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Issue 60 / December 2019
Editor-in-Chief Javier González Lagunas
Assistant Editor Deepak Krishnan
Graphic Designer María Montesinos
Executive Committee 2018-2019 Board of Directors
Alexis Olsson, President Julio Acero, Immediate Past President Gabriele Millesi, Vice President Alejandro Martinez, Vice President-Elect Arthur Jee, Treasurer Larry Nissen, IAOMS Foundation Chair Mitchell Dvorak, Executive Director
Members-at-Large
Rui Fernandes Javier González Lagunas Sanjiv Nair
Regional Representatives
Eric Kahugu, Africa Kenichi Kurita, Asia Nick Kalavrezos, Europe Alejandro Martinez, Latin America Arthur Jee, North America Jocelyn Shand, Oceania Nabil Samman, Editor-in-Chief, IJOMS
Committee Chairs G.E. Ghali, Education Alejandro Martinez, Governance and Ethics Alfred Lau, Membership and Communications Sean Edwards, Research Luiz Marinho, 24th ICOMS-2019, Brazil David Koppel, 25th ICOMS-2021, Glasgow Ed Dore, 26h ICOMS-2023, Vancouver FACE TO FACE Registered in U.S. Patent and Trademark Office. ©Copyright 2018. I nternational Association of Oral and Maxillofacial Surgeons. Chicago, Illinois, USA. All rights reserved under international and Pan American copyright conventions.
CONTACT US
International Association of Oral and Maxillofacial Surgeons IAOMS Foundation 200 E. Randolph St., Suite 5100 Chicago, IL 60601 USA / communications@iaoms.org
Letter from the Editor AS I SEE IT WHEN I think about an Oral and Maxillofacial Surgery Department, a massive hospital in a big capital comes to my mind. It comes with a number of staff surgeons and a formal training program. I can see pre-graduate students moving around. But I have a bias: this is how I trained, and the way I like to function. But there are other models for the specialty that are essential to deliver good and solid medical care to all the population. People who live in far and distant areas deserve the same standard of care, and they should be offered access to our specialty. Smaller hospitals with a minimal number of professionals that attend the everyday needs of their patients and who are able to diagnose and refer cases to centers who will offer the best multidisciplinary treatment in complex cases. Our friends form South Pacific, South America, Canada and Scandinavia share with us their experiences, problems and wishes. Multiple geographic situations and different needs require diverse health models. In this Winter issue we also have a very special guess. Dr Piet Haers is not only the former President of IAOMS and former editor of IJOMS, but also the person who convinced me to accept the job of editing the newsletter of our association. In our Women´s section we welcome three generations of Spanish surgeons that represent a sociological portrait of changes not only in our profession, but also in the daily life of our country in the last few decades. It is definitely worth reading it. Finally, in this issue we are publishing the farewell of our president Alexis Olsson. I only have good words to say about him, not only in our professional relationship in IAOMS, but also in the personal. So, all the luck in your new projects, and thank you for all your endeavours for the Association. It will be early January when this issue of FACE TO FACE will be delivered, bur from all of us involved in the production of this magazine we wish you a Happy New Decade!
Javier González Lagunas EDITOR IN CHIEF
CONTENTS December 2019 10 SPECIAL REPORT Away and alone.
MISSIONS 22
My IAOMS clinical fellowship experience.
26 FROM PROUST TO PIVOT Piet Haers.
NEXTGEN 30
Challenges of working in distant isolated areas.
32 WOMEN IN IAOMS
One profession, three generations.
REPORT OF MEETINGS 39 XXI CIALACIBU 2019.
40 COPY ME
Sialoendoscopy.
BEYOND THE O.R. 44
Are the “others” so dangerous?
LOOKING AHEAD TO 2020 THIS PAST YEAR has been filled with innovation and growth for IAOMS and the IAOMS Foundation. We made significant progress in advancing our strategic goals of building our membership by providing topnotch educational programs and resources. In order to better reach our global audience, IAOMS continues on our path of digital transformation through investment in and utilization of new technologies. EDUCATION Our biennial International Conference on Oral and Maxillofacial Surgery (ICOMS), held in beautiful Rio de Janeiro, was undoubtedly the highlight of 2019. ICOMS provided nearly 1600 attendees with an extraordinary scientific program, fun social events and plenty of opportunities to network with colleagues and connect with friends. In 2019 we continued to expand our e-Learning opportunities. In addition to offering five scientific webinars we launched the first IAOMS Virtual Conference which allowed attendees to engage in live conversation with the keynote speaker and three additional presenters -- all within the comfort of their home or office. New this fall we launched the first IAOMS Podcast Series: Conversations in Rio, featuring conversations with renowned global OMF surgeons who presented educational sessions at the 2019 ICOMS. I encourage you to take a few minutes to listen to the podcasts, available on the IAOMS website and a variety of streaming platforms. Archived webinars are also available on the IAOMS website. IAOMS FOUNDATION The IAOMS Foundation has also experienced another year of growth. This spring we announced the launch of a major fundraising initiative, the Global Impact Campaign. Through the Campaign, the IAOMS Foundation will garner the resources needed to maintain and grow its cornerstone programs and expand its ability to explore new opportunities to meet the educational and training needs of OMF surgeons around the globe. To accomplish these objectives the Foundation has established a minimum fundraising goal of $2,500,000 over five years. We invite you to learn more and participate in the Campaign by visiting the Global Impact Campaign web page.
The IAOMS Foundation is pleased to report that we have been able to expand our cornerstone programs. With the generous and on-going support of the KLS Martin Group along with generous support from the Osteo Science Foundation we are able to offer two twelve-month fellowships in oncology and microvascular reconstructive surgery and one twelvemonth fellowship in cleft lip and palate and craniofacial surgery. Thanks to the generous support of the OMS Foundation this year we were able to add a second fellowship in cleft lip and palate and craniofacial surgery. This collaborative fellowship offers OMS residents and junior faculty from the U.S. the opportunity to train for a year with expert surgeons at Peking University School & Hospital of Stomatology in Beijing, China. Through the generosity of the Osteo Science Foundation the IAOMS Foundation was able to increase the number of Visiting Scholarship awards from two to seven, providing surgeons early in their career the opportunity to study and observe at prestigious training centers around the world. I encourage you to support these and other IAOMS Foundation initiatives by becoming involved with the Global Impact Campaign. LOOKING AHEAD TO 2020 Our educational programs will be the key focus of 2020. Please join us for the International Symposium on Orthognathic Surgery taking place in Vienna, Austria April 30 – May 2, 2020. Upcoming e-Learning programs include a second Virtual Conference in June 2020, the release of the second podcast series and streaming of a live surgery event. In conclusion, thank you to the IAOMS Board of Directors, Executive Committee, staff team and most importantly, our over 4000 members from around the world, for your tremendous contributions to a successful year. A special thank you to new members and members who have renewed their membership for 2020. We look forward to another exceptional year ahead! Warm regards,
Mitchell Dvorak EXECUTIVE DIRECTOR, IAOMS
“Global Impact” Campaign 2019 and Beyond Join us today to help us reach our minimum goal of $2.5 million over five years.
