FEBRUARY 8 –12, 2021 / 7:00 PM – 9:30 PM CST
The IAOMS/ALACIBU NextGen Online Conference will provide a dynamic and robust five-day program with live presentations followed by question and answer opportunities. Each day will include a variety of sessions presented by master surgeons from across the specialty as well as the next generation of young OMF surgeons. Participants will have the opportunity to participate in 2.5 hours of educational content per day throughout the duration of the conference. Thank you to our Emerald Level sponsor for supporting this conference.
SESSION TITLES BY DAY Monday Surgical Innovation Tuesday New Techniques in Dental Implants Wednesday Dynamic Cases in Orthognathic Surgery Thursday Insights and Best Practices in Pathology Friday From Diagnosis to Outcomes in Cleft Lip & Palate and Reconstructive Surgery
Visit www.iaoms.org/nextgenonlineconference to register today.
®
Issue 63 / December 2020
Editor-in-Chief Deepak Krishnan
Assistant Editors Noor Al Saadi Lilis Iskandar
Graphic Designer María Montesinos
Executive Committee 2020-2021 Board of Directors
Gabriele Millesi, President Alexis Olsson, Past President Alejandro Martinez, Vice President Sanjiv Nair, Vice President-Elect Arthur Jee, Treasurer Larry Nissen, IAOMS Foundation Chair Mitchell Dvorak, Executive Director
Members-at-Large Piero Cascone Rui Fernandes Fred Rozema
Regional Representatives
Imad Elimairi, Africa Tetsu Takahaski, Asia Nick Kalavrezos, Europe Leopoldo Victor Meneses Rivadeneira, Latin America Ian Ross, 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 Paul Sambrook, IBCSOMS Representative David Koppel, 25th ICOMS-2021, Glasgow Ed Dore, 26th 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. Cover image Adobe Stock
CONTACT US
International Association of Oral and Maxillofacial Surgeons IAOMS Foundation 200 E. Randolph St., Suite 5100 Chicago, IL 60601 USA / communications@iaoms.org
Prelude YEAR ZERO! 2020 would likely end up as an uncounted year in our lives. One that has mercilessly erased just about all entries in our planners and calendars, disrupted our professional and personal schedules, eliminated our travel plans and certainly created new norms in our daily lives. As I write this, the trees outside my window have shed leaves, bright yellow with auburn edges. The winter is upon us. There is news about a vaccine being massproduced. Some postulate that the virus has mutated to a less virulent form – perhaps its single strand RNA brain has realized that it should be kinder to the human host for its own survival. As the virus has adapted, so have we. With time on our hands, oral and maxillofacial surgeons have adopted unusual hobbies and pursued passions that were on the back burner until then. This issue of the Face to Face will highlight basement brewers, syringe painters, stone charmers, and savanna celluloids among others. We have also seen ingenuity in our professional lives. Large webbased gatherings have become the norm in our education. While one can argue for the convenience of learning from the couch and not missing the travails of travel, I would argue that being among friends and colleagues, the comradery, the hugs and handshakes value more than anything. I miss them! This is my first issue as the editor in chief of the Face to Face. My friend, Javier Lagunas leaves me large shoes to fill. I have recruited good help – two incredible young
surgeons as my sub-editors who you will meet in the subsequent pages and in the forthcoming issues, and a very talented graphic designer. We have also taken to slightly changing the format and content of the publication. We are hoping to make it more pictorial and minimal in prose. We are aiming for an “Instagram page of the People magazine” look than our previous appearance. Naturally, we will evolve as we move forward. We will also be only producing three editions of Face to Face in a year – a Spring, Summer and Winter issues. We hope to have meaningful content that appeals to all generations of Oral and Maxillofacial Surgeons from all over the world in these three productions. Here is to herald a new beginning. Hope springs eternal! Be safe all. ■
Deepak Krishnan EDITOR IN CHIEF
CONTENTS December 2020 10 20
SPECIAL REPORT
During the lockdown I discovered that...
WOMEN IN IAOMS
First Global Congress of Women Maxillofacial Surgeons: A report.
24
NEXTGEN
26
HOW I DO IT
32
IN MEMORIAM
34
TAILPIECE
35
MEET THE EDITORIAL TEAM
AAOMS annual meeting.
Superficial Parotidectomy.
Robert Malcolm Cook.
An afterthought on inconveniences.
ADAPTING TO CHANGE
A COMMUNITY CONNECTED Thank you to the IAOMS community for continuing to stay connected with us throughout this challenging year. This community has participated in our extensive online learning programs in record numbers and has fostered meaningful discussions and relationships from across the globe – all from a virtual setting. Our e-learning catalog has grown rapidly this year, with all new IAOMS Scientific Webinars, six segments of the IAOMS Stay Connected Series, four hours of education from the IAOMS Virtual Conference, eight episodes of the IAOMS Podcast Series, and the launch of the new IAOMS Microlearning Series all available ondemand, 24/7 via the e-learning portal. If you have not yet heard the news, please join us for the first IAOMS/ ALACIBU NextGen Online Conference which will take place February 8-12, 2021. We are proud of the IAOMS family, and we will continue towards our mission to help build your career and the OMF profession. We wish you all a healthy and joyous holiday season, and we look forward to connecting with you in 2021! MEMBERSHIP
We are incredibly grateful to those who either joined IAOMS or renewed their membership in 2020. Many of our members are enrolled in our new Automatic Renewal Program. Those enrolled will not receive renewal reminders; your membership will conveniently renew on January 1st (you will receive a reminder of your auto renewal in December). Those who are renewing annually are receiving dues notices and we hope you will take a moment to renew for the 2021 membership year. Should you have questions about your membership status, please contact Membership Manager Katie Cairns. IAOMS member benefits include online access to the International Journal of Oral and Maxillofacial Surgery (IJOMS), with print copies of the IJOMS via mail now available for $75 USD for IAOMS members (login to
your account to subscribe). IAOMS is committed to offering valuable resources to our members, including a sizable catalog of e-learning products which include scientific webinars, virtual conferences, and our new microlearning series. We will soon introduce an electronic version of the International OMF Reference Guide. This guide is filled with essential information on patient care in the practice of oral and maxillofacial surgery and is a valuable tool to quickly obtain answers to questions that arise during treatment. To learn more about IAOMS membership, visit our website or reach out to Membership Manager Katie Cairns for more information. We hope to see you among our members in 2021! CONFERENCES
IAOMS/ALACIBU NextGen Online Conference: We hope to see you – virtually – at the first IAOMS-ALACIBU NextGen Online Conference being held February 8 through February 12, 2021. From the next generation of young surgeons to master surgeons across the specialty, this online conference will provide a dynamic fiveday program with live presentations and question and answer opportunities. Registration for this online conference is open to all members and nonmembers. Visit www.iaoms.org/onlineconference to learn more about the latest updates, including speaker announcements, session topics and registration details. We encourage all IAOMS and ALACIBU members to participate in the e-poster session. All poster submissions must be submitted to IAOMS by January 6, 2020. To learn more about poster submission guidelines and eligibility, visit our website here.
