Facial Plastic and Reconstructive Surgery Service Educational Goals

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1 Facial Plastic and Reconstructive Surgery Service Educational Goals 1. First-Year Resident (PGY-2) I. Knowledge Goals. Upon completion of this rotation the PGY-2 resident will have basic knowledge of the anatomy, embryology, and physiology of the hard and soft tissues of the face and neck as derived from the Basic Science Course, Journal Club, Facial Plastic Surgery Conference, Grand Rounds, departmental soft tissue course and specialty lectures (see Sections 8 and 9). The resident will: 1. Demonstrate knowledge of biomedical, surgical, clinical, and social sciences relevant to patient care. 2. Explain concepts of patient history and physical examination in Facial Plastic and Reconstructive Surgery, including: a. Components of a complete Facial Plastic and Reconstructive Surgery history and physicial, and how to perform such an examination. b. Formulation of an appropriate differential diagnosis. c. Formulation of an appropriate plan of investigation. d. Interpret plain radiographs, CT images and MRI images of the facial bones and related structures. e. Classification of facial nerve injuries. f. Classification of auricular malformations. g. Perioperative management of patients presenting to the Facial Plastic and Reconstructive Surgery clinic. h. Present new and established patients with disorders related to Facial Plastic and Reconstructive Surgery in a clear, concise and accurate way. 3. Describe the anatomy and physiology relevant to facial plastic and reconstructive surgery, including: a. Anatomic landmarks and terminology used in nasofacial analysis. b. Facial proportional relationships and common methods of defining key angles, aesthetic units, Frankfort horizontal line, etc. c. Define the SMAS and understand its relationship to the facial nerve and facial muscles. d. Describe the anatomy, physiology and pathophysiology of the skin. e. Describe the Anatomy and physiology of local skin flaps. f. Describe the Anatomy of the eyelid and periorbita. g. Explain the embryology of the external ear. h. Explain the anatomy of the eyelid, as well as the mechanisms of injury of these structures. i. Describe the anatomy and embryology of the external ear and classify major auricular anomalies. 4. Discuss the clinical presentation and pathophysiology of facial defects and deformities, including: a. Mechanisms of injury for common facial injuries.

2 b. Potential for associated injuries in specific scenarios of facial trauma. c. Mechanisms of facial fractures, with emphasis on specific constellations and types of maxillary and mandibular fractures. d. Pathophysiology of nasal obstruction. e. Genetics and physiology of hair loss. f. Norwood's classification of hair loss. 5. Discuss concepts relevant to surgical repair of facial defects and deformities, including: a. The temporal sequence of events in wound healing. b. Biochemical and cellular events of normal and disordered wound healing. c. Mechanisms of bone healing. d. Formulation of an appropriate plan of medical or surgical treatment for the patient with congenital or disease processes involving the face or seeking aesthetic changes. e. Correction of the secondary nasal deformities in terms of the nasal tip tripod concept. f. Angiosome concept pertaining to flaps. g. Soft tissue anatomy of the face with respect to surgical rejuvenative procedures. h. Basic approaches to face and brow lifting. i. Aesthetics associated with brow and face-lift. j. Basis for correction of prominent ears. k. Appropriate diagnostic tests for evaluation of facial paralysis. 6. Describe the anatomy, embryology, and physiology of the upper aerodigestive tract as derived from the Basic Science Course, Journal Club, voice conference, Grand Rounds, Tumor Board, departmental courses, and specialty lectures (see Sections 8 and 9). II. Skill Goals. First-year residents are expected to apply the above knowledge to become proficient in the following skills by the end of this year of training: 1. Perform appropriate triage and initial general management, as well as implement acute management for soft tissue trauma in order to reduce the risk of complications. 2. Perform appropriate triage and initial general management, as well as implement acute management for ear or eyelid trauma in order to reduce the risk of complications. Know the need for ophthalmologic or other testing or consultation. 3. Anticipate how trauma might affect the functions, origins, insertions and actions of facial mimetic muscles, nerves and vessels. 4. Appreciate the need for and implement the initial general trauma management in patients sustaining injuries to the head and neck. 5. Investigate, evaluate, and improve patient care practices, including: a. Analyze basic facial features and recognize abnormal relationships.

