hyperbaric O2 treatment
▪ 🚩
Place multiple skin incisions to allow drainage of serous
exudate
▪ Without hyperbaric O2 treatment, chances of survival is
poor.
Figure 1. Scar formation
● The RELAXED SKIN TENSION LINES of the face result from

the inherent properties of the dermal collagen and elastic tissue
of the skin in various regions combined with the tension
intermittently exerted on it by the underlying muscles.
→ They lie perpendicularly to the long axis of the
underlying muscles and parallel to the dermal collagen
bundles and will become the wrinkle lines later on.
→ Will become the wrinkle lines later on
Figure 2. Hypertrophic scar (L) vs. Keloid scar (R)
Table 1. Hypertrophic vs Keloid scar 1. CLINICAL SIGNIFICANCE
HYPERTROPHIC SCAR KELOID SCAR
● Confined to the wound ● Not confined
→ Widened, unsightly scar → Extend beyond the original
that does not extend border of the wound
beyond the original
boundaries of the wound.
● Can regress ● Does not regress
→ It reaches a certain size
and subsequently
stabilizes or regresses
● Oriented collagen ● Random eosinophilic
collagen Figure 4. Diagrammatic illustration of ideal incision placements
→ Histologically, differentiated ● In older patients with wrinkles, lines are very easy to identify.
by the overgrowth of dense ● For younger patients, aside from asking them to do some series
fibrous tissue composed of facial movements or pinching of the skin to make the lines
of large, thick, randomly
visible, the diagrammatic illustration in Fig 4.
arranged eosinophilic
● Incisions made parallel to these lines: betters cosmesis
collagen fibers
mucinous stroma and
with
📢
→ Incisions may heal better and produce less scarring than
🚩
myofibroblasts those that cut across.
Scant mucin Mucinous stroma ● A scar that crosses the skin tension lines at a right angle or
perpendicular to it would have maximal contraction and
No myofibroblasts Myofibroblasts
would be unsightly.
● KELOIDS
→ less common and have a genetic component that limits to B. COSMETIC UNITS
less than 6% of the population.
▪ Primarily seen among black and Asian populations.
→ Frequently associated with pruritus & pain clinically.
→ Most common sites of keloid formation in the head and
neck region are the:
▪ earlobes
▪ mandibular border
▪ posterior neck
II. BASIC CONCEPTS
A. SKIN TENSION LINES
● INTERLAY of the collagen and elastic tissue plus the tension by
the underlying muscle
● PERPENDICULAR to the muscles
● PARALLEL to the dermal collagen bundles
Figure 5. Boundaries of the six cosmetic units of the face (Forehead,

cheeks, eyes, nose, lips, and chin).
● The six cosmetics units of the face are the forehead, cheeks,
eyes, nose, lips, and chin
→ Divided by the contour lines of the nose, lips and chin which
are the:
▪ Nasolabial folds
▪ Nasofascial sulcus
▪ Mentolabial crease
Figure 3. Relationship of facial muscles and skin tension lines ▪ Pre-auricular sulcus
● Clinical significance: → In a place covered by hair

→ Guides placement of incisions ▪ useful in designing the incision during an elective surgery
▪ incisions and scars can be hidden by placing them at the → Junction of 2 cosmetics
junction of cosmetic units → Inner paralleling favorable skin tension lines.
▪ e.g. the junction of the lip and cheek; along the nasolabial II. SCAR REVISION
fold where the eye has changed in contour
▪ In contrast, an incision in mid-cheek, -chin or tip of the
A. INTRO TO SCAR REVISION
● Ideal scar:
nose is always obvious.
→ Flat: level with the surrounding tissue
→ Choice of ideal tissue replacement for repair of a defect.
→ Good color match
▪ Ideally, to repair defects, get within the same cosmetic
→ Narrow
unit because skin surface attributes such as
→ Parallel to or lying within a relaxed skin tension line
pigmentation, texture, hair quality and pore size are
📢
(RSTL)
consistent within a unit.
💡
● Sometimes, scars can be aesthetically unacceptable (e.g.
📢
Cosmetic Units: Illustrative Case | Video lecture post-traumatic scars)
→ Revision technique can be employed after performing a
🚩
detailed analysis of the scar.
● Note: Not all scars can be improved with scar revision
technique.
→ Scars that are already optimal or have good cosmesis can
be made worse with a poorly thought of attempt at revision.
● Patients should be carefully counseled to assure that their
🚩
expectations are realistic
● Reminders:
→ Perform a detailed analysis of the scar
Figure 6. Cosmetic units → Expectations must be realistic
▪ 📢 If a patient expects that scars are completely not
visible, they should be informed that it is not possible or
they are likely to be displeased with the outcome
→ “Camouflage”
▪ 📢 Successful scar revision is really all about disguising of
📢
the fact that a scar is present and will always be present
▪ It is technique is just to trick the observer's eye into
Figure 7. (Left) Cheek rotation flap; (Right) 3 weeks post op
overlooking or ignoring the scar’s presence.
● The postoperative appearance at the third week without any
B. TIMING OF THE SCAR REVISION
cosmetics already shows that the wound is healing flat ,
📢Scars shrink and become less noticeable as they age.
→ 📢 Scars usually take 12 months to mature but may continue
narrow and well camouflaged on the face. ●
to improve spontaneously for 1-3 years.