Mitchell Dvorak EXECUTIVE DIRECTOR, IAOMS
Letter from the President
Dear IAOMS Members & Friends, It is hard to believe that the final issue of FACE TO FACEÂŽ is coming up in this dramatic year. I would like to extend my gratitude to our IAOMS members and the OMFS community for your patience, commitment and understanding as we battled this global pandemic together. The year 2020 has certainly been a challenging and unpredictable year for us all around the world. Unfortunately, we cannot yet jubilate about powerful vaccines or medications, but must continue to trust in our clinical research. It seems there may be some light at the end of the tunnel, with the first vaccines soon to be approved by FDA and EMA! When I recently looked into the sky in my garden, I felt looking into a mirror of our present state of mental health. Black clouds narrowing our horizon but still light and blue sky promising in the center! And that is how we function, also in the IAOMS and our team! So, let us fight the pandemic together and try to think positive! As you may already be aware, it is with a heavy heart that the IAOMS Board of Directors had to take the difficult decision to cancel ICOMS 2021 in Glasgow, Scotland without an alternative date or conference. The decision had to consider financial obligations and risk, as well as a close review of the budget. With already invested money, upcoming hard contracts to sign for the venue(s) and social fundraising events, as well as no realistic conference insurance or confidence in attendance and/or sponsorship revenue, we could not proceed. Additionally, and of the utmost importance, we carefully considered the safety of all the participants, delegates, speakers and industrial partners and possible Covid-19 requirements in this unprecedented period of uncertainty. The IAOMS
Board was left with no real option but to take this action. The 2022 calendar year was also seeming to include the resurgence of postponed and rescheduled scientific meetings, therefore leaving little availability for an ICOMS. For all of us who know what an ICOMS means for our association and our global community, this is a devastating decision for the IAOMS as well as for my presidency. We are incredibly grateful for the tremendous efforts of the British local Organizing Committee, under the leads of David Koppel, including their innumerable hours of planning and scheduling to prepare ICOMS Glasgow to be the best. I want to emphasize our deep gratitude to the BAOMS and their Organizing Committee for all their
hard work and enthusiasm. But leaders must keep the welfare of our members and the security of the Association in mind. There is no option to convert an ICOMS to a virtual meeting. An ICOMS is a face to face event, flavored by the multicultural spirit and the meeting of friends and exchange of scientific knowhow and experience. We all miss that so much. I wish for the opportunity to be closer to our members in person as the current IAOMS President, but I am hopeful and excited to see you all at ICOMS Vancouver in 2023. Despite unusual circumstances, we continue to stay connected and adapt to change. IAOMS has concentrated on our efforts to provide more digital programs to meet the needs of our members. In 2020, we witnessed record breaking attendance for our e-learning programs and provided more online content than ever before. We truly could not have accomplished such success without all of you. This year we introduced the IAOMS Stay Connected Series, the IAOMS Virtual Conference, and developed eight brand new episodes of the IAOMS Podcast Series. Additionally, we hosted numerous IAOMS Scientific webinars featuring Dr. Nabil Samman, Dr. Eric Kahugu, Dr. G.E. Ghali and more. I am also delighted to share with you our most recent endeavor; the IAOMS Microlearning Series. I had the great pleasure to assist our headquarters in the launch of the IAOMS Microlearning Series this past July, and we are working hard to secure new speakers and topics for future videos. My installment of this new series includes three brief segments highlighting “Tips and Tricks in Orthognathic Surgery” and is available now on www.iaoms.org. I encourage you to continue to take advantage of these programs by visiting www.iaoms.org, and navigating to our e-learning portal. We have a tremendous amount of on-demand content, and we are excited for some of our upcoming programming to be announced in 2021. I would also like to share an update with you all regarding Face to Face, our fantastic quarterly
publication. Several months ago, we learned of that our Editor in Chief, Javier González Lagunas, would depart from his role and involvement with Face to Face. After many years of exceptional service and dedication, I want to express my personal and sincere gratitude to our longtime editor Javier González Lagunas. You have brought brilliance and enthusiasm to Face to Face, and we cannot thank you enough. On that note, we are also excited to announce and welcome our new Editor in Chief, Deepak Krishnan. We are confident Deepak Krishnan and his team will provide outstanding work moving ahead. Looking at the calendar, we are getting close to the end of an unbelievable year which showed the vulnerability of us, as human beings, and our societies! On behalf of the IAOMS Board of Directors, Executive Committee and Chicago Headquarters, our thoughts are with those of you who had to cope with terrible losses of family or friends, fighting in the front line for our patients and handling deprivations. Suddenly all our lives were turned over. I want to assure you that we, as an Association, totally sympathize with all our members and try to stay connected as much as we can in this challenging times. Let us try to think positive, vaccines are on the horizon! As your president and friend, I wish you and your families all health, safety and some joy and peaceful rest during this holiday season. May the year 2021 bring us all together once again! With my warmest wishes,
Gabriele Millesi IAOMS PRESIDENT 2020-2021
During the lockdown I discovered that...