Campaign Priorities
Fellowship Program Expansion
Gift of Knowledge 2.0
Scholarship Growth
Networking and Events
Funding additional fellowships to include new areas of study and new partner institutions
Creation of a unique plan for training in each global region, developed in partnership with local leaders
Awarding more annual scholarships to ICOMS and short-term training appointments
Conducting networking and educational events throughout the year, such as the World Café and International Reception
Your Pledge by the Numbers Campaign Pledge
(payable over five years)
Annually
Monthly
Weekly
Daily
$50,000
$10,000
$833
$192
$27
$25,000
$5,000
$416
$96
$14
$10,000
$2,000
$166
$38
$5
$5,000
$1,000
$83
$19
$2.50
To get involved, contact Tyler Eble at foundation@iaoms.org https://www.iaoms.org/iaoms-foundation/global-impact-campaign/
Letter from the President BIDDING FAREWELL AS my presidency comes to an end this December, I would like to say thank you to the IAOMS Board of Directors, Executive Committee, IAOMS Foundation, Staff and of course, our wonderful members. The last two years of service to the IAOMS community has been full of memories, networking, learning and genuine joy. It seems like just yesterday that I stepped into my role as President, and I am forever grateful for the opportunity to have served. As I bid farewell, I would like to recognize the global growth this international association has witnessed. Between 2018 and 2019, we have worked as a team with great commitment to grow the IAOMS into a global presence and streamline our strategic goals. Together, we have engaged members through new forms of communication to further strengthen our connection and presence. We are striving to learn, and to connect with our specialty. I am proud to once again highlight our tremendous growth in membership – now surpassing 4,000 IAOMS members! IAOMS is now active on most social media platforms including Facebook, Twitter, Instagram, YouTube and LinkedIn. This online network allows us to meet our members, engage and interact regularly, and share information on a variety of platforms that better suit individual preferences. Additionally, we have elevated our methods of providing educational resources by expanding our digital offerings and online webinars. These E-Learning opportunities allow us to provide programs to on a global scale, as well as allows members to participate with ease and little to no expense for the member. The members are at the core of our mission and we will continue to work with you as we grow! A tremendous example is the Mexican Association of Oral & Maxillofacial Surgeons (AMCBM), contributing to the growth of our association by becoming a vertical membership association, and joining our other vertical members, The Netherlands, Switzerland and Hong Kong. This signifies that 100% of their registered oral & maxillofacial surgeons are now fellows in the IAOMS. I am humbled and honored to have participated in courses and training programs across the world over the last two years. These include:
• The IAOMS - AMCBM (Asociación Mexicana de Cirugía Bucal y Maxilofacial) Microvascular Course series • The IAOMS Foundation Gift of Knowledge courses in Myanmar and the Dominican Republic. • In close partnership and cooperation with regional associations, we have conducted guest society sessions and symposiums with the AAOMS in Chicago and Boston, the EACMFS in Munich, the ACOMS in Taipei, most recently, ALACIBU in Cancun. • We have also established a 5 year commitment to host the Global Health Café Session at the annual AAOMS meetings. I want to thank the presidents and leadership of the regional associations for their commitment, hard work and friendship! It is with great pleasure that we also acknowledge the newest Affiliated National Associations that the IAOMS Council approved at ICOMS in Rio de Janeiro. They are • Asociacion de Cirugia Oral y Maxilofacial de Guatemala. • Azerbaijan Society of Oral and Maxillofacial Surgeons. • Libyan Association of Oral and Maxillofacial Surgery. • Myanmar Society of Oral and Maxillofacial Surgery. • Saudi Society of Oral and Maxillofacial Surgery. We are consistently evolving and commanding a global presence that has stemmed from hard work, team spirit, and innovative ideas. Across continents, languages and time zones, we will continue to achieve our mission as a team. I look forward to many more years of witnessing this association grow to its greatest potential. As I step into my role as Immediate Past President, I want to extend my best wishes to our incoming President Dr. Gabriele Millesi. The IAOMS will flourish with your guidance and leadership. Thank you all for an unforgettable and most rewarding opportunity. It has been a privilege to serve as your President. Sincerely,
Alexis B. Olsson IAOMS PRESIDENT 2018-2019
AWAY AND ALONE
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Maxillofacial Surgery in TONGA By Amanaki Fakakovikaetau OMFS Unit – Vaiola Hospital, Ministry of Health. Tonga
PERSONAL EXPERIENCE IN TONGA Tonga did have one OMFS surgeon who underwent training in New Castle, NSW, Australia in the late 1970`s and I was sent to do my training as a part of the Ministry of Health succession plan. Upon my return to Tonga, he retired from active services. With the only other ENT surgeon in Tonga, we did the complex OMFS and ENT surgical cases together for e.g., oral and nasopharyngeal malignancies, mid-face fractures, TMJ ankylosis etc. Some cases that sought late opinion were referred to the Ministry of Health Oversea referral Committee for approval to send overseas to Australia, New Zealand or India for surgical management.
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So, with the OMFS training done in Adelaide, it did help me immensely to manage most cases locally and send only those cases that need complex management. Also with available and improved IT, I can discuss cases with any colleagues overseas. I haven`t done any orthognathic surgery cases yet in Tonga!. THE OMFS IN THE PACIFIC ISLAND Workforce and needs Only Tonga, Fiji and Papua New Guinea are able to manage their own OMFS cases, the other Pacific Islands will be lucky to have a visiting OMFS or Interplast team bi-annually to manage their cases.
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So, there was a need for OMFS training. Also, it was required that, that trainee must suit the Pacific Islands situation and the type of OMFS cases they have. I was invited and become a permanent member in 2016 of the Industry Advisory Committee (IAC) of the School of Dentistry and Oral Health, FNU, Suva Fiji. Our tasks were to review the existent and newly developed programmers from the industrial and professional perspective and submit these programmers to FNU Senate for approval. The IAC did recommend the post graduate diploma in oral surgery and also Master in Oral surgery program. OMFS Training at FNU The Post-Graduate Diploma in Oral Surgery (12 months program) thus commenced at FNU and now eight countries do have at least one OMFS Registrar for their cases. There are two trainees now as first intake in the Master in Oral Surgery (4 years duration) and expected to complete in 2021. I do think the future of OMFS in the PIC`s has been taken care of and now the country should prioritize its training needs to accommodate the OMFS cases. A Wish For The Future Just a wish, maybe once in a while to be invited to attend some regional or international OMFS scientific conference from us in the “remote region” as to update information and networking. Funding will be an issue but it is good to plan ahead. ■
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Dr Amanaki Huufifalelotu Fakakovikaetau trained in the Dental Faculty, University of Papua New Guinea, Papua New Guinea from 1982 to 1988 with an Australian scholarship. In January 1989, he became a Dental Officer with the Oral Health Services, (Ministry of Health – Tonga) and continued his postgraduate study in the Oral and Maxillofacial Surgical (OMFS) Unit of Adelaide University with a WHO scholarship (1995 – 2000). He returned to Tonga to take over the established OMFS Unit at Vaiola Hospital-Ministry of Health (main and tertial hospital in the Island State with a population of just above 103,000 people).
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Working in PATAGONIA By Armando Gentili Neuquen. Argentina
When you think about Patagonia you think about huge distances, empty roads and extraordinary wildlife. But how is it to work as an Oral and Maxillofacial Surgeon there? I will share with you my experience after 25 years of working there. Patagonia is located in the Southern end of South America. The Argentinian Patagonia is a region of plains that includes six provinces. You will find the Rio Negro and NeuquĂŠn Valley 1200 km Southwest from Buenos Aires in the Northern area of Patagonia, close to Chile and the Andes Mountains. The valley is a 90 minute flight from Buenos Aires. It is located in two provinces, namely NeuquĂŠn and the Rio Negro, and stretches for 1000 km with approximately one million inhabitants strung out in different cities along the Valley. This Valley is world-famous for its pear and apple production which is exported to Europe and Asia. Sheep farming is common in southern areas of Patagonia. It is also rich in oil and gas.
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For such a huge area, we are only five maxillofacial surgeons attending the general population. I was politically involved in the local government of the region and I am proud to say that were able to establish a new Dental School in Allen (Rio Negro province). It is now one of the 17 faculties that train dentists in Argentina. Our Dental school partially shares the facilities of Ernesto Accame public hospital. All the cities in the valley have public hospitals of different complexities according to their population. The main hospital for Maxillofacial Surgery in the area is Pedro Magullanski Hospital in Cipolleti, where two of my colleagues take care of patients in the public system. There are no trainees in maxillofacial surgery in Patagonia, being Buenos Aires the main center in Argentina for postgraduate training. It is a long-standing goal for us to achieve the capacity of training maxillofacial surgeons in the area. In 2005 we were able to organize a very successful national meeting (SACTB) in Neuquén. I have dedicated myself to Oral and Maxillofacial Surgery since I graduated, so I receive patients from general dentists, general practitioners and orthodontists. Currently, I carry out my activity in the private sector both in Allen (Rio Negro Province) and in Neuquén (Neuquén Province), both separated by 25 kilometers. We perform the whole range of pathology of our speciality (as it is understood in Argentina). From low complexity surgeries with local anaesthesia (mouth pathologies, cysts and tumors, pre-prosthetic surgery and dental implants or dental infections) to management of dysfunction of the TMJ and orthognathic surgery When I started my practice, I also used to work for the public health system. Trauma was then quite prevalent, especially secondary to car accidents, firearm wounds or interpersonal violence. Currently, it is my younger colleagues in the Magullanski hospital who take care of those patients. ■
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Maxillofacial Surgery in NORTHERN SWEDEN By Peter Arvidsson Lulea. Sweden
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LULEĂ… is located in the Swedish region of Norrbotten, 910 kilometers north of Stockholm. The area is large, 97.239 square kilometers, but only inhabited by 250.497 people. The region of Norrbotten is the largest in Sweden and consists of 25% of its area. It has borders with Norway in the West and Finland in the East. People make a living from the mining industry, steelwork, lumber and paper industry, health care, tourism and municipal services. In their spare time, people go fishing, hunting and enjoy the outdoors. The area has some eminent teams in ice hockey and basketball both for men and women. In the area, we have the Sami population with their own language and culture. Their language is one of the two minority languages that are spoken in the area
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in OMS, one dentist, one dental hygienist, one secretary and eight dental nurses. The citizens of Norrbotten are used to travelling long distances to get to other cities, work etc. A trip to the far away hospital seeking much needed care is usually not perceived as a challenge. The medical care in Sweden is publicly financed through taxes and patients only pays a symbolic sum at each visit. They also get transportation to the hospital for a symbolic sum. When the patient gets acutely ill, transportation to the hospital can be provided by helicopter. We take care of patients that are residents of our region. There is an occasional tourist that needs our care.