● Traditionally done at 6 to 12 months
● Immediate surgical revision is delayed until the scars
lighten in color which is usually seen after several months or a
year when a wound has healed.
→ This allows time for scar maturation and better defines what
needs to be accomplished during the revision.
→ Patients often need to be counseled and reassured during
Figure 8. Incision lines placed on the patient this waiting period that the outcome is likely to be improved if
● Incisioned were placed at the junction of the cosmetic units and appropriate time is taken for the scar to mature and the
proper treatment is selected.
🚩
run parallel to or within the skin tension lines.
📢
● Note: The shadows that are cast from the changes in ● Earlier (=2months) for obvious poor cosmetic outcome.
contour tend to hide the scars well. → May be performed as early as 2 months for those that will
obviously heal poorly and would result in poor cosmesis.
C. SITES FOR SKIN INCISION ▪ Particularly: scars that are perpendicular or outside the
● Most favorable sites for incision: skin tension line.
→ Inside an orifice (nose, mouth, and ear) ● Optional:
→ Dermabrasion at 6 to 9 weeks post-injury
📢
▪ useful in designing the incision during an elective surgery
− This is rarely useful in scar revision unless the ▪ 📢 Utilizing the high fibroblastic activity in the wound at this
surgeon can move a scar from an unfavorable site into time to aid in favorable wound healing.
an orifice or hairline.
→ Pulse dye laser treatment at 3 weeks 📢

will help decrease
💡
📢
Clinical scenario | Video lecture
the erythema.
● Before planning any scar revision technique, we analyze the
scar first and the factors that make it noticeable.
Table 2. Four factors that determine whether a scar is favorable or not
FAVORABLE UNFAVORABLE
Flatness Flat Raised/depressed
Texture difference Less noticeable in More noticeable in
(exacerbates color very narrow, razor wider scar
difference) think scar
Linearity Irregular or Linear scars cutting
non-linear scar are across RSTL
less noticeable
Color Redness Figure 9. Before vs after scar revision surgery
● Scars that are flat with the surrounding skin can always be ● Scar oriented:
covered by makeup, and are favorable. → across RSTL (unfavorable)
● Scars that are raised or depressed are associated with a → in the middle of a facial cosmetic unit (unfavorable)
shadow that no amount of makeup will disguise, and they are ● In this situation, you must accept the unfavorable location and
considered unfavorable. instead camouflage the scar by irregularizing it by using the
● Scars tend to be smoother and shinier than the surrounding aforementioned scar revision techniques.
skin, and this textural difference is unfavorable. ● These techniques are all designed to convert a linear scar to an
→ This textural difference is more pronounced in wide scars like irregular one.
that in a burn scar, which is usually wide, that revision is not ● This is done to trick the eye because a straight line is more
practical. obvious to our eyes.
→ Lasers may be better helped in the improvement of texture. ● Scar revision surgery provides an erratic scar that diffuses light
● Irregularity is the principle of camouflage patterns
2. Z-PLASTY
→ As a rule, irregular scars or non-linear scars are less
noticed by the eye and are more favorable. ● 📢a powerful scar revision technique
→ These are linear scars in linear borders of cosmetic units or ● The result not only irregularizes the scar, but also lengthens it
linear scars along relaxed skin tension lines. and alters the direction.
→ Therefore, linear scars cutting across relaxed skin ● Indications:
→ Lengthening
tension lines are considered unfavorable.
● The final factor to a scar’s detectability is color. ▪ 📢 for scars with some element of contracture or
→ To which the surgeon has the least control. shortening, distorts surrounding tissues, or even interferes
→ Redness of a healing scar is expected and can take months with the function of the surrounding tissues.
→ Reorientation
to fade.
→ Patients need to be advised that only time will fade the ▪ 📢for scars that run perpendicular to relaxed skin tension
noticeable redness. lines or across facial junctions.
C. SCAR REVISION SURGERY

