A novel use of the facial artery based buccinator musculo-mucosal island flap for reconstruction of the oropharynx.

The buccinator musculo-mucosal island or Zhao flap can be used to reconstruct a wide range of intra-oral defects including floor of mouth, tonsillar fossa and lateral tongue. We describe our experience with the inferiorly based facial artery buccinator musculo-mucosal flap for a novel use in the reconstruction of oropharyngeal tumours at the tongue base and lateral pharyngeal wall. We prospectively reviewed all patients who underwent buccinator musculo-mucosal island flap reconstruction examining indication, operative details, and post-operative outcomes. We describe our technique for its novel use in lateral pharynx/tongue base reconstruction through neck dissection access. Deeper flaps were adequately visualised and monitored using flexible nasoendoscopy. There were no flap failures with all patients achieving primary healing with minimal complications. All donor sites closed directly with minimal scarring. Two patients reported mild tightness on mouth opening and two patients reported transient weakness of the mandibular branch of the facial nerve. In our experience the buccinator musculo-mucosal island flap is an extremely versatile 'like for like' local flap option due to its long arc of rotation. As inset can be achieved via neck dissection access, this avoids lip/jaw split as per conventional oropharyngeal surgical management further minimising morbidity. We present the first series of its effective use in oropharyngeal reconstruction.

Guidelines for the excision of cutaneous squamous cell cancers in the United Kingdom: the best cut is the deepest.

Surgical excision remains the gold standard for the management of cutaneous squamous cell cancers (SCC) and national guidelines for operative radial margins predict 95% oncological clearance with a margin of 4 mm for low-risk and 6 mm for high-risk tumours. We retrospectively analysed all cutaneous SCC excisions performed across 4 regional Plastic surgical units in England over a consecutive 24-month period and collected data on tumour characteristics, operative and histological margins and completeness of excision. We identified 633 eligible SCC excisions of which 265 (42%) were over 2 cm in diameter with 37 recurrent tumours (5.8%). The mean radial operative margin was 6.5 mm across all tumours and 8.4 mm for tumours greater than 2 cm. The mean histological tumour diameter was 21 mm. The overall incomplete excision rate was 7.6% (7.9% for tumours >2 cm). Ninety-four percent (45/48) of incomplete excisions involved the deep margin and only 3 out of 633 excisions (0.47%) were incomplete at a radial margin only. No differences were observed in tumour size or excision margin between incompletely and completely excised tumours. Incomplete excisions were most common on the ear, nose and cheek. In summary our analysis demonstrates that despite adherence to recommended surgical margins for cutaneous SCCs the incomplete excision rate remains higher than expected. We believe that this is because most incomplete excisions are incomplete at the deep margin and question the utility of performing increasingly wide excisions, and, the generalisability of the evidence upon which recommendations for radial margins are based.

Sentinel node status predicts survival in thick melanomas: the Oxford perspective.

AIMS: To determine the prognostic value of SLNB in patients with thick melanoma in terms of overall survival (OS) and recurrence-free survival (RFS). METHODS: 136 patients with primary tumours (Breslow thickness ≥ 4.0 mm) underwent SLNB. OS and RFS were calculated and a multivariate Cox regression model used to determine the important prognostic factors for predicting OS and RFS. RESULTS: Median Breslow thickness was 5.5 mm and 60% were ulcerated. Median follow up was 4 years (95% CI = 4-5) with 54 patients having died at the time of analysis. 5-year OS for SLNB positive patients was 32%, compared to 78% for negative patients. The significant predictors of poorer OS were increasing age (p = 0.03), increasing Breslow thickness (p = 0.03) and SLNB positivity (p < 0.0001). 5 year RFS was significantly worse in the SLNB positive population compared to the negative patients (p < 0.0001); 27% versus 66% respectively. CONCLUSIONS: Patients with a thick melanoma and a positive SLNB have a significantly worse RFS and OS compared to those with a negative SLNB. Over three-quarters of patients with a negative SLNB survived five years. These findings have implications for the subpopulations included in adjuvant therapy trials and we advocate SLNB be recommended in patients with thick melanomas.

