Facial Plastic and Reconstructive Surgery

Hunter Archibald, MD

Facial Plastic & Reconstructive Surgery

Otolaryngology-Head and Neck Surgery

University of Massachusetts Medical School

Milford Ear, Nose & Throat Surgery

 Facial Plastic & Reconstructive surgery is a broad discipline within Otolaryngology-Head and Neck Surgery. Procedures and care for patients ranges from trauma and cancer reconstruction to aesthetic and aging face surgery. Our goal in reconstruction is to use function and form to restore patients to a normal appearance and life. My philosophy for cosmetics is to achieve a result that is aligned with the patient’s goals and does not appear “operated on”. There are many subdisciplines within FPRS that we offer at the University of Massachusetts Medical Center.

Rhinoplasty, Functional and Cosmetic and Septoplasty

 Rhinoplasty is a surgery to change the appearance of the nose. This may include straightening the nose, changing the appearance of the dorsum (bridge), or nasal tip. Rhinoplasty is sometimes combined in the same surgical procedure with a septoplasty (straightening the septum). This would be called a septorhinoplasty. A rhinoplasty is generally a cosmetic procedure. Usually a rhinoplasty is an outpatient procedure. Sometimes cartilage grafting is required for rhinoplasty.

 Septoplasty is a surgery to help straighten the nasal septum (the midline partition inside the nose). This is most commonly completed to help with nasal breathing. Sometimes a septoplasty is completed as part of a rhinoplasty (cosmetic procedure) or as part of a reconstructive procedure. Nasal valve repair is the widening or strengthening of a narrow portion of the nasal airway. Sometimes cartilage grafting is required for nasal valve repair. Grafts may come from the ear, rib, or cadaveric sources.

 Rhinoplasty is commonly described as the most challenging procedure in facial plastic surgery. Skin, cartilage, bone, and nasal lining all must be considered when approaching a nose. It is essential to plan for healing in the long term. Noses continue to heal for months to years, and graft placement and dissection must account for development of scar contracture. In every rhinoplasty we aim to balance both form and function – achieving a beautiful cosmetic result that a patient is able to breathe through easily.

Mohs Repair

 Mohs reconstruction is a set of techniques to repair defects that occur from skin cancer removal surgery (Mohs surgery). We coordinate with the Mohs surgeon to repair the defect in a timely fashion after the Mohs surgeon completes the removal and ensures the cancer is gone. The extent of the removal will determine what type of reconstruction is necessary. Sometimes we are able to complete this repair under local anesthesia in the clinic and sometimes it is advisable to complete in the operating room under sedation or general anesthesia. Sometimes the wound edges can be closed with suture, while sometimes tissue adjacent to the wound must be used to help close the wound. Sometimes a skin graft or cartilage graft is necessary. Sometimes skin from the forehead or cheek is necessary to fix a defect. If this is the case, you may require two or more procedures, at least 3 weeks apart. It is always a balance between achieving the best result with the least invasive repair.

Paramedian forehead flap and melolabial (cheek) flaps

 Paramedian forehead flaps are an important tool to help repair the nose after cancer or trauma. A strip of skin with an artery and vein from the forehead is used to recreate the nose. The “flap” is sewn to the defect and with its blood supply, is able to heal in from the sides. Once it has sufficiently healed in from the sides and grown a new blood supply, it may be divided from the forehead. Melolabial flaps are similar, but the donor site is from the cheek instead of the forehead. These are multistage surgeries.

Free flap microvascular surgery

 Free flap surgery is a technique that is necessary for the most challenging surgical defects. This is essentially a tissue transplant within a patient’s own body. The surgeon uses tissue from one part of the body (called the donor site) and moves it to the defect site for repair. Blood supply is essential to this process. A small artery and vein is taken with the donor tissue, and connected to an artery and vein in the defect site. This allows the donor tissue to survive and heal. Frequently a surgical microscope is necessary to connect the arteries and veins. Patients are monitored closely post-operatively ensure that the vessels have appropriate bloodflow, sometimes requiring intensive care monitoring. There are a variety of donor sites and choosing the appropriate site is a combination of defect characteristics and patient factors. Common sites include the forearm skin (radial forearm,) thigh skin and muscle (anterolateral thigh,) thigh muscle (gracilis), fibula bone and skin, and latissimus muscle.

