The all too common panfacial fracture and the unfortunate increase in gunshot wounds of the head and face result, in spite of high-quality modern reconstructive techniques, in clinical situations requiring palliative surgery in the broad sense of the term. Permanent change of appearance, ever-increasing restriction of jaw movement, progressive premature loss of dentition and ongoing care of damaged eyes and orbits present continuing palliative challenges to surgeons and their teams (Fig. 18.3).

There are now an increasing number of patients with severe deformities who because of advanced health-care systems can lead relatively full lives but are in need of continuing monitoring with a view of surgical and other palliative measures as the disease process continues to manifest itself with age. An example of such conditions is the craniosynostosis syndromes of Crouzon and Apert. Even after full protocol management severe symptoms such as eye exposure, airway obstruction and loss of dentition may occur with age requiring surgical intervention for palliation (Fig. 18.4).

Other disease processes lend themselves to be considered in this context. Degenerations where bone and/or soft tissue withers and/or disappears over time such as Romberg’s hemifacial atrophy or hypertrophy and aberrant growth of Proteus syndrome (elephant man syndrome) (Fig. 18.5a–c).

The necessity of the team approach and systems-based practice is widely recognised in the literature if not so widely practiced in reality [5–9].

Those patients with cancer require a continuum of management as the disease progresses, and it is not always evident to the patient or treating specialists whether treatment is still being aimed at cure or for the relief of symptoms. If surgery is to be used for the dedicated purpose of relief of symptoms, this will need to be made clear. The decision processes necessary during the progress through incurable disease to death are best managed by a team so that the protocols can be adjusted, and all modalities of care necessary to palliate the patient are introduced in a timely and effective manner.

Some palliative measures may need to be introduced at a time when there is still a hope of cure and such therapies are in place, for example, airway protection, measures to reduce disfigurement and covering a potentially vulnerable vessel.

Measuring outcomes is intimately bound up with delivery of the service by a multidisciplinary team as surgeons and patients expectations may not match and the differences may not be communicated. The role of social worker, palliative nurses and others on the team is crucial in bridging this gap. Meaningful data on the outcomes of palliative surgery are understandably difficult to come by; however, it is clear that there is little time between decision to palliate and time of death placing an emphasis on surgeons not to make the surgical intervention more burdensome than the disease. Many of the problems encountered with meaningful outcome measures in this difficult area of practice are well described by Shuman and colleagues [10, 11]. These authors and others fully acknowledge that further research in the experience of managing patients with terminal head and neck malignancy is greatly needed.

There is little or no literature directed to the broader concept of palliation as applied to the nonfatal but incurable diseases mentioned previously.