I CAN…
01
LOCKDOWN HOBBY— HOME BREWING By Kishore Nayak Bangalore, India
“What were they thinking? It's an alien apocalypse! Quick, grab the beer!”
BREWING your own beer is by no means a new hobby, but more of reclaiming a lost art. Brewing is as ancient as the advent of human civilization. Brewing beer is combination and understanding of a little bit of physics, chemistry and biology and application of some culinary skills and a lot of imagination. While it sounds tedious, it is undoubtedly fun to do. The option for many when wanting a beer is to head to a store and buy a standard Lager or Ale or if you’re lucky a microbrewery, but it’s a matter of personal pride, being able to say “I brew the beer I drink.” Or perhaps it’s the ability to experiment… and frankly, it’s just plain fun. No better way to beat the lockdown blues!
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How is beer made? Beer requires 4 BASIC INGREDIENTS: WATER, BARLEY, YEAST AND HOPS. Along with barley other adjuncts like wheat, rice ,corn, rye, etc., can be used. The grain provides the starch that is converted to sugar, mainly maltose. Hops are then added giving beer its characteristic bitterness and aroma along with flavour, which makes it more drinkable. A variety of yeasts can be used along with different grain and hops dictating the kind of beer one turns out.
It starts with recipe building‌. While standard recipes are available, withlittle experience and imagination, one gets adept at designing craft beers to suit personal taste. And that is the real pleasure and delight of this hobby. A combination of grains, a particular strain of yeast and choosing to extract the perfect amount of bitterness and flavour from hops and occasionally altering the water chemistry‌ you can produce Lagers, Pilsners, Ales, pale Ales, Stouts, Marzen, Weizens... an endless list making this hobby without boundaries.
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What is the brewing sequence?
1.
Choose and crush the grain to make the starch accessible.
2.
3.
Extract the starch out of the grain and convert them to fermentable sugars. This is the essence of brewing. The crushed grain is subjected to controlled temperatures which activates an enzyme called diastase within the grain to make this happen! This process is called mashing.
The sweet sugary solution collected from the mashing is called wort and typically about 6 gallons (22 litres) is collected and boiled in a large steel kettle for 60-90 mins. The hops are added into the wort at different stages of boiling and sometimes after or during fermentation. December 2020
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4. The wort is cooled rapidly, its specific gravity measured and transferred to a fermenter, then the is conditioned and added to do its magic! Typically fermentation takes between 6 days to few weeks depending on the style of beer and yeast used.
5.
Fermentation completion is judged by the post fermentation specific gravity which also enables the determination of the alcohol content of the beer.
6.
The beer is then transferred to steel kegs and force carbonated with CO2 and chilled . It is typically ready for drinking in 2 to 3 days post carbonation although some styles require longer storage.
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7. The kegs are stored at 2-3* Celsius in a home designed “kegerator� where beer is then available on tap.
8.
The beer then flows to make this hobby like no other. It sure is the best way to beat a lockdown.
There are the good friends who drop in from the other side of the world to see what this really means!! December 2020
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02
PAINTS WITH SYRINGES By Amir H Marashi Charlotte, North Carolina
I HAVE been practicing OMS for almost thirty years. Even though I have always been fond of arts, I never considered myself an artist. A few years ago, I started sculpting. I use multiple mediums, including wood, clay and other unconventional materials. I found the experience fascinating. My favorite sculpting theme is people’s faces! The pandemic has allowed me to explore the artsy part of me. I have also started painting, not portrait painting, but patterns – colors and
16 iaoms.org
contrasts fascinate me. My tools are those we are all familiar with: syringes, periosteal elevator, and so on. I have no formal training in art, yet I find the process of discovery very enjoyable – something like a meditation for me. Many times, I couldn’t wait to come home and continue spending time with my arts. I do recommend this to all my fellow surgeons – let’s explore our hidden talents in arts! Don't be afraid to experiment! After all, we all love working with our hands! ■
December 2020
03
MY LITTLE ESCAPE CORNER By Gabriele Millesi Austria
WITHIN days, the Covid-19 pandemic cropped our wings and banned us to stay on the ground. This was a tremendous restriction for someone like me who loves to travel, eager to explore foreign countries, and head for adventures. Despite being physically grounded, my spirit can still travel by looking at my little escape corner which contains my beautiful, exotic collection of shells and snails from every ocean all over the world. Luckily, we made it at least to the Mediterranean Sea this summer. Although there were no snails on the beach, we brought back small colorful pebbles. Amidst this corona period, I considered bringing some life to the stones by adding tiny succulentes, that I planted in a tiny precious China cup given to me by a Taiwanese friend. Whenever I look at this cup, its picturesque composition puts a smile on my face. With other cups, cheers to my global friends! For the good times to be together again, Kanpai! â– December 2020
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04
WILDLIFE PHOTOGRAPHY
By Amol Kulkarni Rwanda
The lockdown period has brought me a marvelous opportunity to be in solitude with the nature. I was able to introspect and find the version of myself which otherwise would be neglected due to life and work pressures. The feeling of being in solitude was refreshing, powerful and invigorating. Being alone in the camp or on the game trail in Akagera National Park with wild animals around, I was nervous but tremendously grounded. Having been able to capture those moments in pictures crystallizes a source of motivation for me – a chance to revisit them later. The pursuit of perfection in one picture equals the pursuit of a surgeon in bringing back the smile in one’s face. ■ 18 iaoms.org