Long term functional results from major limb replantations.

Replantation is now firmly established as a viable treatment option in traumatic limb amputation, yet there are few long-term studies describing the functional outcome of these cases. The purpose of the present study was to evaluate long-term results in a population of such patients to determine overall success and patient satisfaction. Since 1981, twenty macro-replants involving nineteen patients have been performed in our unit. All patients were reviewed by means of case note analysis, patient questionnaire, and follow-up clinical evaluation for functional outcome using the Tamai scoring system. Acute limb salvage was successful in 18/20 (90%) cases. One patient is still undergoing secondary reconstructive surgery and was unable to be assessed for final outcome leaving 17 replanted limbs that underwent full functional assessment. Overall functional results were good in 7/17 (41%) limbs, fair in 7/17 (41%) and poor in 3/17 (18%). The majority of patients (12/17) claimed to be highly or well satisfied with their outcome and eleven have returned to work since their injury. The current study of major limb replantation demonstrates favorable or acceptable long term functional outcomes in the majority of cases. High patient satisfaction rates even where results were poor emphasise the positive psychological impact of successful replantation.

Randomized controlled trial of fibrin sealant to reduce postoperative drainage following elective lymph node dissection.

BACKGROUND: Excessive postoperative drainage following groin and axillary lymphadenectomy may be associated with a prolonged hospital stay and an increased complication rate. The use of fibrin sealant before wound closure may reduce postoperative wound drainage. METHODS: Consecutive patients undergoing elective groin or axillary lymphadenectomy were randomized to standard wound closure or to having fibrin sealant sprayed on to the wound bed before closure. Postoperative wound drainage, duration of drainage and complications were recorded, as were locoregional recurrence, distant metastasis and mortality. RESULTS: A total of 74 patients requiring 38 groin and 36 axillary dissections were randomized. The median postoperative wound drainage volume for the groin dissection cohort was 762 (range 25-3255) ml in the control group and 892 (265-2895) ml in the treatment group (P = 0·704). Drainage volumes in the axillary cohort were 590 (230-9605) and 565 (30-1835) ml in the control and treatment groups respectively (P = 0·217). There was no difference in the duration of drainage or postoperative complication rate between the treatment groups in both the axillary and groin cohorts. Local recurrence, distant metastasis and mortality rates did not differ between the treatment groups. CONCLUSION: There was no advantage in using fibrin sealant during elective lymphadenectomy in terms of reducing drainage output or postoperative complication rate.

Quality of life following resection, free flap reconstruction and postoperative external beam radiotherapy for squamous cell carcinoma of the base of tongue.

This study was conducted to evaluate quality of life in a cohort of patients with squamous cell carcinoma of the tongue base, treated with primary surgery, reconstruction and postoperative radiotherapy. Twelve patients were assessed in a cross-sectional study using the University of Washington Quality of Life Instrument (UW-QOL). All patients underwent external beam irradiation following primary resection of their tumour and reconstruction. Patients on average reported their overall and health related QOL to be good. Functionally they had good pain control, speech intelligibility, activity and recreational levels. There were some limitations in chewing, swallowing and taste. The results suggest that surgical resection can offer good functional and overall QOL results for advanced tumours when combined with reconstruction. The morbidity associated with postoperative radiotherapy includes reduced swallowing, taste, saliva production and difficulty chewing.

An audit of the tetanus immunisation status of plastic surgery trauma and burns patients.

This study audits the tetanus immunisation management of plastic surgery trauma patients by their referring Accident and Emergency departments, and compares this to nationally published guidelines. We assessed 269 burns and trauma patients, referred from across South Wales, using a questionnaire together with their Accident and Emergency notes or letter. The precise question(s) that had been asked regarding the tetanus immunisation status of the patient, and the immunisation management based on the results of those questions, were recorded. The accurate tetanus immunisation status of the patient was established, the wound was assessed and further management was given as indicated. Only 16 patients had been asked whether they had received a course of tetanus, and 41 patients were not questioned about their tetanus immunisation status by the referring Accident and Emergency department. As a consequence of more accurate questioning, 73 patients (27%) required further action after their arrival in the Plastic Surgery unit. This audit has demonstrated that the management of tetanus immunoprophylaxis in plastic surgery trauma patients cannot be confidently left to the referring Accident and Emergency department but should form an integral part of the treatment at the admitting unit.

