Q: Dr. Eppley, my husband had maxillofacial surgery for an under bite and put cheek implants in to balance his facial features about five years ago. He has had problems with the left cheek implant moving slightly and when he blows his nose his left cheek gets swollen and you can feel bubble like things moving around implant. It has caused him a lot of pressure and pain and this happens more often. I have begged him to go to the Dr but the entire experience of the surgery has traumatized him and so I’m trying to figure out what’s wrong. Please help me try to help my husband.
A: Undoubtably what your husband is experiencing is what one may call a ‘blowhole’ in the simplest of terms. When a maxillary osteotomy (LeFort I osteotomy) is done, the bone cut across the upepr jaw exposes the entire maxillary sinus. While most osteotomy lines experience complete bony healing afterwards, some do not particularly larger maxillary advancements and those that may have been vertically elongated. Any large unhealed bony openings allows air to escape from the maxillary sinus up into the cheek facial area, particularly when the air is forced such as blowing one’s nose. A cheek implant may be laying right next to or even over the original osteotomy line. This air being forced into and around a cheek implant (if it is not secured with a screw) make make it move slightly from the air pressure. Air into the subcutaneous tissues of the face is known as crepitus, which you more commonly call ‘bubbles’.
Thus there is a bony hole right next to the cheek implant as the culprit of all of these symptoms. This is a relatively easy problem to fix by covering the bone hole (sealing the sinus from the face) and stabilizing the implant to the bone with a screw. This is a simple outpatient procedure done under general anesthesia with minimal recovery. The only question is what to use to seal the bone hole as a variety of materials can be used to accomplish that end.
Dr. Barry Eppley
Q: Dear Dr. Eppley, what is the difference between craniofacial and maxillofacial surgery? I am thinking that they use the same surgical procedures and the same materials like bone cement? I am interested in getting my forehead reconstructed from a dent in it due to an injury but don’t know which type of surgeon to go to. And are you practicing both craniofacial and maxillofacial surgery?
A: Maxillofacial surgeons are usually dentists (with or without a medical degree) that have trained in facial bone surgery below the forehead, mainly of the jaws. Craniofacial surgeons are plastic surgeons that have done extra training in craniofacial deformities and have much greater experience in bone surgery above the jaws. Most maxillofacial surgeons will have very limited experience if any in forehead surgery and cranioplasty.
While there are exceptions to either of these types of surgeons and training and experience can vary by country and geographic region, these are general guidelines. I can speak to their differences quite clearly as I have trained and am board-certified in both specialities. You should seek out a plastic surgeon who has considerable experience in cranioplasty and the various materials used to do this type of forehead surgery.
Dr. Barry Eppley
This book has been written to provide a basic education and awareness of the surgical specialty of Maxillofacial Surgery. It is not designed to be an all- inclusive text, but an outline of the terminology, anatomy, diagnosis, and treatment of the broad and complex array of maxillofacial and craniofacial problems. It is intended to serve as a pocket guide that is visually- oriented, can be quickly used as a reference, and read from cover to cover in a short period of time.
Maxillofacial surgery, a long-standing subspecialty of Plastic Surgery, had its beginnings in the early part of the 20th century during World War I when trench warfare created a large number of severe facial injuries. Their treatment required the development of an integrated approach of reconstructive surgery and dentistry which remains the guiding principles of Maxillofacial Surgery today. It has grown from its beginnings in facial trauma to include congenital cleft and craniofacial deformities, jaw surgery, reconstruction of extirpated tumor defects, to aesthetic facial surgery.
Maxillofacial surgery requires an understanding and assimilation of medical and dental principles involving anatomy, biomaterials, and manual dexterity. Surgical manipulation of facial anatomy is unforegiving in its visible outcome to the patient and society.
The specialty of Maxillofacial Surgery combines a knowledge base and techniques drawn from all of the head and neck disciplines with particular emphasis coming from plastic surgery. The field has expanded greatly over the latter half of the 20th century, led primarily by the interest and innovations established by the tenets of contemporary craniofacial surgery where maxillofacial surgery was expanded to the orbits, forehead, and the cranial cavity to make a better life possible for many congenitally deformed but intelligent human beings.
The specialty of Maxillofacial Surgery is designed to provide the highest standards of care for all surgery performed in the face and skull, whether it’s origin be of bone, soft tissue, or both. It can be difficult work in an anatomic area where many essential functional and aesthetic structures intermingle and proper training of the surgeon is paramount to achieve the desired end result, a patient with a more normal face and smile. It endeavors to achieve these aims through education, research, and awareness amongst the general public and medical field about the specialty. This handbook, in its own small way, is another brick for that building. May its reading provide insight into the astonishing work possible from Maxillofacial Surgery.
Dr. Barry Eppley