December 2020
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Women in IAOMS
FIRST GLOBAL CONGRESS OF WOMEN MAXILLOFACIAL SURGEONS: A REPORT By Taranjit Kaur Jamnagar, India
On August 1st, 2020, INDIA hosted a global online meeting for women in maxillofacial surgery. The event was designed to celebrate the journey of women in maxillofacial surgery in various aspects through a series of presentations and discussions, inviting great female maxillofacial surgeons from across the world. Dr Vanaja opened the event by commemorating the first female maxillofacial surgeon in India, followed by a presentation by Dr Neelima Mallick, an honored female maxillofacial surgeon in India. Dr Sabine Girod, a Professor Emeritus at Stanford University, continued with a presentation titled “Where are the women?”, highlighting the global status of women in oral and maxillofacial surgery in the modern world. The presentation was followed by Dr Patricia Radaic, a Consultant and Professor at Sirio Libanes, Brazil, and an AO faculty delivering a topic on “Professional Life experience of women as maxillofacial surgeons”. Dr Divya Mehrotra, Professor, KGMC, Lakhnow, India, also spoke about “The power of role models”, emphasizing the importance of equality in the professional life of a woman. Finally, Dr Victoria Beale, the President of the Society of Women in Maxillofacial Surgery (SWiMS), UK left a special message to young female maxillofacial surgeons on the values of a right attitude, perseverance, and commitment towards the field. The event lasted for about 2 hours 50 minutes and was attended by more than 700 delegates of both women and men from all over the world. As what Dr Patricia Radaic put in her presentation, a quote from Dr Daniel Laskin “Women do not need special attention, but equal treatment“, this global joined force of women in maxillofacial surgy has burned the spirit of gender equality in our field. Thank you to Stryker India for supporting this event.
“Women do not need special attention, but equal treatment” 20 iaoms.org
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Build your career and our profession
Join IAOMS Today •
•
Learn with IJOMS, one of the world’s leading OMF journals with the highest impact factor of all OMF publications; read Face to Face, written for and by members
•
ranging from trainee to experienced surgeons: ICOMS, the IAOMS’ biennial signature educational and networking conference and “The Next Level Forum;” International Symposia, and regional conferences*
Enhance patient care through webinars and
other e-learning opportunities* •
Prepare for the International Board for the
Certification of Specialization of Oral and Maxillofacial Surgery (IBCSOMS) with the IAOMS Review Course
•
Support the next generation through the
IAOMS Foundation Fellowship and Scholarship opportunities
Experience events for all OMF surgeons,
•
Expand your knowledge; access innovative
best-in-class training •
Connect with peers throughout the world
•
Grow among the next generation of oral and
maxillofacial surgeons through our NextGen programmatic initiatives; network with your colleagues through our online community
Visit iaoms.org to become a member or renew your membership. Questions? Contact Membership Manager Katie Cairns at kcairns@iaoms.org
200 E. Randolph St., Suite 5100
•
Chicago, Illinois 60601 USA
•
+1.312.577.7660
*IAOMS members may benefit from reduced fees.
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•
www.iaoms.org
FOUNDATION CHAIRMAN REPORT
Dear Friends and Colleagues, As we reflect on a year faced with challenges and uncertainty, we are grateful for the resilience and the spirit that defines the global oral and maxillofacial community. We appreciate your patience, commitment, and support of the IAOMS and IAOMS Foundation as we adapt to the obstacles brought on by this global pandemic. While the opportunity to connect face to face at events around the world has been limited this year, we appreciate your participation in digital programs and conferences in the absence of in-person events. In October, the IAOMS Foundation had the honor to host the IAOMS/AAOMS International Reception once again at the 2020 Virtual AAOMS Annual Meeting. In anticipation of the 25th International Conference on Oral and Maxillofacial Surgery (ICOMS) previously planned for Glasgow, Scotland, we hosted a virtual scotch tasting that introduced some of the finer nuances of Scottish whiskies. It was truly a pleasure to raise a glass with you and to take a whisky journey together from our respective homes. It was a warming reminder that even amid a pandemic, our colleagues and friends can come together for an evening of camaraderie. We would like to thank the American Association of Oral and Maxillofacial Surgeons (AAOMS) for the opportunity to be a part of this virtual meeting. Like many organizations, the IAOMS Foundation continues to explore new ways to support the needs of our specialty. As we look to the future, ensuring we have the ability to resume key programs and continue expanding research, education, and training opportunities for the global community of OMFS is imperative. The demand for education continues to expand, particularly in the current environment. We know the role of the Foundation will only grow more critical as we navigate through these challenging times. Please join us now, at the end of the year, by making a gift, in any amount, to help ensure we are prepared for the future. To make a gift, or to learn more about the IAOMS Foundation’s plans for the future, please visit www.iaomsfoundation.org. On behalf of the IAOMS Foundation Board of Trustees, thank you for your continued commitment to our organization. The year 2021 will be a very special year for the Foundation and we look forward to celebrating it with you. Sincerely, Larry W. Nissen IAOMS Foundation Chairman
NextGen
Maurits de Ruiter.
