The Aging Surgeon Cohort: Their Impact on the Future of the Specialty.

Achieving technical excellence in surgery can happen at any point of a surgical career. The accumulation of wisdom brought by the aging surgeon's decades of experience, however, can only come with time and practice. With the accumulated life and professional experience obtained, aging surgeons can still contribute a valuable perspective/point of view to young trainees and colleagues. This article reviews the current literature of the aging surgeon and suggests strategies for how aging surgeons can use their expertise in an innovative fashion to train and develop the future legacy of the specialty.

Fibula Free Flap Reconstruction of the Maxilla Leading to Extracapsular Ankylosis of the Mandible.

After en bloc resection of the maxilla or mandible, surgeons may choose to replace the missing bone and soft tissue with a fibula free flap (FFF). One of the complications that may arise during the healing of an FFF is heterotopic ossification along the free flap pedicle. Heterotopic ossification is most often noted incidentally on postoperative radiographs and rarely creates a functional deficit. Subperiosteal dissection of the pedicle from the bone during the harvest of the FFF is believed to be the main contributing factor that leads to this formation of bone along the flap soft tissue. Pain or limitation of movement of the jaws, depending on where heterotopic bone forms, are related functional issues. Changes in facial appearance due to expansion related to this phenomenon of bone deposition may also occur. This paper presents a patient that developed a functional deficit secondary to heterotopic ossification of an FFF that required surgical intervention. The goal of our surgery is to maintain the blood supply to a vascularized flap while removing the heterotopic bone. We will present the unique aspects of planning this challenging surgery: CASE: A 40-year-old man with a history of right posterior maxillary ameloblastoma underwent a hemi-maxillectomy with FFF reconstruction. The patient developed extracapsular heterotopic bone ankylosis beginning 2 months postoperatively developing severe trismus and required surgical intervention. Radiographic imaging revealed extensive heterotopic ossification of the vascular pedicle that extended from the most proximal positioned end of the fibula to the inferior lateral border of the mandible. A radiographic computed tomography with contrast imaging revealed an intact vascular pedicle with surrounding heterotopic bone. Virtual planning and stereolithic modeling were utilized to plan the heterotopic bone removal. In the operating room, we removed the heterotopic bone in small segments according to the virtual plan to avoid injuring the vascular pedicle. A coronoidectomy was also performed to help gain more range of motion. An adipofascial flap using the buccal fat pad was raised into the area of defect to prevent future recurrence. The patient was put on a strict physical therapy regimen to help regain his range of motion. CONCLUSION: Heterotopic ossifications along free flap pedicles are a known complication of the FFF. A conservative management approach should be used since most postoperative patients will be asymptomatic and findings are incidental on postoperative imaging. Surgery should be reserved for symptomatic patients. Heterotopic ossification needs to be considered as a differential in a microvascular reconstruction postoperative patient when the patient presents with a slow onset of facial swelling, neck mass, or trismus. Virtual planning is an essential tool in the surgeon's planning armamentarium dependent on the timing of the procedure so that the vascular integrity of the flap can be protected after the initial anastomosis.

LeFort Distraction in the Cleft Patient.

The cleft patient may present with significant maxillary deficiency requiring maxillary advancement to establish balanced facial form and function. Often these skeletal advancements require movement of the maxilla of more than 10 mm. The cleft patient poses special challenges because of difficulty of mobilizing tissues on a multiply operated maxilla, as well as long-term stability. Distraction osteogenesis is a technique that may be applied to help move the maxilla over a long distance and slowly expand the soft tissues. A discussion of the orthodontic and surgical considerations when planning and executing the technique is presented.

Oral and Maxillofacial Surgery Team Anesthesia Model and Anesthesia Assistant Training.

The model for oral and maxillofacial surgery (OMFS) delivery of office-based, open airway anesthesia has morphed from the operator-anesthetist to the delivery of team anesthesia, supporting a widespread focus on organizational aspects of the delivery of care. The training, continuing education, and coordination of a diverse anesthesia team provides a system to improve the safety and efficacy of anesthesia delivery. The hallmarks of this system include communication, checks and balances, monitoring, team dynamics, protocols, emergency scenario preparation and rehearsal, and crisis resource management during an emergent situation. This system contributes to and continually supports a culture of safety in the OMFS office.

Best Practices for Management of Pain, Swelling, Nausea, and Vomiting in Dentoalveolar Surgery.

Pain, swelling, nausea, and vomiting associated with outpatient oral and maxillofacial surgical procedures are common occurrences in daily practice. The need to minimize these often unavoidable consequences of surgical intervention is of utmost importance in delivering a good experience for our patient population, thus improving outcomes of our surgery as well as anesthesia. A review of current therapies available to manage these experiences is presented to enable the practitioner to develop multimodal protocols and custom tailor treatment based on procedure and patient risk factors for these unfortunate consequences of surgery.

Motivating factors for patients undergoing orthognathic surgery evaluation.

PURPOSE: Orthognathic surgery is generally performed to correct facial abnormalities related to the maxilla and/or mandible, and there are a variety of reasons for which patients choose to be evaluated for this procedure. We surveyed 637 cases to determine the patients' motivating factors for seeking surgical consultation. PATIENTS AND METHODS: We reviewed 637 cases from 1990 to 2006 in this study, and data were extracted from 501 appropriately completed surveys to determine why patients seek corrective maxillofacial surgery. Patients aged under 12 years and those with an identified syndrome were not included in the final data set. RESULTS: The results indicate that patients with dentofacial deformities have multiple complaints related to their poor maxillomandibular relationships. However, their primary motivation for undergoing surgical evaluation is not appearance; it is their bite/function. Of the 501 patients reviewed in this study, 216 (43%) were male and 285 (57%) were female. Age ranged from 12 to 45 years. Of the patients, 76% stated that their appearance was affected by their condition, but only 15% stated it was their primary motivation for undergoing surgical evaluation. Thirty-six percent stated that their bite was their primary motivation for seeking treatment. CONCLUSION: The most common reason for surgical evaluation was correction of bite or functional disability, not improvement of appearance. Most previously published studies on this subject included smaller sample sizes and showed appearance to be the primary motivating factor.