Vascularisation of tissue-engineered grafts: the regulation of angiogenesis in reconstructive surgery and in disease states.

Angiogenesis (the formation of new blood vessels) is essential for the growth of new tissue, tissue repair and wound healing. Tissue engineering, the construction of new tissue and organs for reparative purposes, relies on angiogenesis for the vascularisation of these new grafts. In tissue engineering, the emphasis to date has been on vascularisation of newly constructed tissue grafts by an extrinsic blood supply, and relatively little attention has been given to the possibility of building these grafts around an intrinsic blood supply. However, there are many disease processes, notably tumour growth, where excess angiogenesis can be a major problem. The purposes of this review are, first, to examine various methods of vascularising tissue-engineered grafts, and, second, to compare the role of angiogenesis in tissue engineering, where stimulation of angiogenesis is paramount, with pathological states, such as tumour growth, where angiogenesis needs to be inhibited.

The influence of extracellular matrix on the generation of vascularized, engineered, transplantable tissue.

In a recently described model for tissue engineering, an arteriovenous loop comprising the femoral artery and vein with interposed vein graft is fabricated in the groin of an adult male rat, placed inside a polycarbonate chamber, and incubated subcutaneously. New vascularized granulation tissue will generate on this loop for up to 12 weeks. In the study described in this paper three different extracellular matrices were investigated for their ability to accelerate the amount of tissue generated compared with a no-matrix control. Poly-D,L-lactic-co-glycolic acid (PLGA) produced the maximal weight of new tissue and vascularization and this peaked at two weeks, but regressed by four weeks. Matrigel was next best. It peaked at four weeks but by eight weeks it also had regressed. Fibrin (20 and 80 mg/ml), by contrast, did not integrate with the generating vascularized tissue and produced less weight and volume of tissue than controls without matrix. The limiting factors to growth appear to be the chamber size and the capacity of the neotissue to integrate with the matrix. Once the sides of the chamber are reached or tissue fails to integrate, encapsulation and regression follow. The intrinsic position of the blood supply within the neotissue has many advantages for tissue and organ engineering, such as ability to seed the construct with stem cells and microsurgically transfer new tissue to another site within the individual. In conclusion, this study has found that PLGA and Matrigel are the best matrices for the rapid growth of new vascularized tissue suitable for replantation or transplantation.

Baby walkers--still a major cause of infant burns.

Baby walkers have been implicated in many forms of paediatric trauma, ranging from finger tip entrapment to severe head injury. Their relationship to childhood burns has been documented previously. The Department of Trade and Industry published further warnings in 1984 and the British Standards Institution in 1989. We wished to determine if the degree or frequency of thermal injury had been lessened by these recommendations. All parents of children under 15 months of age admitted to this unit in 1994 were asked if their child was in a baby walker at the time of injury. Eight of the 32 infants, aged between 6 and 12 months, were burned in their walking aid. Half of the burns were contact and half scalds, and the average in-patient stay was 8 days. One patient required formal resuscitation and three were grafted. The incidence and severity of thermal injury sustained in baby walkers remains at a high level despite increased safety measures. Perhaps it is time to concur with the American Academy of Paediatrics and recommend a ban on these dangerous aids.

Comparative biomechanical analysis of a new circumferential flexor tendon repair and a modified Kessler repair.

