Plastic Surgery Case Review (eBook)

Oral Board Study Guide

Albert S. Woo, Reena A. Bhatt (Autoren)

eBook Download: EPUB

2021 | 2. Auflage
296 Seiten
Georg Thieme Verlag KG
978-1-63853-644-4 (ISBN)

Infos

<p><strong><em>The quintessential plastic surgery oral board prep and reference on common procedures</em></strong></p> <p><cite>Plastic Surgery Case Review: Oral Board Study Guide, Second Edition</cite> by Albert S. Woo, Reena A. Bhatt, and esteemed contributors, features new cases in each chapter, as well as updated and expanded content. Like the widely acclaimed prior edition, the book is an excellent resource for plastic surgery residents and trainees of all skill levels, highlighting key adult and pediatric cases commonly featured on the plastic surgery oral board examination. The text is written in a 'mock oral' format – designed to encourage critical thinking and analysis of case management – from initial workup to preventing key errors in judgment.</p> <p>Organized in 10 sections, the short, high-yield chapters provide a thorough yet quick review of the most pertinent information. The second edition features extensive updates including section restructuring, all new cases, and an additional section providing a more comprehensive review of plastic surgery. Each case includes high-quality photographs and one- to three-page descriptions including work-up, initial assessment, history, physical examination, diagnostic imaging, patient counseling, treatment, ethical considerations, potential complications, and critical errors.</p> <p><strong>Key Highlights</strong></p> <ul> <li>Additional topics include non-operative cosmetic techniques, Pierre Robin sequence, prominent ear deformity, giant congenital hairy nevus, male-to-female and female-to-male transgender, secondary breast deformities, electrical burns, degloving injury, traumatic amputation, and brachial plexus injury</li> <li>A concise, reader-friendly format ideal for learning core topics and prepping for the oral board exam quickly and efficiently</li> <li>High quality board examination-type case photographs, figures, and illustrations enhance visual learning and knowledge retention</li> </ul> <p>This is an essential resource for every plastic surgery resident looking to prepare for the oral boards, as well as medical students and trainees interested in developing a quick understanding of 'bread and butter' plastic surgery topics.</p> <p>This book includes complimentary access to a digital copy on <a href='https://medone.thieme.com/'>https://medone.thieme.com</a>.</p>

Textauszug

Case 2 Zygomatic Fractures

Vinay Rao and Albert S. Woo

Case 2 (a, b) A 34-year-old male presents to the emergency department complaining of right cheek pain, numbness, and swelling after an assault.

2.1 Description

• Right mid-facial and periorbital edema with malar depression and mild right hypoglobus, with presumed enophthalmos

• Computed tomography (CT) demonstrates comminuted, displaced right zygomaticomaxillary complex (ZMC) fracture, and fracture of coronoid process of mandible

• By definition, the right orbital floor is fractured in a displaced zygomatic injury

2.2 Work-Up

2.2.1 History

• Mechanism of injury: Helpful in determining angle of force and severity of injury

• Change in vision, loss of vision, or diplopia

– Must rule out orbital injury prior to operative intervention

• Trismus can occur with medial displacement of the zygomatic arch impinging on the temporalis muscle

• Relevant medical history (previous facial injuries or fractures), surgical history (previous facial surgeries), and social history (alcohol, smoking, drug use)

2.2.2 Physical Examination

• Signs of ZMC fractures are malar depression (masked by soft tissue swelling early on), periorbital ecchymoses, enophthalmos, and/or hypoglobus (usually masked by orbital swelling), inferior slant of the palpebral fissure, and tenderness at infraorbital rim and along zygomaticofrontal (ZF) suture

• Numbness of the cheek, nose, upper lip, and teeth: Typical of V2 distribution

• Associated eye examination: Look for visual changes, diplopia, or extra-ocular muscle entrapment

2.2.3 Pertinent Imaging or Diagnostic Studies

• High resolution maxillofacial CT scan

– Evaluate the five articulations of the zygoma: (1) lateral orbital rim (zygomaticofrontal), (2) inferior orbital rim, (3) zygomaticomaxillary buttress, (4) zygomatic arch, and (5) lateral orbital wall (zygomaticosphenoid)

– Evaluate orbital floor defect on coronal cut images

2.3 Patient Counseling

• Older patients, in particular, may consider nonoperative management despite displaced fractures. Surgeons must help weigh risks against benefits of surgery.

• Patients must be informed of possible development of enophthalmos/hypoglobus, malar asymmetry/depression, or appreciable bony step-offs. These clinical examination findings may become more prominent as facial swelling subsides.

• With operative management, adverse events/complications must be discussed, including asymmetric malar positioning, development of possible entropion/ectropion and a remote possibility of vision loss.

2.4 Treatment

2.4.1 Initial Management (in the Emergency Department)

• Always start with ABCs of trauma. All emergent injuries must be managed first.

• Ophthalmology consultation in all orbital fractures to rule out injury of globe must be performed prior to operative interventions as manipulation may exacerbate eye injury.

• Definitive treatment of facial fractures may be delayed for up to 2 weeks without compromising results.