3 b. Manage acute and chronic wound healing to maximize surgical results. c. Describe and draw basic bony facial anatomy. d. Describe and draw facial and nasal subunits. e. Interpret major features of axial and coronal CT and T1/T2 MRI scans in patients with facial anomalies. f. Plan several possible skin flaps for closure of facial defects, and integrate patient specific features as variables in selecting a given flap. g. List possible pedicled and free flaps appropriate for a particular setting and the proper pre-operative preparation for a specific free flap repair. h. Demonstrate the technique of free flap repair and anticipate potential complications. i. Completely evaluate and diagnose patients with suspected fractures of the mandible and maxilla and institute appropriate initial management. j. Describe the mechanisms of facial fractures, with emphasis on specific constellations and types of orbital and frontal sinus fractures. k. Evaluate and diagnose patients with suspected nasal and naso-ethmoid, and institute appropriate initial management. i. Anticipate the need for ophthalmologic and neurosurgical consultation. l. Assess patients for the cause(s) of nasal obstruction. i. Formulate a plan for treatment of nasal obstruction. ii. Assess dorsal nasal deformities. m. Assess and categorize primary and secondary nasal deformities. i. Describe the steps of closed and external rhinoplasty. ii. Describe cleft lip nasal findings. n. Institute appropriate emergency management of facial nerve trauma. 6. Progress through outpatient clinic or emergency procedures under direct supervision of faculty as follows, but not limited to: PROCEDURE MINIMAL NUMBER REQUIRED CUMULATIVE PROGRAM AVERAGE FOR PGY-2 COMMENT Closure of facial and nasal skin laceration Closure of ear laceration Excision of benign skin neoplasms Biopsy malignant skin neoplasms Residents initially perform these procedures under direct faculty supervision. After demonstrating competence as judged by the faculty, the resident may be directly supervised by a chief

4 Closed reduction nasal fractures Drainage of auricular hematomas Incision & drainage superficial soft tissue abscess(face, neck, septum) Intralesional injections Local flap/adjacent tissue transfer, closure of defect (e.g., torn ear lobule) 2 5 resident, with the faculty present in the clinic Perform ambulatory and inpatient surgical procedures. The following operations are a modification of the RRC key procedures, and serve as minimal technical skill goals for the Facial Plastic and Reconstructive Surgery Service at The Eye and Ear: PROCEDURE CPT-95 EXPECTED RANGE &(PROGRAM AVERAGE) FOR PGY-2, ASSISTANT EXPECTED RANGE &(PROGRAM AVERAGE) FOR PGY-2, SURGEON AVERAGE, AMERICAN BOARD OF OTOLARYN- GOLOGY REPORT OFGRADUATING RESIDENTS, SURGEON Blepharoplasty 15822/8, 15823, 15820/1 Brow Lift 15824/.5, 67900/ (3.5) 0 (0) (1) 0 (0) 0 Cleft repair, Lip 40700/1/2 0-1 (0) 0 (0) 0.8 Cleft repair, Palate 42200/ 05/10, 42215/ (0) 0 (0) 1

5 Excision skin lesions, primary closure Facial Rehabilitation, static sling/ muscle transfer Facial Rehabilitation, nerve transfer 11440/6, 11420/6, 11620/6, 11640/ /1, 15842/ /6, (1.5) 5-15 (6) 28.5 (Increase experience in clinic and minor OR) 0-1 (0.5) 0 (0) (0.5) 0 (0) 0 Grafts, Splitthickness skin Grafts, Fullthickness skin (2) 0-1 (1) (1) 0 (0) 4.5 Grafts, Composite/ dermal/ fat/ fascia/ cartilage/ bone/ other 15760, 15770, 21230, 20910, (0.5) 0-1 (0.5) 10 Microtia Repair 21230, 14060, 15120, (0.5) 0 (0) 0 Other eyelid procedures (e.g, ectropion, ptosis repair) n/a 0-3 (2) 0 (0) 0 Otoplasty 69300, (0.5) 0 (0) 3 Pharyngeal Flap Repair complex laceration (0) 0 (0) (0) 0-1 (1.25) 0

6 Reduction facial fracture, nasal 21310/ (1.5) 2-6 (3) 10.5 Reduction facial fracture, malar 21356/ (0.5) 0 (0) 7 Reduction facial fracture, mandible 21453, 21454/ (0.5) 0 (0) 17.5 Resurfacing Procedures (0.5) 0-1 (0.5) 1.3 Rhinoplasty 30400, (11) 0 (0) 16 Rhytidectomy 15826/8/9 0-2 (0.5) 0 (0) 2.75 Scar Revision 12001/18, 13131/ (2) 2-4 (4) 22 Septoplasty/ Turbinectomy 30520, (19) 5-10 (6.25) 91 (increase experience during tonsil OR day) III. Attitude Goals.See A.1.III. 2. Fourth-Year Resident (PGY-5) I. Knowledge Goals.The fourth-year resident on the Facial Plastic and Reconstructive Surgery should build upon knowledge base acquired in the prior years and should: 1. Describe concepts of patient history and physical examination in Facial Plastic and Reconstructive Surgery, including: a. Demonstrate mastery of all knowledge goals developed in the third year. b. Apply methods of analysis to unique individuals to assist with development of a surgical plan for aesthetic improvements. 2. Describe the clinical presentation and pathophysiology of facial defects and deformities, including: a. Pathology associated with cleft lip nasal deformity. b. Mechanisms, diagnosis and management of blepharoplasty complications. 3. Explain concepts relevant to surgical repair of facial defects and deformities, including:

7 a. Management of post-traumatic CSF rhinorrhea. b. Rationale for and techniques of cartilage grafting to the nose. 4. Describe methods of skin rejuvenation. 5. Describe management issues associated with patients with microtia. 6. Discuss characteristics of facial aging, including: a. Characteristics of forehead and periorbital aging. b. Characteristics of the aging nose. c. Characteristics and clinical presentations of the senescent midface. d. Characteristics of the aging mouth, jawline and neck. e. The Dedo classification of the aging neck. 7. Discuss complex primary or secondary deformities of the nose, including: a. Nasal valve stenosis. b. Nasal valve collapse. c. Twisted nose. d. Middle vault collapse. e. Pollybeak deformity. f. Columellar-alar disparity. g. Nasal tip bossa. h. Tip ptosis. i. Tip retraction. j. Tip under- or over- projection. II. Skill goals. Fourth year residents should continue to build upon the skills acquired during the first three years of residency and demonstrate the ability to: 1. Select patients, plan and execute scar revision techniques. 2. Perform pedicled myocutaneous flaps for head and neck reconstruction. 3. Execute the techniques of repair of comminuted or complex nasoethmoid, orbital and frontal bone fractures, as well as repair of injuries of the orbital adnexa. 4. Manage CSF leaks, surgically and non-surgically. 5. Implement techniques for correction of secondary and cleft lip nasal deformities based on a thorough understanding of the nasal tip tripod concept, using closed or open approaches, including management of: a. External nasal valve collapse. b. Nasal valve stenosis. c. Twisted nose. d. Pollybeak deformities. e. Bossae, over- or under- projecting tips. f. Tip ptosis. g. Alar retraction. h. Columellar show. i. Under- and over- rotation of the nasal tip.

8 6. Perform appropriate skin rejuvenation (lasers, superficial or medium depth chemical peels) based on patient- specific findings. 7. Apply brow and face lifting techniques to specific patients. 8. Diagnosis and manage brow and facelift complications. 9. Perform lower blepharoplasty (transcutaneous or transconjunctival). 10. Perform cheek and chin implantation. 11. Perform interposition nerve grafts, facial nerve reanimation, nerve muscle transfer, dynamic slings, and ancillary procedures for facial paralysis. 12. Perform further ambulatory and inpatient Facial Plastic and Reconstructive Surgery procedures at The Eye and Ear: Procedure CPT-95 Expected Range &(Program Average)for PGY-5, assistant Expected Range &(Program Average)for PGY-5, surgeon Average, American Board of Otolaryngology Report ofgraduating Residents, surgeon Blepharoplasty 15822/8, 15823, 15820/1 Brow Lift 15824/.5, 67900/ (4.2) 2-6 (3.6) (2.8) 1-3 (1.8) 0 Cleft repair, Lip 40700/1/2 0-1 (0.8) 0-1 (0.2) 0.8 (increase experience by scrubbing with Smith / Schwimmer at BIMC on non- OR days) Cleft repair, Palate 42200/05 /10, 42215/ (1.4) 0-1 (0.8) 1 Excision skin lesions, primary closure 11440/6, 11420/6, 11620/6, 11640/6 0 (2.2) 2-4 (16.2) 28.5

9 Facial Rehabilitation, static sling/ muscle transfer Facial Rehabilitation, nerve transfer 15840/1, 15842/ /6, (2) 0-1 (1.2) (0.4) 0-1 (0) 0 Grafts, Splitthickness skin Grafts, Fullthickness skin (1) 0-2 (13) (0.4) 0-1 (2.8) 4.5 Grafts, Composite/ dermal/ fat/ fascia/ cartilage/ bone/ other Microtia Repair 15760, 15770, 21230, 20910, , 14060, 15120, (1.6) 0-2 (4.4) 10 (Increase experience by logging cartilage grafts from otology cases) 0 (2.8) 0-2 (0.6) 0 Other eyelid procedures (e.g., ectropion, ptosis repair) n/a 0 (5.4) 1-4 (2.2) 0 Otoplasty 69300, (3.2) 2-6 (4.8) 3 Pharyngeal Flap (0.4) 0-1 (0.2) 1

10 Repair complex laceration (1) 0-1 (13) 0 Reduction facial fracture, nasal Reduction facial fracture, malar Reduction facial fracture, mandible 21310/ / , 21454/ (4.6) 3-7 (12.6) (5) 0-2 (5) 7 0 (5) 0-1 (5) 17.5 (Increase experience by scrubbing with Schwimmer at BIMC on non- OR days) Resurfacing Procedures (0.8) 0-3 (0.6) 1.3 Rhinoplasty 30400, (25.2) (18.2) 16 Rhytidectomy 15826/8/9 0 (4.2) 0-2 (1.2) 2.75 Scar 12001/18, 0 (2.6) 1-4 (9.2) 22 Revision 13131/52 III. Attitude Goals. See A.1.III. and A.3.III.

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