By Andrew M. Read-Fuller Texas, Dallas
THE COMBINED AAOMS/IAOMS meeting was held virtually from October 1-10. Although this was the first time the meeting was not held in person, the attendance exceeded expectations with over 3400 surgeons and staff members participating, including over 600 trainees. The speaker lineup was diverse and engaging and included not only American and international oral & maxillofacial surgeons, but also comedian Jay Leno, as well as Dr. Anthony Fauci, who is one of the key physicians leading the government response to the COVID-19 pandemic in the United States. Among the lineup of presenters in the educational programming were several dynamic young international surgeons. Maurits de Ruiter, surgeon at Amsterdam UMC and Diakonessenhuis in the Netherlands spoke about perioperative management of obstructive sleep apnea patient undergoing MMA. Alfred Lau, oral & maxillofacial surgeon from Hong Kong and 24 iaoms.org
Alfred Lau.
Camilo from Once Upon a Whisky tours explains the correct way to drink scotch at the IAOMS Foundation event. December 2020
“The attendance exceeded expectations, with over 3,400 surgeons and staff members participating”
chair of the NextGen and Membership and Communications committees for IAOMS, gave an excellent presentation on autogenous bone grafting and growth factors. Despite the physical distance between attendees, the IAOMS and AAOMS did not neglect the social events and networking opportunities that make their meetings memorable. The IAOMS Foundation hosted a scotch tasting event to toast the strong work of the Foundation in the past year as well as to prepare members for the upcoming ICOMS in Glasgow in 2021. Although this has undoubtedly been a challenging year for all oral & maxillofacial surgeons across the world, the AAOMS/ IAOMS virtual meeting demonstrated the strength of the OMS community, and proved our steadfast ability to connect, learn, and laugh despite the obstacles and distance that stand between us. ■ December 2020
1. IAOMS President Prof. Gabrielle Millesi virtually toasts IAOMS and AAOMS members at the scotch tasting event. 2. Dr. Anthony Fauci. 3. Dr. Victor L. Nannini, AAOMS President. 4. Jay Leno and AAOMS President Dr. Victor Nannini. iaoms.org 25
How I do it SUPERFICIAL PAROTIDECTOMY
ALLEN CHENG DDS, MD, FACS Medical Director, Oral/Head and Neck Oncology Legacy Good Samaritan Cancer Center, Portland, Oregon, USA
ASHISH PATEL DDS, MD, FACS Medical Director, Craniomaxillofacial and Neck Trauma, Legacy Emanuel Medical Center, Portland, Oregon, USA
PAROTIDECTOMY is defined as the surgical removal of the parotid gland. The most common indication for parotidectomy is for the treatment of neoplasms of the parotid gland. It is also used for management of symptomatic inflammatory diseases of the parotid gland that are refractory to medical management. Parotidectomy can range from complete to selective depending on the clinical indication, this includes: radical parotidectomy with facial nerve resection, total parotidectomy, superficial parotidectomy, partial superficial parotidectomy, and extracapsular dissection parotidectomy. (**the previous statement might not be true in cases of palliative treatment) Benign salivary gland neoplasms are most commonly affecting the parotid gland. These include pleomorphic adenoma, papillary cystadenoma lymphomatosum, oncocytomas, myoepitheliomas, and intraductal papillomas. On the other hand, malignant parotid gland neoplasms are less common, such as mucoepidermoid carcinoma, adenoid cystic carcinoma, acinic cell carcinoma, adenocarcinoma not otherwise specified, carcinoma ex pleomorphic adenoma, salivary ductal carcinoma, mammary analogue secretory carcinoma, metastatic disease, usually from cutaneous squamous cell carcinoma or malignant melanoma, and lymphoma. For neoplasms of the parotid gland that are likely to be benign, we prefer removing the nodule using extracapsular dissection. This is a technically challenging, minimally invasive approach that has demonstrated an equivalent disease control as a superficial parotidectomy with lower risk of facial nerve injury, and minimum facial contour deformity. However, it requires a foundational understanding and experience in performing a more formal parotidectomy with facial nerve dissection. Also, in patients where the clinical diagnosis is less clear, a superficial parotidectomy or partial superficial parotidectomy is preferred. In this article, we will describe the steps we follow to perform a traditional superficial parotidectomy.
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Surgical steps PLACE PROBES FOR FACIAL NERVE MONITORING. (Figure 1) We typically use 4 channel electromyographic monitoring with the nerve integrity monitor (NIM) 3.0 Nerve Monitoring System. Although the use of nerve monitoring is not mandatory, we find it very helpful as it provides an additional method of nerve verification.
MARK OUT A MODIFIED BLAIR INCISION, that is, a preauricular incision that extends posteriorly under the lobule of the ear before wrapping anteriorly into a cervical crease (Figure 2). The cervical extension can be lengthened to accommodate a simultaneous neck dissection, if necessary. When designing the posterior auricular portion of the incision, avoid the temptation to extend it too far posteriorly before wrapping anteriorly, as this will create a peninsula skin flap that is more prone to necrosis. Alternatively, a more esthetic modification (not pictured) would be to use a rhytidectomy incision, where the posterior turn extends further posteriorly into the hairline of the neck. This provides less exposure anteriorly and should be only undertaken by surgeons experienced in performing parotidectomies.