● 🚩Criteria:
→Longer than 2cm
→Wider than 2mm
→Distorts normal anatomy
📢
→Does not lie in or along favorable skin tension lines
● The treatment plan may be as simple as to make unfavorable
scars more favorable
→ May be via simple direct excision and closure or as
complicated as to do other techniques and adjuncts to scar
revisions
● Scar revision surgery basic techniques:
→ Z-plasty
→ W-plasty
→ Geometric broken line closure
Figure 10. Z-plasty to correct oral commissure. (A) upturned oral

commissure; (B) Outline of a single Z-plasty; (C) Z-plasty converts the
commissure into neutral position.
3. W-PLASTY
Figure 13. (A) Regularly irregular W-plasty; (B) Irregularly irregular

Geometric broken-line closure
● W-plasty is a straightforward and simple way to irregularize any
scar.
● The flaps are all triangles, and results in a continuous zigzag
that echoes the letter “W”
● The design is easy to create and execute
● The only downfall is that the resulting scar is REGULARLY
Figure 11. Illustrative case for a cleft lip patient with lip discontinuity due to IRREGULAR
a poorly done cheiloplasty.
→ As a mode of camouflage, it may catch the eye even more
● A revision surgery using Z plasty or even multiple Z plasties is than the more sophisticated geometric closure.
necessary to reorient or lengthen the lip vermilion and achieve
better cosmesis.
● Technical aspects:
→ Two 60˚ angles
→ 3 limbs of equal lengths
▪ Central limb
− Always along the scar or line of contracture
▪ Lateral limbs
− Are parallel to each other and should be parallel to the
relaxed skin tension lines
📢
→ Transposition increases scar length to 75%
▪ Undermining the 2 flaps created by incising the limbs
and transposing them theoretically increases the length of
scar by 75%
→ Angles less than 30° may result in flap tip necrosis
Figure 14. Il Running W-plasty
→ Those greater than 75° may result in redundant standing
● The running W-plasty is particularly useful around areas of
cutaneous cones
convex curvature, such as along the:
→ Mandibular border
→ Antihelical fold
→ Nasal dorsum
→ Occasionally a vertical forehead scar
▪ like in Fig 14, wherein consecutive small triangles of skin
are excised on each side of the scar, and the resultant
triangular flaps are opposed and sutured together
● Best applied to scars of >2cms
● As many of the component incisions as possible should be
placed parallel to relaxed skin tension lines
📢 With the Z plasty technique of scar revision, the surgeon
Figure 12. 60° Z-plasty
● ● The intermingling of small scars and normal tissue camouflages
must be aware that it requires 2 extra incisions and the site
subsequent scars to correct a single scar. ● The maximum segment length is 6 mm, meaning the broken
→ The surgeon must make sure that its use must significantly lines or edges of the flaps should not exceed 6mm in length.
improve the appearance of the scar. → Ideally, it should be only about 3-4mm in length
🚩
● Angles should not exceed more than 90°
● Advantage of W-plasty over Z-plasty: the scar does not
cause overall scar lengthening.
4. GEOMETRIC BROKEN LINE CLOSURE MICRODERMABRASION

● Popularly known as Diamond Peel or Fractionalized
microneedling machine or the Dermapen
● For optimal results, wait at least eight weeks before
dermabrading a scar
Figure 15. Il Geometric broken line closure