 To ensure the best healing and function of the defect and donor sites, careful wound care and sometimes postoperative physical therapy and exercises are necessary.

Facelift and necklift

 A facelift is a surgery to restore youthfulness to a face and neck, with particular attention paid to the jawline and neck. This is generally a cosmetic procedure. Generally I complete what is referred to as a “deep plane” facelift to achieve a durable and longer-lasting result. 

Browlift

 A browlift is a surgery to restore youthfulness to the brow and forehead or to help with visual obstruction. This is sometimes a cosmetic procedure. There are different approaches for browlift, including endoscopic, midforehead, and direct. The choice of approach will depend on the clinical case.

Blepharoplasty (eyelid surgery)

 A blepharoplasty is a surgery to remove excess skin from the eyelid or eyelids to improve visual obstruction or achieve a more youthful appearance. 

Botox injection

 Botulinum toxin, or “botox,” is a neuromodulator that temporarily paralyzes striated and smooth muscles. It is applied via intradermal and intramuscular injection in the clinic. It can be helpful for patients with facial nerve paralysis and can be completed for cosmetic purposes. It takes 4-7 days for botox to start having an effect, with maximal effect around 2 weeks. Generally functional botox lasts for 2-3 mo. and cosmetic botox lasts 4 mo.

Facial Nerve Injury and Reanimation

 Facial reanimation is a set of procedures used to help restore function and symmetry to patients who have had injuries to one or both of their facial nerves. The facial nerves send impulses to our facial muscles that allow us to smile and close our eyes. The procedure chosen to help with reanimation depends on the timing of the nerve injury and the extent of injury.

Eyelid Weight

 An eyelid weight is placed under the skin of the upper eyelid to help the lid close completely and prevent corneal exposure. It is usually placed when a patient has a facial nerve injury. It can sometimes be placed under local anesthesia or in the operating room.

Fascia Lata Sling

 This is a “static” procedure to restore symmetry to the affected side. A strip of fascia (lining tissue) from the thigh is harvested and placed through small incisions in the temple and upper lip to pull the upper lip up and restore facial symmetry. This is an outpatient procedure generally.

Temporalis Tendon Transfer

 This is a “dynamic” procedure where a strip of the temporalis muscle is reoriented to help the patient with eye closure or smiling. This procedure helps with mouth symmetry and sometimes patients are able to achieve a volitional smile.

XII-VII (Hypoglossal to facial nerve transfer)

 In this procedure, a small portion of the nerve to the tongue is transferred to the facial nerve to provide power to it. Generally, this can restore facial tone but not volitional movement. In some cases, we are able to connect the facial nerve directly to the hypoglossal, and in other cases a nerve graft is required to bridge them.

Cross-face nerve graft

 In this procedure a nerve from the leg is transferred to the face. The sural nerve is a sensory nerve that runs from the ankle into the thigh. This nerve is harvested from the leg and connected to a small branch of the working facial nerve in the face. It is tunneled across to the injured facial nerve side in anticipation of a second surgery.

Gracilis muscle transfer

 A gracilis free flap is a microneurovascular tissue transplant from the thigh to the face. This is used for patients without a functioning facial nerve. A microscope is used to connect the nerves and blood vessels. Generally, incisions in the face, neck, and leg are required for this procedure. It will take at least 9 months before the muscle starts functioning. Over time, the goal for patients is to achieve a

Scar revision

 Noticeable scars can occur from trauma or prior surgeries. Sometimes steroid injection, silicone sheeting, or massage are sufficient to improve the appearance. However, sometimes a surgery is necessary. Generally, this involves excising the scar, reorienting and re-closing the area. This may be done in clinic or in the operating room.

Facial Trauma

 Facial trauma encompasses a range of injuries. 

Closed nasal reduction

 Nasal bone fractures are the most common and may occasionally be managed with observation. If there is a change in nasal breathing or obvious change in appearance, closed nasal reduction may be advisable.

Orbital fracture surgery

 Orbital fractures are common in the adult facial trauma population. If a patient is having restriction of eye movements, significant change in the protrusion of the globe, or persistent double vision, it is reasonable to offer surgery. The patient should always be evaluated by an ophthalmologist prior to surgery for a thorough visual examination.

Mandible or Midface fracture

 Mandible and midface fractures happen commonly in facial trauma. The type of repair is dependent on the location of the fracture or fractures. Sometimes no surgery is required and a specific diet is recommended.