Me, Peter Arvidsson.
and the other is Meänkieli. The region is very well connected to the rest of Scandinavia. The local airports not only connect to Stockholm and Gothenburg but also Norway and Finland. The network of roadways are mostly in good condition and one can travel by car bus or train. Chartered trips to rest of Europe and the Far East are popular. The climate here tends to be harsh with a long and dark winters and a short but intense summer. The spring and autumn are quite short. In the North, we have the mountains that see a lot of tourists in the summer that go there hiking and fishing. The regional hospital of Sunderby is located in the outskirts of Lulea, about 15 kilometers outside the city Centre. It has about 2.500 employees and 380 beds. Even though there are four other hospitals in the region, they are located far from each other. This means that most people in Norrbotten have a long way to travel to get to a hospital (especially Sunderby hospital). Oral and Maxillofacial surgery is a part of the ENT in Sunderby hospital. We are a staff of three OMF surgeons - two double qualified and one single qualified, one resident
Our scope of practice consists of oral surgery, implant surgery, oral medicine, dental treatment of in-hospital patients, TMJ surgery, resections of benign tumours and cysts, reconstructive surgery, trauma and orthognathic surgery. We are also on call seven days a week. We work closely with our ENT colleagues when managing trauma and infections. Patients with malignancies are referred to the ENT department at the University Hospital in UmeĂĽ. The patients get their treatment there, including resection of the tumour and radiation, and then followed up with us for continued care and rehabilitation. Our portfolio has Marita, Sadegh and Sanna.
Sunderby  hospital.
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Kristina and Mari.
Mattias and Veronika.
evolved over the years. We have noticed trends that suggest that trauma has declined and odontogenic infections have increased in frequency. Even though you might think that we should receive a lot of facial trauma from snowmobile accidents, they are quite rare because most riders use helmets.
Pedro and Helene.
Dental health in Sweden is has seen a paradigm shift with increasing costs associated with care combined with a decrease in the number of dentists. We have been seeing patients with severe dental infections that require treatment at the hospital present with really poor dental status. We have also noted an increase in malignancies. The educational system in Sweden requires that you are a dentist to pursue the path to OMF surgery. The training programs have been based on single qualified doctors. In our hospital, we accept patients who need all kinds of oral and maxillofacial surgeries with the exception of malignancies. We are seeing more and more elderly patients with more complex co-morbidities and on multiple medications. We felt the need more medical education in the and in 2012 four regions in the North of Sweden started an OMF training program that also included a medical degree. Two of those surgeons who completed the program now work in our department and we can already see
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how much their skills and knowledge can contribute to our patient care. The work in the surgery ward runs more smoothly and it´s easier to evaluate a patient’s health. More and more OMF surgeons in Sweden are now double qualified and this will enable us to move forward in the development of our specialty. As may be the case worldwide resources are limited and we are facing cutbacks in our region because of an increase in health costs and a reduction of people at work that pay taxes. Even though, we can still operate patients under general anaesthesia two days a week, we only perform operations under local anaesthesia at our department, the three other days. We look forward to a promising future with our next generation of well-educated surgeons that work together pushing the boundaries of treatment to new frontiers. Hope springs eternal in Northern Sweden. â–
December 2019
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Being a Maxillofacial Surgeon in NEWFOUNDLAND By Rebecca Woodford St. John's. Newfoundland
NEWFOUNDLAND is called “The Rock� for a reason, because a rock is exactly what it is. This small island on the East Coast of Canada is surrounded by the Atlantic Ocean, and made mostly of rock. Labrador, however, is on the mainland of Canada, bordering Quebec. Together, these two lands comprise the province of Newfoundland and Labrador. The island reaches from the most Eastern point of North America, Cape Spear, to the majestic mountains of Gros More, and is blessed with the natural beauty of cliffs, seashores, and forests. Newfoundland and Labrador is certainly a place for those who love the outdoors as there is plenty of spots to go fishing or trails to go hiking, and you may even come across waterfalls, inlets, coves, or luck into viewing a magnificent iceberg.
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Newfoundland and Labrador is also home to the oldest city in North America - St. John’s, where you can visit the many shops on Water Street, or go for a whale watching tour out past the narrows; you can have a feed of fish ‘n chips or visit George Street and find any pub, bar or club to fit the mood of the night. Newfoundland and Labrador has its own culture, history, and attractions unlike any other place in the world. Each city, town, bay, cove, tickle, and inlet often have their own accent and slang. Along with our dialect, Newfoundlanders are also known for their
kindness and hospitality. Unfortunately, this became well known worldwide on September 11th, 2001, when many flights were diverted to a small town called Gander. This town, and countless Newfoundlanders, opened their arms and homes to strangers during such a devastating time. The hospitality, compassion and acceptance of Newfoundlanders was truly portrayed during this tragedy, as many have seen in the Broadway musical
Newfoundland and Labrador is also home to the oldest city in North America - St. John’s, where you can visit the many shops on Water Street, or go for a whale watching tour out past the narrows...
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Come From Away, which was based on the people of Gander and their kindness during 9/11. If you have never been to Newfoundland and Labrador, I would highly recommend it. My only advice would be to visit during the summer months (June – August) as the summer is short and sweet, and the winters can be cold, windy, and long. Even with these short summers and cold winters, this province will always be my home. It is often said that you can take a person out of Newfoundland, but something always brings them home. And in my case, this was true. I currently work in St. John’s as an Oral and Maxillofacial Surgeon in private practice, as well as have hospital operating room and admitting privileges, and provide on-call services for Oral and Maxillofacial Surgery. I am co-chief of the division of Oral and Maxillofacial Surgery with Eastern Health and a clinical assistant professor with the Memorial University of Newfoundland (MUN). The beauty and hospitality of Newfoundlanders, my family, and the opportunity to give back to a province that I love so much, are some of the many reasons I returned home to Newfoundland to work. At this time, there are only two full time Oral and Maxillofacial Surgeons (including myself), who provide care for the entire province of Newfoundland and Labrador. This allows us to provide full scope services for the 521,542 (StatsCan, 2019) residents of the province, which can be a little overwhelming at times. Fortunately, our department has incredible collegiality with Plastic Surgery, Otolaryngology, Emergency Medicine, and many other dental and medical professions, and we often work together on cases that require interdisciplinary approaches. One difficulty with being on an island with many small communities is access to care. Both full-time Oral and Maxillofacial Surgeons are based out of St. John’s (to allow maximum possible access to care), which often means that patients have to travel from across the island (often up to 12 hours) or even from the mainland (Labrador) for Oral and Maxillofacial Surgery services. This can often be costly and a barrier for some to achieve access to care. Also, in remote areas there is limited access to dental and medical professionals, yet alone to
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specialists such as Oral and Maxillofacial Surgeons. Consequently, when they present to the city for specialist care, it is often on an emergency basis for acute or emergent care, usually in situations that could have been prevented with better access to general preventative/maintenance care. There is also no dental school or dental specialty training in Newfoundland and Labrador. As a result of this, we do not have dental students or Oral and Maxillofacial Surgery residents to teach or bear the load of treating the entire province, so our department of two carries that workload. This can both be rewarding and challenging. However, since coming home to Newfoundland in 2015, I have seen the division of Oral and Maxillofacial Surgery grow, and the future is bright. The interdisciplinary collegiality with other dental and medical generalists and specialists has been rewarding and has provided unique opportunities for both personal and professional growth. There truly is no place like home. ■
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Maxillofacial surgery in the AMAZON REGION By José Thiers Carneiro Jr. Belém, Pará. Brazil
THE AMAZON REGION is world renowned for its natural beauty and biodiversity. Particularly, the Brazilian Amazon is a source of immense wealth that contributes to the development of the region. The region serves as a large reservoir for ores such as iron and bauxite. Despite such wealth, health access and promotion is still a challenge in the Amazon, where there are many indigenous, Quilombola, and riverside communities living in remote and hard to reach areas. Due to the long distances and diluted infrastructure of the region, these communities remain sequestered from the major cities. In some communities, river transport is the only possible means of access to education and health services. Despite the stark contrast between the south/ southeast regions of Brazil (which are wealthy), and the northern region (the Amazon states and the poorest of the country), there has been a significant increase in the number of hospitals and healthcare facilities in towns on the countryside. As a consequence, the previously existing need for resorting to major cities in search of health services has decreased in recent years.