● Simply a W-plasty in which additional shapes besides the
triangular flaps of the W-plasty are employed.
● The resulting scar is IRREGULARLY IRREGULAR with Figure 17. Microdermabrasion
maximum potential for camouflage. LASERS
● Both of the techniques (W-plasty and geometric broken line ● Include both ablative and non-ablative lasers
closure) break a straight line and provides an erratic scar ● Done for stimulation of neocollagenesis
that diffuses light ● Most popular of these lasers are the Fraxel or the Pulse Diode
● It produces superior irregularization of scar when compared Lasers
to W-plasty, so that the scar is not easily detected by the
observer’s eye
● The design consists of random irregular geometric patterns
interlocked with a mirror image pattern on the opposite wound
edge seen in the figure
● These random geometric patterns or the triangle, rectangles,
squares and semi circles should be no longer than 6mm in
🚩
any dimension
→ Note: Figures less than 3mm are difficult to close and
those larger than 7mm are too visible to provide effective Figure 18. Lasers
camouflage. D. OTHER SCAR MANAGEMENT OPTIONS
● Done to further improve the appearance of the scar short of
doing the other interventions previously mentioned.
● Massage
● Topical therapy: Vitamin E, oil, OTC and prescription scar
🚩
creams with moisturizer and steroids
● Important to protect from sun exposure for the first 12
months
● Silicone sheeting: Apply 12 hours/day for 6 months
Figure 16. Illustrative case for geometric broken line closure IV. RECONSTRUCTION OF FACIAL DEFECTS
💡
● Provided good cosmetic outcome
📢
● Although time consuming, this is the technique of choice for Clinical scenario: Reconstruction of Facial Defects | Video lecture
most long and unbroken facial scars

5. ADJUNCTIVE MEASURES
INTRALESIONAL STEROID INJECTION
● Injecting the scar with steroids at the first sign of hypertrophy
and thereafter at 3-4 weeks interval is particularly done after a
keloid surgical removal to prevent recurrence.
DERMABRASION
● Maximizes the aesthetic results
● This is a method of smoothening and blending scars with the
surrounding skin
● It used to be performed with powered hand motors and diamond
fraises or wire brushes
● The purpose is to mechanically level the skin and set the Figure 19. Clinical Scenario of a patient with a chief complaint of plaque,
stage for re-epithelialization and new collagen production nose and right cheek
● Once the wound is healed, the result is one of blending and

smoothening over the extent of the revised scar.
● Given this patient with skin a skin lesion associated with significant ● 🚩 Note: the skin graft may either be a full or split thickness
destruction of the right nasal ala (Fig 19), what do you do? depending how much dermis is included.
● First, get the History of Present Illness. ● Split Thickness Skin Grafts contain varying thicknesses of
→ HPI revealed that the lesion started 10 years PTC as a small dermis
plaque, which later on progressed despite self-medication ● Full Thickness Skin Grafts contain an entire dermis.
with various creams and ointments.
→ Consult was done for 6 years with dermatology service B. SKIN FLAP
wherein biopsy was done, and she was advised complete ● Consists of skin and subcutaneous tissue
excision, which she refused to have done. ● Transferred into another location
📢
→ Progressive increase in size with bleeding episodes ● Still has its own blood supply
prompted present consult. → Transferred from one part of the body to another with a
● The lesion here is glaringly a skin malignancy. vascular pedicle or attachment to the body being maintained
📢
→ It can either be a melanoma or non-melanomatous skin for nourishment.
malignancy (BCC, SCC, Keratoacanthoma), premalignant ● Although the skin graft is often simpler, there are cases in
(low grade lesions), rare tumors. which a flap is required or more desirable.
● Hence, biopsy is necessary to identify the specific skin
malignancy. 💡
📢
Illustrative Case: Skin flap | Video lecture
● Proper planning of a flap is essential to the success of the
● Plan for a definitive management, which will require a
operation.
multidisciplinary team approach, involving the surgeon,
● All possible sites and orientation for the flap must be considered
dermatologist, pathologist, radiation oncologist and even a
so that the most suitable option is selected like in this case,
psychiatrist because surgical intervention in this case will be
where the flap designed is advanced to close the defect.
greatly disfiguring.
A. SKIN GRAFT
● Consists of epidermis and some portion of the dermis
● By definition, something completely removed from the body
→ completely devascularized or removed from its blood
supply and is then
● Transferred into another location
💡
📢
Illustrative Case: Skin graft | Video lecture
Figure 21. (A-B) A dorsal nasal flap is used to repair a distal nasal defect
brought about by a wide excision for a tumor.
Figure 20. (A) Skin defect on the nose after Mohs micrographic surgery for
basal cell carcinoma; (B) Skin graft; (C) Transferred skin graft onto the nose
● The wound edges seen in Fig 21 cannot be cannot be
approximated end to end.
→ This needs to be closed to avoid wound contraction or Figure 22. (C) Despite the long incision line required to create the flap, the
contracture since this is a full thickness wound. final aesthetic result is favorable; (D) One year post procedure
● In this case, a skin graft from the nearby skin overlying the
clavicle of approximately the same size is harvested.
● This skin graft is eventually transferred to close the defect on
the nose.
● Grafts of any kind require vascularization from the bed into
which they are placed for survival.
1. SKIN FLAP (BILOBED FLAP)
Figure 23. (A) Defect on the nasal side wall Figure 26. Defect flap design
● BILOBED FLAP: Two lobes geometrically designed beside ● This is the defect created on the cheek and the nose. The flaps
each other on a pivot point. designed to close the defect are from the forehead and the
● The flaps are incised, undermined, and rotated like in Fig 23 cheek.
● The nasal ala and alar rim were likewise reconstructed using
cartilage derived from the concha.
Figure 24. Bilobed flap