3A
1
2
3B
3C
DEVELOP THE SKIN FLAP IN A SUBCUTANEOUS PLANE. When making the skin incision, take it to the depth of the subcutaneous fat, in a plane superficial to the superficial musculoaponeurotic system (SMAS). Then, starting in the preauricular region, develop the skin flap. We typically use Dean’s scissors or rhytidectomy scissors to perform this. While using double pronged skin hooks to provide counter-tension, leaving the tines of the scissors slightly open (see Figure 3A), push the scissors forward underneath the skin. With the tines slightly open, you should be able to see the impression of these tines under the skin (Figure 3A), while the portion of the subcutaneous fat being cut, is at the intersection of the tines of the scissors (see Figure 3B). Therefore, the depth of the flap is controlled by how narrow or wide the tines of the scissors are kept open. This dissection is taken anteriorly just beyond the palpable parotid gland. The ideal thickness of the flap should leave most of the subcutaneous fat on the skin flap. Making the skin flap too thin increases the risk of Frey’s syndrome (gustatory sweating). Be careful not to go too far anteriorly, as the facial nerve becomes more superficial (Figure 3C). December 2020
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4A 4B Where to look for the facial nerve trunk
Junction of boney and cartilage EAC
Digastric muscle Tragal pointer Sternocleidomastoid muscle
CREATE SUPERIOR AND INFERIOR TUNNELS TO THE APPROPRIATE DEPTH AND IDENTIFY THE SURGICAL LANDMARKS THAT ALLOW FOR LOCALIZATION OF THE FACIAL NERVE TRUNK (FIGURES 4A AND B). First, superiorly, in a supraperichondrial plane, sharply follow the cartilaginous portion of the external auditory canal (EAC) deep until you reach the junction of the cartilaginous and boney EAC. Next, inferiorly, identify the sternocleidomastoid and dissect its medial side enough to allow it to be retracted laterally. Then trace this superiorly until its attachment to the mastoid process. Using blunt dissection, identify the posterior belly of the digastric muscle. Follow this posterosuperiorly to the mastoid notch (just medial to the origin of the sternocleidomastoid). By doing this, you have established the depth where the facial nerve trunk lies above and below the trunk (see Figures 4A and 4B). The facial nerve exits the temporal bone at the stylomastoid foramen, which is between the mastoid and styloid processes (both of which are palpable at this point). The surgical landmarks that assist in localization of the facial nerve trunk are the junction of the bony and cartilaginous EAC, the mastoid process, the styloid process, the tragal pointer (the triangular projection of the cartilaginous EAC), the origin of the posterior belly of the digastric muscle at the mastoid notch, and the tympanomastoid suture. During this dissection, you will often have to ligate and divide the retromandibular vein as well as the anterior branch of the greater auricular nerve.
Facial nerve trunk Junction of boney and cartilage EAC
Digastric muscle
Tragal pointer
5
IDENTIFY THE FACIAL NERVE TRUNK. With all of the landmarks identified, the location of the facial nerve trunk is narrowed to a small area between the superior and inferior tunnels created in Step 3. The posterior belly of digastric muscle and the junction of the bony and cartilaginous EAC will assist you in identifying the depth the facial nerve. In this area, using blunt dissection, thin out the soft tissue above the depth previously established until you come close to the appropriate depth. During this, we use the nerve stimulator to verify that divided tissue does not contain the facial nerve trunk. Once at the appropriate depth, use your blunt dissectors and gently spread along the direction of the nerve, tips down. We prefer Dierks Dissectors #2 for this, but McCabe dissectors or small hemostats work just as well. With this maneuver, the nerve trunk will eventually come into view (figure 5A and 5B). You will likely run into audible alerts from the NIM system as you come close to it. 28 iaoms.org
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6B
6A Pes anserinus of facial nerve
Facial nerve trunk
TRACE OUT THE FACIAL NERVE TRUNK UNTIL YOU VISUALIZE THE PES ANSERINUS (THE BRANCH POINT BETWEEN THE CERVICOFACIAL AND TEMPOROFACIAL DIVISIONS) (FIGURE 6A, B, AND C). Before visualizing the pes anserinus, you should avoid dividing soft tissue on either side of the nerve. It is very easy to inadvertently pick up one of the divisions or branches of the nerve when bluntly dissecting and present it for division by your assistant.
6C 7A
FRAME THE BRANCHES OF THE NERVE (FIGURE 7 - VIDEO). Using blunt dissection, begin tracing out the most inferior or superior division and branches of the nerve. This can be safely done because the branches do not cross.
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8
DISSECT THE NEXT ADJACENT BRANCH, ELEVATING THE SUPERFICIAL LOBE IN A BROAD FRONT (VIDEO 8 VIDEO). While tracing out a branch, elevate the superficial lobe of the parotid in a broad front by connecting the dissection with the previously elevated tissue. Continue in this fashion until the entire superficial lobe (or tumor if performing a partial superficial parotidectomy) is elevated.
9
10A
O N C E T H E S U P E R F I C I A L LO B E I S ELEVATED IN A BROAD FRONT, CLEAVE THE SOFT TISSUE ANTERIOR TO THE TUMOR, SUPERFICIAL TO THE BRANCHES OF THE FACIAL NERVE (FIGURE 9). This is performed by dissecting bluntly from the nerve out, superficially. Make sure the branches are clearly in view when performing this maneuver. Also make sure that you are anterior to the tumor.
10B Marginal mandibular branch Cervical branch Cervicofacial division
Buccal branch Zygomatic branch Temporal branch Temporofacial branch Facial nerve trunk
EXAMINE EACH OF THE BRANCHES OF THE FACIAL NERVE AND CONFIRM FUNCTION WITH THE NERVE STIMULATOR (FIGURE 10A AND 10B).
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11 HARVEST ABDOMINAL FAT GRAFT AND SECURE IT WITH RESORBABLE SUTURE TO THE PAROTIDECTOMY DEFECT (FIGURE 11).
CLOSE THE SKIN INCISION IN LAYERS. We typically use a Blake suction drain. Once healed, the incision is well camouflaged (Figure 12A and 12B). The concavity will be visible. But, because it is lateral defect, it is a deformity that is mostly well tolerated. For patients with high esthetic concerns, consider reconstructing the defect with a buried adipofascial flap such as an anterolateral thigh flap, parascapular flap, or lateral arm flap. â–
12A
9
12B
BEHIND THE SURGEON WITH DR. FAISAL QUERESHY: Networking, social media, and associations. How does an experienced educator find ways to further his knowledge within the specialty? Learn the story behind Dr. Faisal Quereshy and how he continues to access new information utilizing the OMF community. Moderated by IAOMS Education Consultant Debra Zabloudil.