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In this context, there is also a substantial increase in the number of Oral and Maxillofacial surgeons, either due to job opportunities offered in the region or the creation of new residency programs. Years ago, it was necessary to travel to other regions of the country to enroll in a training program and become an Oral and Maxillofacial surgeon. In stark contrast, in 1997, only a few hospitals treated maxillofacial injuries in Belém, capital of the State of Pará. Most of the procedures were related to trauma or pathology. Trauma was usually managed conservatively through maxillomandibular fixation
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or skeletal suspensions, and there were a handful of OMSs available in these regions. As there were no residency programs in the area, my choice was to seek training in the city of São Paulo, where there was a very well structured program at Santa Casa de Misericórdia, a prestigious center that produced several eminent surgeons that branched out to settle in the most diverse places of Brazil and other neighboring countries. I came back to Belém in 2003. Despite the demand, there were only a few hospitals to practice the speciality. Along with other colleagues, who were also returning following specialty training, we worked diligently to increase awareness of the specialty and to help patients with our skillset in the capital and nearby larger cities. Currently, we have two residency programs in Belém. One of them is offered at Ophir Loyola Hospital, and the residents receive training in various fields of expertise, such as orthognathic surgery, temporomandibular joint (TMJ) surgery, treatment of orofacial disorders, facial trauma, and reconstructive surgery, among others. In addition to Ophir Loyola Hospital, residents also perform in other hospitals affiliated to the program, offering exposure to a large and varied surgical volume, necessary for solid training. At the Federal University of Pará, we have a postgraduate Program in Dentistry, in which, among other
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specialties, we offer opportunities for researchers at Masters and PhD levels in OMS. Continuing education has been encouraged by the Brazilian College of Oral and Maxillofacial Surgery through courses and meetings. In 2012, we hosted the VIII North/Northeast OMS Surgery Meeting (VIII ENNEC) and, in 2016, the city of Manaus, State of Amazonas, hosted the X North/Northeast OMFS Surgery meeting(X ENNEC). In 2020, Belém will be honored to host the Brazilian Congress of Oral and Maxillofacial Surgery (COBRAC), an event that for the first time will take place in the northern region. It will definitely be a milestone for the speciality in the Amazon region, given that this is the largest congress on OMS in Latin America. We expect about 2.000 participants from various countries. Despite the progress made in the last twenty years, we still have much to improve. Our biggest challenge is to shorten the distances and waiting lists for treatment for people living in the Amazon region that travel vast distances seeking care. To that end, it will be necessary to increase the job offers for specialists, so that they can work beyond the big cities. It will also be necessary to encourage professionals to work in remote areas and increase the number of hospitals receiving patients with maxillofacial injuries. We can only hope that this too will happen over time. ■
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Missions
MY IAOMS CLINICAL FELLOWSHIP EXPERIENCE By Santosh Kumar Yadav Chitwan. Nepal
I WAS one of the fortunate recipients of the IAOMS Fellowships in Oral and Maxillofacial Oncology and Reconstructive Surgery in the years 2013-14. My training was at Beijing University School of Stomatology in China under Prof. Guang Yan-Yu. I would like to share my experiences during my fellowship and how I have utilized my training in my career thereafter. The fellowship year exposed me to a level of surgical complexity that allowed me to acquire new knowledge, develop new skills, and expand my boundaries in the interest of providing the best treatment to our patients. During my stay, I had the opportunity to participate in surgical procedures in all areas of Oral and Maxillofacial Oncology and Reconstructive Surgery and understand the various aspects of interdisciplinary care. This type of surgery allowed me to evaluate treatment alternatives, compared and analyzed in accordance to the developments reported in the scientific literature and consider the advantages and disadvantages to standardize the diagnosis, management and treatment in our patients. It was very gratifying to see the interdisciplinary medical management that exists in the hospital, the high degree of professionalism and commitment to patient-doctor to treat the disease. Likewise, the position and participation of the Department of Oral
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and Maxillofacial Surgery are of vital importance for the treatment of head and neck cancers. My stay in Beijing and my experience at the University School of Stomatology motivated me deeply and positively influenced the path I have taken the last few years and keeping with my firm intention to take maxillofacial surgery to the highest level. This experience has been one of the most rewarding experiences in my life, not only for the reason that I could get rich in profound ways professionally and directly receive the benefits of the extensive experience at China, but that I can pass on this knowledge to new generations who are committed to the future development of Oral and Maxillofacial Surgery. After my training as an IAOMS Fellow, many things have changed within me. Before, even after doing Master in Dental Surgery (MDS) in Oral and Maxillofacial Surgery (OMFS), I was not able to touch or treat oral cancer patients. But, after the training, I can operate on those patients. This has provided me with huge satisfaction as an Oral and Maxillofacial Surgeon and helped me to perform cancer surgeries with confidence. So, my personal perspective as an OMFS has changed a lot. I am very much grateful to IAOMS for making me such an able person.
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Returning home, I was full of enthusiasm to face new challenges in doing reconstructive surgery. Reconstructive and microsurgery have made considerable developments over the past few years because of several efforts made in research, technology and clinical experience towards innovating methods in the pursuit of ideal reconstructive techniques. After joining the institution, I got to do a number of cases of reconstructive surgery with minimal instrumentation in our local set-up, but the results were pleasing. Postoncological and post-traumatic patients who have been disfigured or rendered dysfunctional have directly benefitted from this effort that provided chances to regain an adequate quality of life and to develop a social relationship. Some of the cases that I had the opportunity to do were radial forearm free flap (RFFF), anterolateral thigh flap (ALT), free fibula flap (FFF), pectoralis major myo-cutaneous flap (PMMC) and submental flap all had satisfactory or good results. Head and neck reconstruction is a challenging field which needs active and healthy interdisciplinary approach across the different related specialties to provide the best oncological and reconstructive options for each patient's treatment. But, unfortunately, a team effort is lacking in our country due to limited faculties under the same roof in a hospital. This was a very distressing feeling that I realized while working. Nepal is a developing country with many people still under the poverty line and remains the poorest country in South Asia and 20th poorest in the world with a GDP per capita of US$ 600. Many people cannot afford for the treatment of cancer despite the cancer incidence being 50,000-70,000 per year.
Twenty years ago, cancer was almost a non-existent disease, considered as incurable, not often diagnosed due to limited diagnostic facility and had limited or no treatment options. But recently, the scenario has changed with the development of various diagnostic tools and treatment modalities. Oncology in Nepal is still at its childhood. Even though the developed world has sophisticated technology and an array of the targeted therapies and newer molecules for cancer treatment, Nepal has just initiated its struggle against cancer and is very far away from the recent achievements in the field. Considering treatment of cancer in Nepal, at present, there are only 4 centers in the country treating cancer patients with the radiation therapy facilities, 1) B.P. Koirala Memorial Cancer Hospital, Bharatpur; 2) Manipal Teaching Hospital, Pokhara; 3) Bir Hospital, Kathmandu; and 4) Bhaktapur Cancer Hospital. Considering the cost of cancer treatment, as per capita income of an individual is only US$ 600, majority of the population find it difficult to bear expensive cancer treatment since they have to pay from their pocket due to lack of health insurance and as a last resort they end up selling their property and valuables and losing the life due to late visit.