We present the technical details and the results of a biomechanical analysis of a new type of circumferential flexor tendon repair, designed with the more stringent requirements of zone II injuries in mind. Apart from good initial strength we aimed for a design with little bulk at the repair site and good control of the tendon edges. The new repair is achieved using a single, continuous, inverting and locking suture of the periphery of the tendon. The repair was compared with a Kessler core suture of 4/0 polydioxanone, with Tajima and Strickland modifications, to which has been added a simple running circumferential suture (6/0 polypropylene), the repair currently used in our unit. Fresh human cadaver flexor tendons were divided and repaired by one of the two techniques (n = 12 for each technique), using 5/0 polypropylene for the new circumferential suture. A third group of tendons (n = 8) were divided and repaired with a 5/0 multifilament steel circumferential suture. The repaired tendons were tested at longitudinal stress to failure. The first two groups of tendons were tested at two crosshead speeds. Overall, crosshead speed had no effect on ultimate tensile strength (P = 0.5). The 5/0 polypropylene circumferential repair (median 32.29 N) was significantly stronger than the Kessler repair (median 24.03 N) (P = 0.046). The circumferential repair was significantly stronger with steel (median 56.04 N) than with polypropylene (median 32.29 N) (P = 0.007). The size of the repair site, resistance to gap formation and the patterns of failure were analysed on video recordings.

Are antibiotics necessary in the surgical management of upper limb lacerations?

Previous research has shown that antibiotic usage in patients with superficial sharp lacerations has no influence over infection rate. This study is a prospective controlled trial, using systematic allocation, of 250 patients of which 113 received co-amoxiclav (Augmentin) and 137 did not. Special emphasis was placed on wound debridement and irrigation. All sharp soft tissue lacerations including those with nerve, tendon and muscle damage were entered into the trial. The results show a low overall infection rate of 4%. The infection rate in the group treated with antibiotics was 5% and 3.2% in the group who received no antibiotics. Lacerations operated on up to 48 h from the injury were included and there was no correlation between the length of time waited and the infection rate. We conclude that antibiotics are an unnecessary adjunct in the treatment of sharp lacerations of the hand and upper limb, provided meticulous surgical debridement is performed.

An unreported cause of rupture of the extensor pollicis longus tendon.

Avulsion fractures of the index metacarpal at the insertion of extensor carpi radialis longus are rare. We report such a fracture and the resulting complication of division of the extensor pollicus longus tendon, by the avulsed bony fragment. Careful clinical assessment and appropriate radiological examination is needed to diagnose this rare fracture and internal fixation is recommended.

Randomized comparison of oral and intravenous fluid regimens after gallbladder surgery.

Numerous studies of post-operative fluid status have utilized sophisticated measurements of electrolyte distribution and fluid shift without relating results to clinical practice. The aim of this prospective randomized study was to investigate the response of patients undergoing abdominal surgery of moderate severity to conservative post-operative fluid administration. Forty-five patients undergoing open cholecystectomy were randomized to receive 2.51 of fluid (1 l normal saline and 1.51 5% dextrose), 1 l of normal saline, or free oral fluids (groups 1, 2, 3, respectively). Serum and urine osmolality and electrolytes were measured pre-operatively and at 24 and 48 h post-operatively. Patients remained in the study irrespective of the urine output. Plasma electrolytes and osmolality remained within normal limits in all three groups despite significant changes in urine electrolyte and osmolality in groups 2 and 3. This confirms that a conservative approach to fluid administration has no detrimental effect on hydration in fit patients with uncomplicated surgery.

Formal assessment of the surgical trainee: a review of eight years experience at St Lawrence Hospital, Chepstow.

In light of the proposals for a continuum of higher surgical training, we reviewed an 8-year experience of formal assessments of surgical trainees. We undertook a retrospective analysis of 34 completed assessment forms, retrieved from records, and a postal questionnaire of 54 former (and current) trainees. Our study revealed that all trainees agreed in principle with formal assessments. Eighty-one per cent found their assessment either useful or excellent and a further 17 per cent found the advice received was influential in their careers. The consultants, in turn, were able to modify the training programme as a result of constructive feedback. Based on our experience we recommend formal assessments of surgical trainees as an important and rewarding part of an impartial peer review system within a continuum of higher surgical training.