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IN MEMORIAM
Robert Malcolm Cook
12/11/1928 - 22/08/2020
By David Wiesenfeld and Andrew Heggie Melbourne, Australia
A highly accomplished Oral and Maxillofacial Surgeon, Bob Cook was a major figure and leader of the specialty, as well as a teacher and mentor to many trainees and junior surgeons. In 1989, Bob was awarded, “Member of the Order of Australia” in recognition of his service to Dentistry and Maxillofacial Surgery. Bob was born in Bluff, on the southern coast of New Zealand in 1928. His family moved to the eastern suburbs of Melbourne in 1936 where he attended Camberwell High School. He completed his secondary education at Scotch College and was accepted to study Dentistry at the University of Melbourne, graduated in 1952. After serving as the first Resident Dental Officer at The Royal Melbourne Hospital in 1953, he continued further surgical training at The Eastman London and the Royal Infirmary Bolton, United Kingdom, and was awarded the FDSRCS. When Bob completed the MDSc (Melb) in Oral Surgery, he was appointed as “Oral Surgeon” to four Melbourne public hospitals, for which he provided oncall services for facial trauma, particularly from motor vehicle accidents. At that time, there were no seat belts nor airbags, thus front-seat drivers and passengers were often projected through the car windscreens. It was common for him to manage multiple pan-facial trauma patients in a single-weekend duty. Over time, his Units grew, and others joined. Bob restricted his trauma load to the Royal Melbourne Hospital where he
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subsequently became the Head of Unit in 1971 until 1988 and supervised the training of a generation of Oral and Maxillofacial Surgeons in Victoria. Bob was an innovative surgeon – with the encouragement of Head Plastic Surgeon, John Hueston, he advanced the care of patients with facial injuries, and initiated the correction of facial deformities, both developmental and acquired. In 1964, following a study visit to Hugo Obwegeser’s Unit in Zurich, he performed the first mandibular osteotomy in Australia, several years before these procedures were adopted in the United States. This early pioneering work set the scene for the rapidly developing field of orthognathic surgery in collaboration with orthodontics. He also played a role in the development of the multi-disciplinary care of Head and Neck cancer patients at the Royal Melbourne Hospital which combined the expertise of General, ENT, Plastic and Oral and Maxillofacial Surgeons. Bob was a highly energetic, enthusiastic and thoughtful practitioner and was regarded as a skilful, quick surgeon who leads by example. Attested by many of his colleagues, he demonstrated a steel-trap memory for detail, could recall names of those he met despite only fleetingly. When junior staffs hoped they had successfully buried some oversights or errors, Bob would unexpectedly pounce with evidence at a later
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stage, keeping everyone on their toes. He was the consummate political representative for Oral and Maxillofacial Surgery (OMS) in the surgical world and highly respected by other craft groups,paving the way for the broader acceptance of OMS as a standalone specialty in subsequent years. Bob served as President of the Australian and New Zealand Association of Oral and Maxillofacial Surgeons in 1978-1981. He was the first Australian to become the President of the International Association of Oral and Maxillofacial Surgeons (IAOMS) in 1992, a wonderful ambassador for Australia. He was a prolific traveller and through the IAOMS he developed lifelong friendships with fellows around the globe, whom he continued to meet regularly. His contacts also assisted a number of young surgeons to obtain subspecialty Fellowships in the UK, USA and Europe. As President of the Victorian Branch of Australian Dental Association in 1964, Bob actively participated in building a relationship between the profession and government through committee works. With others, he was instrumental in establishing and examining in the Specialty Fellowship in Oral and Maxillofacial Surgery within the Royal Australasian College of Dental Surgeons. At the University of Melbourne, in collaboration with Peter Reade, he taught and examined at undergraduate and postgraduate levels. He supported the development of the MDSc in OMS and assisted in guiding the University processes to adopt the FRACDS(OMS) as a national standard. His lasting legacy at the University of Melbourne is the establishment of The Robert and Gillian Cook Family Award for enrolled post-graduate students to support research in OMS.
Bob’s contribution to Australia extended beyond the surgical world. He served as a Surgeon Lt. Commander and Consultant Surgeon to The Royal Australian Navy and was an active member of many clubs including Rotary, The Melbourne Club, Royal South Yarra Tennis Club and both Flinders and Metropolitan Golf Clubs.
With his wife, Gillian, he maintained an active social and vigorous lifestyle. At their farm in Flinders overlooking Bass Strait, he conducted a successful Simmental cattle breeding program. They both skied with their international friends well into their mid 80’s. In between everything else, Bob He was the first Australian was also an accomplished scuba diver. He remained active until about 18 months ago, to become the President and passed away peacefully in his sleep.