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The cost of radiation treatment and palliative intent is around US$ 200-250. The expense of chemotherapy is separate and has to be borne by the patient and that depends on the regimen and the molecule used. Also, the patient has to pay for all the diagnostic facilities including the expensive CT scan and MRI, which adds another US$100-200. This also does not include the expenses of surgical treatment if required by the patient, which is much more expensive than radiation treatment. Recently, the Government of Nepal has taken a very encouraging step to help people suffering from cancer by providing a fund of US$ 440 (NRs 50,000) to support each individual having cancer. This amount is not provided to the individual but is provided to the institution for covering the expenses of the radiation treatment, chemotherapy, and investigations. With a view of serving the poor people, I have recently joined a government hospital where the cost of treatment is low compared to private institutions. Here I get to do lots of cases (Oncological including reconstruction, Trauma, Salivary gland diseases, Infections, TMJ pathology, Pre-prosthetic, Aesthetic surgery) which have helped me to develop my clinical skills and practice. Besides being Central Government Hospitals, with quite a good number of patients and infrastructure, an Oral and Maxillofacial Unit is still not BER OF MAJOR THE TABLE SHOWING THE NUM YEAR OCTOBER THE ING DUR CASES PERFORMED 2014 TO SEPTEMBER 2019
Maxillofacial trauma 666 Oral and maxillofacial tumours and cysts 120 Infections 50 Salivary gland diseases 20 Reconstructive surgeries 20 TMJ pathology 14 Pre-prosthetic and aesthetic surgery 12 TOTAL 902 24 iaoms.org
well set-up and it’s running under a dental department. There is still a lack of manpower for team-work and many difficult surgeries have to be performed in limited resources. This is a totally different scenario than what I saw in during my fellowship. Travelling through this journey what I have felt is that it is very important to train our other colleagues for better teamwork. There are lots of cases but efficient teamwork is lacking. So, I just have a vision that if this hospital itself could be developed as a training centre, patients, surgeons and the entire OMFS unit could be benefitted. For that, trainers visit is important and if this is feasible, our dream of teamwork will be fulfilled as one trainer in one unit will be training so many young surgeons. The major challenge observed in oncology service in Nepal is the high cost of the treatment and because of the lack of insurance, and proper health policy, people have to bear all burden by themselves. Another major challenge is the lack of awareness about the prognosis of disease as most of the patients, their family, and even a lot of physicians and health care professionals consider cancer an incurable at any stage. This leads to delay in presentation of patients to hospital and thus increasing the number of advanced stages cancers and thus the morbidity and mortality. As oncology is a specialized field, lack of human resources is another problem in a developing country. Since oncology requires a wide variety of health care professionals including a radiation oncologist, physician, physicist, oncology nurses, therapy radiographer, palliative care experts, counsellors etc., it’s very difficult to have all of them available in one center, which makes the work environment more challenging for all. To conclude, though the patients have benefitted to a certain extent while performing surgery at a low cost or even free of cost for very poor patients in the government hospital, lack of proper instruments and teamwork is still an insure which needs to be addressed by the concerned. If every field in the cancer treatment is developed, the morbidity and mortality due to oral cancer can be decreased and it will not be seen as 2nd most common cancer in Nepal in the coming years. ■December 2019
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icoms2021glasgow.com
From Proust to Pivot
AN APPARENTLY INNOCENT QUESTIONNAIRE FOR ORAL AND MAXILLOFACIAL SURGEONS
Piet Haers
Consultant OMF / Cleft Surgeon at NHS Redhill, Reino Unido
What is your favorite word? Motivation. Passion.
What sound or noise do you hate? Traffic noise. What is your favorite curse word? Ask my friends.
What is your least favorite word? Impossible.
Who would you like to see on a new banknote? Bill Gates.
What is your favorite drug? Golf.
What profession other than your own would you not like to attempt? Accountant.
What sound or noise do you love? The sea in all weather.
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If you were reincarnated as some other plant or animal, what would it be? Zantedeschia ethiopica. If Heaven exists, what would you like to hear God say when you arrive at the Pearly Gates? You too! What is your idea of perfect happiness? Sunday pm with the whole family. What is your greatest fear? Incapacity to communicate. What is the trait you most deplore in yourself? impatience. What is the trait you most deplore in others? Lack of empathy. Which living person do you most admire? My mother. What is your greatest extravagance? Wines. What is your current state of mind? At peace. What do you consider the most overrated virtue? Political correctness. On what occasion do you lie? When asked if I enjoy food I dont like. What do you most dislike about your appearance? The aging belly. Which living person do you most despise? All who promote intolerance.
What or who is the greatest love of your life? My wife and children.
What is the quality you most like in a man? Trustworthy.
When and where were you happiest? Home.
What is the quality you most like in a woman? Caring.
Which talent would you most like to have? Proactive hindsight.
Which words or phrases do you most overuse? Suction please. Be careful.
If you could change one thing about yourself, what would it be? Patience.
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What do you consider your greatest achievement? Being editor in chief of IJOMS.
What is your most treasured possession? My father’s watch.
If you were to die and come back as a person or a thing, what would it be? Myself.
What do you regard as the lowest depth of misery? Three over par, twice in a row.
Where would you most like to live? Sout-East Asia.
What is your favorite occupation? Cleft surgery. What is your most marked characteristic? Action. What do you most value in your friends? Their honest friendship. Who are your favorite writers? - Robert K Massie. - Leon Uris. - James Clavel. - Umberto Eco. - Leon Tolstoy. Who is your hero of fiction? Hornblower. Which historical figure do you most identify with? No idea. Who are your heroes in real life? Some of my patients. What are your favorite names? Gabriela, Elisabeth, Josephine, Emmanuel, Laura, Judith. What is it that you most dislike? Waste of time. What is your greatest regret? Not to do better. How would you like to die? Being able to say goodbye to my loved ones. What is your motto Plus que doit. â–
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FOUNDATION CHAIRMAN REPORT
THE STANDARD OF EXCELLENCE AS ANOTHER year comes to a close and I take time to reflect on the events that have transpired, I am reminded of the spirit that defines our specialty. The world is evolving at a rapid rate and the demands on our lives are continuously building. Our work does not stop when the office lights turn off. We carry it with us everywhere we go, whether it’s on our devices or on our minds. When we hear the ping or feel the vibration, we respond. We respond not because we have to, but because we choose to.
2019 IAOMS FOUNDATION HIGHLIGHTS
Oral and maxillofacial surgeons possess an unmatched passion to do good in this world. We are dedicated to being excellent in all aspects of who we are - because excellence in our profession is the expectation that we impose upon ourselves. We are excellent surgeons, excellent care givers, excellent colleagues, and excellent teachers. This mindset enables us to have a profound impact on the lives of the individuals who we interact with on a daily basis.
Funded 2 Fellowships in Oncology and Microvascular Reconstructive Surgery
In my opinion, what truly sets us apart is our determination to help one another with realizing our fullest potential as surgeons and as people. I observe this everyday through the work of the IAOMS Foundation, which is fueled by the generosity of our specialty. The commitment to our cause has never been stronger, which has enabled us to take the Foundation and its programs to new heights.
Funded 2 Fellowships in Cleft Lip and Palate and Craniofacial Surgery Finalized a brand-new Research Fellowship in Regenerative Medicine
I am incredibly grateful to all of the IAOMS members, industry collaborators, foundations, and regional society partners who have supported our vision financially, as well as those who have volunteered their time and leadership to bring our ideas to life. It is because of you that we are able to grow these programs and provide lifechanging opportunities for the individuals who are able to experience them. However, our work will not be complete until we are able to fund all of the requests we receive.
Conducted Gift of Knowledge Courses in Myanmar, the Dominican Republic, and Mexico
To that end, we have embarked on one of the boldest initiatives in our organization’s history. Earlier this year, we launched the IAOMS Foundation Global Impact Campaign. Announced during the 2019 ICOMS in Rio de Janeiro, this is a global fundraising effort with a goal of generating a minimum of $2,500,000 over the next 5 years.