● The first lobe was rotated along the pivot point to cover the
primary defect.
● The second lobe was rotated to cover the defect created by the Figure 27. Closed defect
first lobe ● This is the defect now closed via advancing the cheek and
● The remaining defect was closed via direct closure. transposing the forehead flaps. Note the defect created on this
● The resulting scar is inconspicuous like in Fig 24, with the flap side of the face (encircled part).
design placed along the junction of the cosmetic units and along
relaxed skin tension lines.
📢 V. CLINICAL APPLICATION
A. DEFECT RECONSTRUCTION
Figure 25. Basal cell carcinoma excision reconstruction

● The patient (presented earlier) underwent a wide excision of the
skin lesion, which turned out to be basal cell carcinoma upon
skin biopsy.
Figure 28. Defect left open for skin graft

● This defect on the side of the face was left open and was
scheduled for skin grafting during the amputation of the pedicle
of the forehead flap.
● The patient has a stenotic right nostril not only causing

aesthetic, but functional problems as well.
● She is complaining of nasal obstruction; hence, reconstruction
of the right nasal ala was undertaken using a composite graft.
→ COMPOSITE GRAFT: skin + cartilage or other tissue
Figure 29. Front and side view of patient
Figure 30. Skin graft harvested from the inner thigh
Figure 34. Composite graft

● This is the wedged-shaped composite graft (red arrow)
harvested from her ear consisting of cartilage sandwiched
between layers of epidermis, dermis and fat, used to reconstruct
the nasal ala.
● Survival of these grafts are much lower than that of the
conventional full thickness skin grafts.
B. MEDICAL PHOTOGRAPHY
Figure 31. Patient prior the procedure with wide excision done. ● Place the patient in the FRANKFORT HORIZONTAL PLANE.
→ This plane connects the lowest point of the orbit and the
superior point of the external auditory meatus.
Figure 32. Six months post procedure

Figure 35. Frankfort horizontal plane
Figure 36. How to take medical photographs in front, lateral, side, back and
Figure 33. Stenotic right nostril close-up views
REVIEW QUESTIONS (2022) REFERENCES

1. Which of the following will MOST likely be compromised in ● Plastic Reconstruction Video Lectures 1-4 by Dr Uy-Regalado
a Newborn with a very WIDE cleft lip?
a. Sucking ability
b. Swallowing ability
c. Gastro-intestinal function
d. Respiratory status
2. Surgery for cleft palate is carried out at age range of:

a. 18-24 months
b. 18-24 years
c. 18-24 days
d. 18-24 weeks
3. What is the percentage of patients presenting with Microtia

will also have Aural Atresia?
a. 100%
b. 80%
c. 50%
d. 0%
4. In lower motor neuron lesion, there is paralysis of the:

a. Ipsilateral upper and lower face
b. Ipsilateral lower face
c. Contralateral upper face
5. A 25/M involved in a motor vehicular accident hit his face

against the road splintering the glass of his helmet. He
sustained multiple lacerations all over his cheek and
forehead. MOST important to the management. MOST
important to the management of this patient prior to
suturing is:
a. Removal of all foreign bodies
b. Administration of tetanus vaccine
c. Reduction of fractured segments
6. A 5y/o child sustained a deep lacerated wound on his

upper lip. To preserve the normal function of the lip,
suturing would involve the realignment of the:
a. Philtrum
b. Orbicular oris
c. Vermilion border
d. Mucosa
7. A 30/F claims that she developed a keloid from a previous

surgery on her ear lobule done two (2) years ago. What
should be examined to differentiate a keloid from a
hypertrophic scar?
a. Color of the wound
b. Border of the original wound
c. Tenderness on palpation
8. The main difference between a skin graft and a skin flap is:
a. Blood supply
b. Nerve supply
c. Epidermal involvement
Answers: a1, a2, b3, a4, a5 | b6, b7, a8
Appendix A.
Assessment of Sucking and Feeding Techniques for Infants with Clefts of Lip and Palate
Appendix B.
Classification and grading of microtia
Appendix C.
House-Brackmann Facial nerve Grading System
I VI (TOTAL
II (MILD DYSFUNCTION) III (MOD.) IV (MOD. SEV) V (SEVERE)
(NORMAL) PALSY)
Slight weakness noticeable