of the International Association of Oral and Maxillofacial Surgeons (IAOMS) in 1992, a wonderful ambassador for Australia. December 2020
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Always a devoted family man, Bob is survived by his wife Gillian, their children Hamish, Alistair, Matthew, and Kirsten, and nine grandchildren. His broadly rounded life of service and commitment was well-lived. He will be remembered fondly by his family, friends and colleagues. RIP. ■
AN AFTERTHOUGHT ON INCONVENIENCES By Deepak G. Krishnan
THE SIGNS AND SYMPTOMS of a pandemic fatigue are here. Just about everyone has had enough with these masks, the social (physical) distancing, the lock downs and never-ending teleconferences. Regardless of the corner of the world we live in, a virus previously unexposed to the human race has touched us and taken its toll. In some of the worst-hit nations, the official count is reaching exponential tolls of infecting up to 200,000 fellow humans. Perhaps by the time this column sees light, at least some of us would have been vaccinated. We do not yet know what problems will arise next from this “solution”. At work and on social media, friends and colleagues are constantly complaining of the inconveniences the pandemic has caused them. Cancelled weddings, birthday parties, graduations, elective surgeries, basketball games, and international conferences have been the center of discussions among disappointments. For many of us, the pandemic seems to be happening on TV to someone somewhere else in the world – in a slum in Mumbai or an ER in New York, not in my neighborhood! For a handful of us who either caught the disease or watched someone we knew die from it, the perspective is different. Several members of my team contracted the illness, and some had significant symptoms. Fortunately, we have not lost any members of our team, but I know of colleagues elsewhere in the world who have succumbed to the fatal effects of the virus. Early this summer, I was brushing up on principles of critical care including ventilator management in anticipation for being deployed to our ICU if there was a surge in my small Midwestern city. Fortunately for everyone, that did not happen. However, it could still happen any day. One can only hope that the PPEs and the antivirals hold up their part of the 34 iaoms.org
promise. Every member of the medical team in our tertiary care academic medical center serving a large Midwestern population in the US is working long hours, odd shifts and adapting to the new ways of life. Sacrifices have become an anthem of life – pay cuts, high risk patient care, staying away from the family for fear of infecting them, just to list a few. The medical community all over the world have come together like never before at a time when we need them the most. Our sacrifices and inconveniences do not require a validation. An oath of the ancient Greeks, which the youngest amongst us take when being set out into the world, shall be maintained, “this responsibility must be faced with great humility and awareness of my own frailty.” A pandemic is ploughing through humanity and is incurring some major inconveniences to everyday life. And yet, we show up at our respective patient care units and do our best under the circumstances. So, the next time a family member or friend starts complaining of the minor inconveniences, don’t hold back – pinch your mask at the nose, find a soapbox to stand on and be a spokesperson for each nurse, respiratory therapist, housekeeper and internist fighting on the front lines – be a hero! ■ December 2020
Meet the editorial team Deepak Krishnan
Noor Al Saadi Is an oral and maxillofacial surgeon who graduated from Oman medical speciality board (OMSB). She cleared her fellowship exams from the Royal college of Surgeons in Ireland. She is currently working at the plastic surgery department - craniofacial surgery unit in Muscat, Sultante of Oman. She is involved in the management of cleft lip and palate, craniofacial trauma, craniosynostosis and other craniofacial anomalies. She is also an exam-item writer and a member of the exam committee of the oral and maxillofacial surgery program at the OMSB. Her involvement in the International Association of Oral and Maxillofacial Surgeons (IAOMS) was in 2017 when she attended the NextGen meeting at the 23rd International Conference of Oral and Maxillofacial Surgery (ICOMS) 2017 in Hong Kong where she was chosen as the NextGen representative of Asia by Dr Gabriele Millesi, she also won the best “Future Maxillofacial Instrument Design Competition” at the same conference. Since then she was involved in different NextGen activities including online exams and face to face magazine, where she has authored multiple articles that were published in the previous issues.
Teaches and practices as an oral and maxillofacial surgeon at the University of Cincinnati in Cincinnati, Ohio in the United States. He served as the chair of NextGen council of the IAOMS from 2013 to 2017 and has been the co-editor of the Face to Face since 2017. Deepak prides in having trained in several countries, including India, Kenya, USA and Canada under some stalwarts of oral and maxillofacial surgery. Deepak now leads one of the oldest OMS training centers in the US. Mentorship has been the keystone of his career and he is now at a crossroad of transitioning from a mentee to a mentor. His professional interests have been in pediatric oral and maxillofacial surgery, surgery for dentofacial deformities, surgery of the TMJ and benign pathology. He has published a number of research articles and constantly engages in the clinical research. He currently serves as the chair of the Committee on Anesthesia (CAN) of the American Association of Oral and Maxillofacial Surgeons (AAOMS), one of the Committee of Education and Training (CET) of the AAOMS, as well as the secretary and treasurer of the American College of Oral and Maxillofacial Surgeons (ACOMS). He is a past-president of the Ohio State Oral and Maxillofacial Surgeons and the current president of the Ohio Dental Society of Anesthesiology. He is also a senior examiner for the American Board of Oral and Maxillofacial Surgery and a Fellow of the American college of Surgeons (ACS). Deepak has no clue what to do outside of work, is a socially withdrawn inept, an introvert who struggles with the concept of work-life balance. His wife Preethi acts like a single parent who raises their teenage daughters and deals with their drama singlehandedly while Deepak submitted another paper to some “esteemed journal” this past weekend! December 2020
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Lilis Iskandar Is a PhD candidate at the Centre for Oral, Clinical & Translational Sciences – Faculty of Dentistry, Oral & Craniofacial Sciences – King’s College London. Her research focuses on bone tissue engineering for oral and maxillofacial surgery (OMS) and her current study is fully sponsored by Indonesia Endowment Fund for Education. She is a dentist graduated from Universitas Indonesia. She co-founded and currently lead Nusantara Innovation Forum, a collaborative global forum for researchers, professionals, students, and entrepreneurs aspiring to promote Indonesian development through research and innovation. Upon finishing her PhD, her plan is to continue her clinical training in OMS. Her involvement in the International Association of Oral and Maxillofacial Surgeons (IAOMS) started when she attended and presented her research at the 24th International Conference on Oral and Maxillofacial Surgery (ICOMS) 2019 in Rio de Janeiro where she met Dr Gabriele Millesi and Dr Alfred Lau who invited her to join the IAOMS NextGen Council. Together with other representatives from the Europe region, she presented a summary about OMS in the United Kingdom and its training pathway. She also proposed the IAOMS video competition idea aiming to build awareness and understanding of OMS as a specialty.
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