Expanded the Visiting Scholars program to include 27 Training Centers
Success will ensure the Foundation has the resources needed to maintain and grow its cornerstone programs – Fellowship Program, Visiting Scholars Program, ICOMS Scholarships, and Gift of Knowledge Program – while expanding its ability to explore new opportunities to aid OMF surgeons at all levels of their careers. Learn more by clicking here to visit the Global Impact Campaign website. On behalf of the IAOMS Foundation Board of Trustees, thank you for your trust and confidence in our organization. Your support means the world to us. Sincerely, Dr. Larry W. Nissen IAOMS Foundation Chair
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Increased the number of Visiting Scholar appointments from 2 to 7 Awarded 3 ICOMS Scholarships in the program’s inaugural year
For more information about these programs, visit www.iaoms.org/iaomsfoundation/programs
NextGen
CHALLENGES OF WORKING IN DISTANT ISOLATED AREAS
By Noor J. Al Saadi
Khoula Hospital. Sultanate of Oman
ORAL AND MAXILLOFACIAL SURGERY training in Oman is mainly based in the capital city hospitals. For few months after completion of my training, I was assigned to work in a small hospital away from the capital. I was the only maxillofacial surgeon in town. There was no designated clinic for maxillofacial surgery, nor a department to refer to. My mission was to establish one! With the little exposure that I had, I found that working in a distant isolated area came with its own benefits and challenges. There are many advantages for the community to having a well-established maxillofacial facility in the local hospital. Service will be accessible and readily available, hence less time wasted and reduced expenses. In addition, there will be reduced load and referrals to tertiary hospitals, and fairly distributed
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health care services throughout the country. Furthermore, fully equipped auxiliary facilities will provide more employment opportunities to the community. Being the first maxillofacial surgeon to join the hospital, it was very difficult to establish service. In the peripheral populated regions, the local community tend to live in scattered neighborhoods usually located away from the populated center. Often patients from these regions face great difficulty to access health care, either due to limited transportation, tough roads or risky weather. Therefore, once they reach, they expect to be treated fully in the local facility without the need to travel any farther. Nonetheless, scarcity of diagnostic and laboratory services, instruments, recovery facilities
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Rural and isolated areas are always at risk of inadequate access and unavailability of service due to the inescapable challenges.
In addition to affecting the locals by posing an extra burden to seek alternatives, such as paying extra charges in private sector or seeking referrals to urban hospitals and polyclinics. Taking everything into account, challenges of working in distant isolated areas are interconnected and act as a circle, where one thing leads to another, hence increasing the complexity of the situation. In conclusion, health care is a fundamental human right and it is obligatory to provide decent medical care and access for all society members. Yet, rural and isolated areas are always at risk of inadequate access and unavailability of service due to the inescapable challenges. This requires governments and communities to collaborate, initiate and establish solutions in order to improve healthcare system in these areas. â–
and operating theatre, in addition to shortage of skilled nursing staff, expert anesthesia services and most importantly, a surgical team; makes it almost impossible, despite the availability of a trained surgeon who is skilled to perform necessary interventions. This will eventually lead to patients being referred to the capital city hospitals for further management and better care. Geographic isolation and limited resources may also hinder continued professional development and limit scope of practice of surgeons. Thereby, surgeons are at risk of losing their skills and opportunities of further training and sub-specialization. Moreover, working as an isolated surgeon is pretty challenging. In addition to the morning duty, very frequently the surgeon will also be on call round the clock almost every night. It is quite stressful and can easily lead to overworking and burnout, making it more difficult to recruit and retain staff in rural and isolated areas. Given the fact that public healthcare sector is usually funded by the government, disparity in the availability versus the exploitation of service make such facilities a permanent vulnerability to limited funding and subsequent difficulty in establishing and improving services and patient care. This would inevitably result in higher chances of local healthcare facilities closure or elimination of certain specialities and subsequent loss of jobs.
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Women in IAOMS
ONE PROFESSION, THREE GENERATIONS
01 THE BEGINNING By Fernanda Lorenzo A CoruĂąa. Spain
IN 1975, when I finished my medical studies at the University of Santiago, only 15% of the students were women. I remember that in the first course, the boys got up to leave us the seat and on other occasions they complimented us screaming when entering class. Over time, attitudes have changed as society has evolved and gradually a positive partnership has emerged today.
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Another anecdote that reflects the gender difference at that time, is when several years ago a companion somewhat younger than me told me that it in her department it was her job to prepare the coffees after the weekly clinical session, just for the fact of being the only woman on her Service. That same year, I went to Madrid to study Stomatology, later starting my postgraduate training in Orthodontics at the RamĂłn y Cajal Hospital. It was there that I discovered Oral and Maxillofacial Surgery. I quickly discovered that Orthodontics was not my calling. I decided to opt for a change and dive into surgery, more out of curiosity and for having a paid job than for real knowledge or vocation. Without much thought, I passed my MIR examination and I started working as a resident in the same hospital. At that time there was already a woman there, but the rest of my colleagues were men. Now I think that at that time it must have been so uncomfortable for my colleagues to start working with me, as it was for me. December 2019
I remember being told that longer surgeries are best avoided as it would be exhausting for me! In the clinical sessions, if a classmate casually swore, he immediately apologized and if he did not, another classmate insisted that he did so. Once a week we used to leave the hospital earlier for a snack but I seldom joined; I amongst their own. When in the operating room, if I requested an instrument from the scrub nurse, they passed it to my male assistant, even when I was the main surgeon – a fact that bothered me a lot. Another anecdote that reflects the gender difference at that time, is when several years ago a companion somewhat younger than me told me that it in her department it was her job to prepare the coffees after the weekly clinical session, just for the fact of being the only woman on her Service. iaoms.org 33
A common remark was about the difficulties of reaching positions of maximum responsibility, which are still mostly occupied by men.
In those days for a woman to be considered as skilled as a male partner, she had to over-perform. Today, this is unthinkable, and perhaps it was nothing more than a reflection of the society of those years in which the professional world was mostly male. In comparison to the surgical world, the situation was somewhat different on medical departments, because the presence of women occurred earlier. On one occasion they told me not to seriously strain myself, because in the end I would marry, have children and end up abandoning the speciality. In fact, shortly after moving to La Coruña, I got married and had my daughters, but at no time did I think about abandoning my profession. Anyway, I must say that this is a period for women in which conciliation was (and still is) difficult. A lot of help is needed and I don’t know what can be done from the administration and hospital services so it has the least impact on the professional lives of women. The situation steadily changed because the number of women in surgical services increased. As the years went by, when I spoke at congresses and 34 iaoms.org
conferences with other colleagues, the situation was totally different in all hospitals. A common remark was about the difficulties of reaching positions of maximum responsibility, which are still mostly occupied by men. I must also say that throughout my professional life I have never seen aggressive or violent attitudes on the part of my colleagues. I have an excellent memory of them, although I must recognize that when a new specialist was going to join the Service, I always preferred that she be a woman, not because of the fact that working with her was different or easier than doing it with a partner, but for sharing other concerns outside the profession. I think that at this moment the situation in all the Services is totally different from when I started and the key has been the massive incorporation of women to the different surgical specialties. I believe that I have been very lucky to develop my work as a specialist in OMFS in Spain and of being able to participate and contribute to its development in our country over the last 40 years. ■ December 2019
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THE BEST IS YET TO COME By Dolores Martínez Pérez Madrid. Spain
I WAS born into a family with a strong medical tradition. My grandparents were both physicians, and so were my father and stepmother, although none of them was surgeons. I am the second of three siblings and the only one who took after them. I did my undergraduate degree in Madrid, at the Universidad Autónoma Medical School. Oral and Maxillofacial Surgery was a field totally unknown to us. After I completed my medical degree, I began Dental School which, at that time, was a medical speciality in Spain (it is now a separate qualification). Following that, I decided to specialise in Oral and Maxillofacial Surgery, a medical speciality with a fiveyear residency program. I chose La Paz Hospital, a large public and university hospital in Madrid. I was the first woman resident in the programme – at the time, there were very few women in our speciality across the country. Coming from Medical School, where half of the students were female, I was not used to being in such a male-dominated environment. When I met other women residents (from other specialities), we bonded over our shared experiences and soon set the basis of a solid friendship. Training years were hard, not very academic, and this forced me to dive into books. We were five residents and we tried our best to do our independent research while learning on the job. The speciality was ever-changing and growing in our country. I met Dr Carla Evans at a national conference, and I was surprised to see that orthognathic cases were first treated with orthodontics. I needed to introduce this approach in our hospital December 2019
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and asked her to invite me to her department for a rotation. I am very grateful to her because she put me in contact with Dr Mulliken at Boston Children’s Hospital and Dr Kaban at Massachusetts General Hospital, with whom I did my first elective rotation. This was one of the best experiences of my training years. I spent two months there and when I returned to La Paz, with the help of my young attending surgeons, we introduced orthodontics in our practice.