Gross Normal on close inspection (slight No movement
sykinesia)
At rest Normal Normal symmetry and tone N. sym & tone N. sym. & tone Asymmetry Loss of tone
Motion
Forehead Mod-good function Slight mod None None
Complete closure with Complete closure Incomplete Incomplete

Eye Normal No movement
minimal effort with effort closure closure
Slight asymmetry Slight weakness Asymmetrical with Slight
Mouth
with max effort max effort movement

18.9 ENT I Plastic Reconstruction

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OTORHINOLARYNGOLOGY I EVALS 18

PLASTIC RECONSTRUCTION TRANS 9

PART 1: COMMON CONGENITAL ABNORMALITIES

📝 - From Old Transes 📌

● Diagnose common congenital and acquired deformities of the

💡 Lips and Nose Subunits | Short Review by Dr. Uy-Regalado

Figure 9. Incomplete and complete cleft

4. UNILATERAL CLEFT LIP AND CLEFT PALATE

Unilateral Cleft Lip and Palate

Figure 14. (Left) Microform cleft; (Right) Submucous cleft.

Feeding Consideration Serious Feeding Problems

● Breastfeeding in an infant with an isolated cleft in the soft

● Persistent airway obstruction

Figure 20. Naso-Alveolar Moulding

5. PRIMARY SURGERY PROCEDURES

→ Better eustachian tube function

Figure 21. Millard Procedure

6. PRIMARY SURGERY: CHEILOPLASTY

→ due to velopharyngeal insufficiency wherein there is 9. SECONDARY SURGERY PROCEDURES

→ 📢this can adversely influence speech and language with

10. SECONDARY SURGERY: ALVEOLAR BONE GRAFTING

F. POOR DENTAL CONDITION

● 🚩 Aural atresia is present in 80% of patients

Figure 30. Classification of microtia (See Appendix B.)

● 🚩 Note: there is a positive correlation between the degree of D. MANAGEMENT

Figure 31. Bone Conduction hearing aids

Table 4. Options for microtia management III. SADDLE NOSE DEFORMITY

B. PATHOPHYSIOLOGY OF A SADDLE NOSE D/T

📢 If you will do a complete PE of the nose on all patients with

▪ Bone: iliac crest or rib

Figure 38. Facial nerve paralysis

→ Paralysis or paresis of all muscle groups of one side of

● Observe ABCs of trauma

▪ trismus: mandibular fracture

● The tube is left for a two week period

● Cleansing and observation is usually sufficient

Figure 11. Contusion

Figure 10. Patient after surgery

III. CLASSIFICATIONS OF INJURY

● Management would include: F. LACERATIONS

Figure 21. Orbicularis oris Reapproximation

Figure 19. Simple Eyelid laceration

Figure 22. Soft tissue injury to the nose

1. STENOSIS AND ATRESIA OF THE NARES

Figure 20. Serious ophthalmologic injury

→ Infrequently seen but if present, is a challenging surgical → Bank cartilage

Figure 23. Silicon nasal stent

Figure 24. Cauliflower ear

● The RELAXED SKIN TENSION LINES of the face result from

Figure 5. Boundaries of the six cosmetic units of the face (Forehead,

● Clinical significance: → In a place covered by hair

to improve spontaneously for 1-3 years.

→ Pulse dye laser treatment at 3 weeks 📢

C. SCAR REVISION SURGERY

Figure 10. Z-plasty to correct oral commissure. (A) upturned oral

Figure 13. (A) Regularly irregular W-plasty; (B) Irregularly irregular

4. GEOMETRIC BROKEN LINE CLOSURE MICRODERMABRASION

Figure 15. Il Geometric broken line closure

most long and unbroken facial scars

● Once the wound is healed, the result is one of blending and

1. SKIN FLAP (BILOBED FLAP)

Figure 24. Bilobed flap