2.4.2 Nondisplaced Fractures

• Simple, nondisplaced fractures do not need surgery and may be managed conservatively

• Recommend soft diet to minimize activation of the masseter

2.4.3 Isolated Zygomatic Arch Fracture

• Temporal (Gillies) approach (▶ Fig. 2.1)

– A 2-cm transverse incision is made in the hairline. Dissect through the superficial and deep temporal fascia layers until temporalis muscle is visible. An elevator is advanced behind the displaced arch.

• Intra-oral approach (Keen) may also be used for reduction.

2.4.4 Displaced Fractures

• Timing of repair: 1 to 2 weeks for adults and within 1 week for pediatric patients

– Addressing fractures at a later time may require osteotomies to allow for adequate reduction. Coronal access may be needed to osteotomize the zygomatic arch.

• Fractures that are significantly displaced or comminuted require open reduction/internal fixation. Plates should be positioned at facial buttresses (▶ Fig. 2.2).

Fig. 2.1 Temporal (Gillies) approach for elevation of zygomatic arch fractures. (Source: Treatment. In: Janis J, ed. Essentials of Plastic Surgery. 2nd Edition. Thieme; 2014.)

Fig. 2.2 Buttresses of the face. Vertical buttresses include the zygomaticomaxillary (ZM) and nasomaxillary (NM). The infraorbital rim, maxillary alveolus, and mandible contribute to transverse buttresses of the face.

Fig. 2.3 Reconstruction of zygomaticomaxillary complex (ZMC) fracture with three-point fixation and orbital floor reconstruction. With standard anterior approach, the zygomaticofrontal (ZF) suture, infraorbital rim, and zygomaticomaxillary (ZM) buttress are plated. Orbital floor is addressed with a titanium plate. (Source: Operative Technique and Exemplary Repair. In: Pollock R, ed. Craniomaxillofacial Buttresses. Anatomy and Operative Repair. Thieme; 2012.)

– Critical points of fixation include: (1) Zygomaticofrontal region or lateral orbital rim, (2) infraorbital rim, and (3) zygomaticomaxillary buttress. At least three points of fixation are necessary to guarantee three-dimensional stability. When indicated, the zygomatic arch may be stabilized as a fourth point of fixation (▶ Fig. 2.3).

• The operative approach is determined by the status of the zygomatic arch. If the arch is comminuted or otherwise irreducible, a coronal incision will be needed for reduction and fixation of the arch. Otherwise, the zygomatic fracture can be addressed with an anterior approach.

• The standard anterior approach consists of three incisions:

– Lateral part of upper blepharoplasty (or lateral brow) incision for access to the lateral orbital rim and wall. Note that the best means of confirming three-dimensional reduction of the ZMC fracture is at the lateral orbital wall, which is accessed through this approach.

– Lower eyelid incision (transconjunctival, subciliary, or subtarsal) for inferior orbital rim and orbital floor

– Upper buccal sulcus incision for access to maxillary buttresses

• Orbital floor evaluation

– Zygomatic reduction may cause orbital floor blowouts to become more prominent.

– If a sizeable defect is present, the floor should be reconstructed with an implant (e.g., porous polyethylene or titanium) or bone graft after the zygoma has been reduced.

2.5 Complications

• Retrobulbar hematoma

– It can occur at time of injury or postoperatively.

– Signs are severe eye pain, proptosis, afferent pupillary defect, change in visual acuity, and ultimately blindness.

– Surgical emergency: Requires immediate lateral canthotomy with inferior cantholysis for drainage of the hematoma.

– Mannitol, acetazolamide, and ophthalmology consult are supplementary measures.

• Diplopia

– Commonly seen after surgery due to edema

– Differential diagnosis following zygomatic repair includes extraocular muscle entrapment, muscle contusion, periorbital edema, enophthalmos, or motor nerve palsies

– Muscle entrapment is ruled out if forced duction procedure was performed

– If no structural abnormality is suspected, the patient can follow-up for monitoring

• Inadequate reduction resulting in malposition or enophthalmos

• V2 distribution (infraorbital nerve) anesthesia/paresthesias

– Most commonly due to nerve contusion and generally resolves within 6 months

• Lower lid ectropion (external incision) or entropion (transconjunctival incision)

– This usually responds to eyelid massage but may require surgical correction.

– The subciliary incision has the highest risk of ectropion when compared to transconjunctival or subtarsal approaches.

• Infection requires antibiotics and possible hardware removal

2.6 Critical Errors

• Failure to assess ABCs in acute trauma

• Missing other facial injuries on examination or CT. Watch out for naso-orbito-ethmoid (NOE) fractures, which may occur concomitantly.

• Failure to identify orbital injury, which can be worsened with surgery

• Inadequately addressing the orbital floor at the time of zygomatic reduction

• Inability to...

Produkt-Details

• Erscheint lt. Verlag: 24.3.2021
• Sprache: englisch
• Themenwelt: Medizin / Pharmazie ► Allgemeines / Lexika
• Themenwelt: Medizinische Fachgebiete ► Chirurgie ► Ästhetische und Plastische Chirurgie
• Schlagworte: Case-Based • Case Reports • case-report session • case review • cases • Exam • oral board • Plastic Surgery • Study guide
• ISBN-10: 1-63853-644-9 / 1638536449
• ISBN-13: 978-1-63853-644-4 / 9781638536444