in academic medicine is hard, but in our country, getting help at home is still affordable and easy. Our hospital has since undergone major changes, growing enormously and so have all surgical departments. This led me to open my department in 2006, independent from ENT, at Fundación Jiménez Díaz. This was
I did other external rotations in Madrid, at the emerging craniofacial unit of the 12 de Octubre Hospital with Dr Salvan, and in Zurich (UniversitatsSpital) with Dr Sailer. I always felt very welcome, and these rotations were a great motivation for me. I finished my residency at a time of economic crisis in Spain. There weren’t many academic positions available and I did not want to go into private practice, so I chose to pursue further training at a large academic centre. I thus applied for a one-year fellowship at Boston Children’s Hospital and, whilst there, I had the privilege to work alongside Dr John Mulliken and learnt to treat vascular malformations, pediatric and craniofacial surgery, sharing his passion for surgery and research. When I returned to Spain, I found there were still very few job opportunities in my field. Through having previously met Dr Margarita Varela, an orthodontist at Fundación Jiménez Díaz Hospital Madrid, I was offered a job there. This was a very academic, both public and private hospital, which lacked oral and maxillofacial surgeons. I launched this speciality alone, without the supervision of a senior colleague. It was a big step up for me and I took it as a personal challenge – I had to lean on my ENT peers at the start, who then went on to assist me in long OR hours for the following thirteen years. During that time, I also got married and gave birth to my only daughter, Marta. My maternity leave was short and I soon returned to my fulltime practice. The part-time job was not an option if I wanted to pursue a career. Raising a family 36 iaoms.org
a great step in my career, it made me independent and the first and only woman in charge of a hospital department (albeit a small one) in Madrid (and I still am). Some great women colleagues lead large hospital departments in other cities in Spain, but I must say that women represent only 12% of the head of Departments. After that I launched two other oral and maxillofacial departments in Hospital Infanta Elena (2007) and Hospital Rey Juan Carlos (2012), also in Madrid, leading the speciality in all three hospitals for several years. I now work only at Fundación Jiménez Díaz with a wonderful team of four more oral and maxillofacial surgeons, as well as an orthodontist assigned to our department. We cover all the areas of our speciality: clefts, orthognathic, TMJ, trauma and head and neck surgery. We enjoy our daily practice, and I have the feeling that the best is still to come. ■ December 2019
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GENDER BARRIERS By Laura Villanueva-Alcojol Badajoz. Spain
MANY generational changes have evolved modern surgery over the past few decades. Despite that, while pontificating over “barriers to career development for women in Maxillofacial Surgery�, it becomes apparent to me that in the 21st century, there remains a kind of prejudice based on gender, and it is clear that active strategies to promote equity are needed.
salary or promotion disparities based on my gender from my colleagues. I believe that my training as a resident was similar to my male counterparts and I am grateful to my mentors that have been superb role models; continuing to be a source of professional advice and training guidance and having facilitated career advancement opportunities.
My name is Laura Villanueva Alcojol; I am in my thirties and I´m a Maxillofacial surgeon. Some years ago, I began my journey into the world of surgery. Most of my counterparts then and now were men and I, am the only female consultant in our Department. To date, I have not experienced any unequal treatment, December 2019
However, the scepticism from patients have been an entirely different matter. Traditional gender roles contribute to unconscious assumptions and implicit biases that have little to do with actual knowledge, skills and abilities of women surgeons. Although it is not the general rule, sometimes patients simply cannot comprehend that I am medically qualified and that I perform surgery. iaoms.org 37
Not uncommon is also the situation where I have watched patients ignore everything I say, and look to my male junior colleague to give the information after the operation.
I introduce myself with my name and job title and yet, after being examined, I have been asked when they are going to meet the doctor. Not uncommon is also the situation where I have watched patients ignore everything I say, and look to my male junior colleague to give the information after the operation. They often continue to look to my male twelve-month qualified trainee while I am explaining their condition or procedure. Perhaps it is not deliberate, and presumably it is just a matter of awareness and education of the general population. Many times female doctors and medical students are confused with nurses, nursing assistants or technicians. Perhaps as we draw 2019 close, it is far too late the time to stop needing to make that explanation. Further, these traditional gender roles also tend to escalate conflicts between personal life and career. Decisions regarding commitments and relationships, childbearing and the challenges of childcare as a surgeon also represent significant barriers to the professional advancement of female surgeons. Traditional gender roles imposed on women the major share of family duties that may constrain the progression of female surgeons in many ways. Because of family commitments, many women are forced to limit geographic mobility which is often necessary for advancement. Moreover, time spent on domestic labour competes with time spent conducting research, and research is arguably an activity critical to academic promotion and success. Women’s roles in the family may preclude them from devoting essential time and 38 iaoms.org
energies to achieving milestones that are essential for promotion. In fact, most men of my department have acknowledged the extent to which their career advancement depended upon sacrifices on the part of their wives. Concerning advancement into a leadership position, although I can´t find obvious barriers or obstacles to impede women from climbing the academic or corporate ladder, and despite the dramatically increased entry of women into general surgery and surgical subspecialties, there remains a gross under-representation of women in the leadership positions of these departments. Furthermore, there are gender disparities on many medical journal editorial boards (particularly at the highest levels), in academic surgery departments, leading speaking slots and high-level professional meetings. This scarcity of women in senior positions inevitably means that their individual and collective opinions are less likely to be voiced in policy and decisionmaking processes, and subsequently, younger women may not be encouraged or motivated to achieve top careers in medicine. Therefore, although I think that progress has been made in the last decades, many other changes still need to be undertaken at the level of individuals (both women and men) and at the level of the institutions that can address and correct the problem. Since diversity affords strength, innovation, and increased productivity to organizations, the evidence suggests that genderdiverse teams may be more successful. It is thus beneficial for organizations to have women present and lead. ■ December 2019
Report of Regional Meetings
XXI CIALACIBU 2019 By José Antonio García Piña Hospital Ángeles Puebla. México
WE WANT TO EMPHASIZE THREE IMPORTANT EVENTS THAT TOOK PLACE DURING THE CONGRESS THE ALACIBU (Asociación Latinoamericana de Cirugía Bucomaxilofacial) in conjunction with the AMCBM (Asociación Mexicana de Cirugía Bucal y Maxilofacial) organized its XXIst International Congress in Cancún, Quintana Roo, México from the 1st of December to the 4th of December 2019.
1. The change of the presidential chain of IAOMS from Dr. Alexis Olsson to Dr. Gabriele Millesi.
This great event brought together 1200 delegates and 113 speakers from all over the world to Cancún International Convention Center. Lecturers showed a high academic standard and the program covered the full scope of our specialty. The program started at 7:00 AM with multiple Breakfasts with the Experts, seminars that approached in depth several “hot topics” of Maxillofacial Surgery. Scientific days ended twelve hours later, around 7:00PM, with multiple lectures being held in 4 different rooms. Residents from all over the world were able to participate with e-posters and oral presentations. The program gave them the opportunity of enriching their knowledge and share their experiences with colleagues from other countries Intra-congress Courses were held during the meeting, including the SORG Course, AO Course, Next Gen session and the IBRA Course with an excellent participation in all of them.
2. The change of Presidency of ALACIBU from
Dr. Adrian Carlos Bencini to Dr. Raul Parra. Also, Dr. Cesar Villalpando Trejo became the new President Elect of ALACIBU for the period 20212023.
3. T he change of Presidency of AMCBM from
Dr. Maria Luisa Lopez Salgado to Dr. German Malanche Abdala.
We have been able to accomplish our goal: to build a specialty with the best standards of practicing, learning and knowledge updating, to give our patients the best available care. Now, we are all looking forward for the next ALACIBU International Congress that will be held in Cartagena de Indias (Colombia) in 2021. We hope to see you there. ■ December 2019
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Copy Me SIALOENDOSCOPY Sialoendoscopy is the minimally invasive procedure for the examination and treatment of pathology involving the terminal branches of the submandibular and parotid glands and ducts. With the advancement in the instrumentation and availability, coupled with positive patient outcomes, this minimally invasive technique has become a well-accepted procedure as both a diagnostic and a therapeutic treatment modality.Â
DR MATTHEW HAWTHORNE Bowen Hills, Australia
Surgeons performing sialoendoscopy should be aware of its limitations along with the inherent risks and complications. The current scopes are semi-rigid and they allow a 30-degree range of movement from the longitudinal axis, therefore, limiting examinations to the predominantly linear duct structures. Sialoliths that are located in accessory ducts, at acute angles to the main duct, are often inaccessible with the current instrumentation. Surgeons should always be aware of the possibility of iatrogenic injury to the duct apparatus from instrumentation that is not performed under direct vision. During the cannulation of the duct, the primary objective is to maintain the scope in the centre of the duct lumen as the endoscope is intubated into the gland. The purpose of this article is not to provide an in-depth review of the literature. However it is intended to provide a pictorial guide of the procedure to assist surgeons in performing sialolith removal. The position of the patient is important for the successful examination of the affected gland. The screen (endoscopic stack) is positioned at the head of the patient to allow direct visualization of the screen above the patients head as the scope is passed in approximately the same direction. If the procedure is performed under general anaesthesia the patient is supine with a nasotracheal tube. It is important to avoid the placement of a throat pack as this will distort the hypopharyngeal tissue. This would make the cannulation of the submandibular duct more difficult. However it would have little impact on the parotid gland examination.
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2 Visualization Fig. 1-2. It is often necessary to ‘milk’ the gland to identify the duct opening by watching the dried papilla to see where saliva is excreted to show the orifice. The orifice is not always at the apex of the papilla and it can be lateral to the very tip of the papilla. If the duct opening cannot be seen methylene blue may assist in identifying the opening.Â
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Cannulation Fig. 3-4. This is performed first and it can be the most difficult part of the procedure. It is important to prepare the site. A mouth prop is placed, and a cheek retractor along with a gauze is used to hold the tongue back to allow the submandibular duct papilla to be viewed. Lacrimal probes, along with a dilator, are necessary to achieve adequate dilation for insertion of the probe into the duct.
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Probe insertion Fig. 5. The finest probe available (0000) is used to carefully feel for the duct opening in the papilla. The use of tissue forceps should be avoided at this stage as bleeding at the peri-ductal tissue increases the difficulty of lacrimal probe insertion. Once the first probe has been successfully inserted the exchange to the next largest probe should be done once adequate dilation has occurred. The probe should be carefully withdrawn and exchanged for the next size as quickly as possible so that the site of the dilated duct opening is not lost. When advancing up the lacrimal probe sizes it may be necessary to drop back a couple of probe sizes if you are unable to insert the next size up easily. Alternatively, the duct dilator can be used when the duct opening has been identified and entered as it will dilate the duct to the necessary size for the insertion of the examination scope that is 1.1mm. The insertion of the duct dilator without the identification of the duct can lead to the creation of a false passage and result in a failed procedure. Fig. 6. Occasionally if all of the attempts using the lacrimal probes fail to identify the duct opening a small papillotomy will be required with direct dissection to the duct to expose and access the main duct.
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Scope insertion Fig 7.. The examination scope should be set up and irrigation connected to ensure that it is air-free before insertion. After the required dilation of the duct has been achieved the scope should be inserted. To assist in the navigation of the gland, a skin hook can be used to insert into the peri-ductal tissue for counter-traction to allow the navigation around the free edge of the mylohyoid muscle. In the parotid gland, the navigation around the anterior border of the masseter muscle is achieved with gentle traction of the cheek once the scope is inserted into the parotid duct. The parotid gland scope insertion is initially angulated towards the skin followed by a change in angulation to a more antero-posterior direction.
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Instrumentation Fig 8. After the duct has been cannulated the scope is advanced, staying in the centre of the lumen, whilst your assistant constantly insufflates the duct to maintain an expanded duct for navigation. If the lumen is lost or you run into the duct wall at any stage, stop, retract the scope to re-establish your orientation then advance again. Using a skin hook near the submandibular duct papilla will allow the duct to be straightened and this improves the ease of navigating around the mylohyoid muscle or the masseter muscle if examining the parotid gland. Fig 9. The sialolith is identified Fig 10-11. A Dormia basket is inserted into the working channel of the scope and under constant direct vision the sialolith is removed. Fig 12-13. Alternatively, specific forceps or microburs can be used. Fig 14. Delivery of the sialoliths from the duct may require a small papillotomy to facilitate the removal of larger stones. If forceful traction is applied on the Dormia basket, this can avulse the duct.
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14 Endoscopic-assisted stone removal Fig 15-16. A large stone can be removed via an endoscopically-assisted approach that utilizes the scope to identify the stone followed by direct the dissection in the floor of the mouth. The tongue and cheek are retracted with a Rampling sponge holder and tenotomy scissors are used for blunt dissection, along with careful haemostasis, to allow the delivery of large stones with minimal intervention.
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KEY POINTS TO REMEMBER: The submandibular gland duct anatomy has a lazy “S” shape around the mylohyoid muscle The parotid gland duct anatomy has a Lazy “L” shape around the masseter muscle Size – Small stones up to approximately 5mm can be endoscopically removed Location – ductal stones are accessible however intraparenchymal stones are often inaccessible Endoscopic-assisted removal – large stones can be removed via an endoscopically-assisted approach utilizing trans-illumination to localize the stone targeting the floor of mouth dissection
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Beyond O.R.
Are the “others” so dangerous? By Javier González Lagunas (follow me on
@golagunas)
ONE of my favourite quotes is the one that says that we should not lose time looking for intelligent life in other planets, but that we should devote all our efforts to find some on Earth! A common topic in general interest press but also in academic publications in the US and Western Europe is the dangers of Medical Tourism. Some of the warnings that patients receive when travelling abroad seeking for surgical treatment are infections, medication dangers, blood product supply challenges or the credentials of professionals. Let`s get serious. I will let you know some figures. Let´s start with the US system, and the numbers of estimated deaths per year: 12.000 due to unnecessary surgery, 7000 due to medication errors in hospitals, 80.000 due to nosocomial infections in hospitals
and 106.000 due to non-error secondary effects of drugs. This is not only an American perspective. In my own country, the Spanish Association of Public Health and the Organización Medica Colegial warn that around 5% of patients admitted to hospitals suffer some adverse effect secondary to medical errors or negligence. A WHO report of 2010 stated that health-care related errors occurred in 8 to 12% of inpatients, with similar statistics in France, Denmark and Spain. In the UK, The Council of Healthcare Regulatory Excellence stated that the General Dental Council had prosecuted 49 individual for unregistered practice. So I think that it would be good if Western Countries stop navel-gazing and perhaps apply the joke that started this column: Do not worry so much about the risks of medical treatment abroad and start working avoiding iatrogeny at home. In a previous column, we already talked about the change of the gravity center in surgical training. A few decades ago, surgeons from India had their post-graduate training in London, and American surgeons went on tour teaching doctors in Southeast Asia. Today, if you want to learn about Oral Cancer surgical treatment head to India, or look for a Chinese Department when you want to specialize in Reconstructive Surgery. Istanbul is now a learning hub for rhinoplasty or a hair transplant. And Shanghai is the place where you will see more TMJ arthroscopies in the world. Today there are no borders for professional services all over the world. You can find crooked professionals in Bogotá, but also in Chicago. There are “unsanitary” medical facilities in Mumbai, but also in Rome. Look for Quality Medical Service wherever you want. You can find it in Melbourne, Cape Town, Beijing, Sao Paulo or Frankfurt. And beware of bad medical professionals living in Miami, London, Cairo or Tokyo, because iatrogeny is pandemic; not just “abroad”! ■
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