One stage reconstruction of the floor of the mouth with a subcutaneous pedicled nasolabial flap.

BACKGROUND: Nasolabial flaps have been recognised as versatile flaps for a variety of defects in the face, nose, lip and the oral cavity. Random pattern inferiorly based nasolabial flaps (NLF) have been utilised for covering small defects on the anterior floor of the mouth, but usually require a second stage procedure to divide the flap base. A subcutaneous pedicled inferiorly based nasolabial flap can provide a one stage repair of moderate sized defects of the floor of the mouth after de epithelialisation of the base of the flap. AIM: To evaluate the feasibility of a single stage reconstruction of intermediate sized defects in the oral cavity with an inferiorly based pedicled NLF. The study includes the indications of use of the flap, flap design, technique, and the complications rate. The incidence of secondary procedures and the final functional and the aesthetic results will also be evaluated. MATERIALS AND METHODS: A group of 20 patients presented with (T1-2) squamous cell carcinoma of the oral cavity have been treated at the Department of Surgery, National Cancer Institute, Cairo; in the period between January 2008 and September 2010. The pathology was confirmed with an incision biopsy and all metastatic work were carried out confirming that all patients were free from distant metastasis at presentation. Preoperative assessment also included assessment of the stage of the disease, the flap design and patient fitness for general anaesthesia. All patients underwent surgical excision combined with reconstruction of the defect with a subcutaneous inferiorly based pedicled NLF. The proximal part of the flap was routinely de epithelialised before it has been tunnelled through the cheek so a one stage procedure could only be required. RESULTS: The mean age of the patients was 62.3±6years, range (52-69years). All patients were diagnosed with squamous cell carcinoma. The anterior floor of the mouth constituted 40% of the defects, the lateral floor of the mouth 20% and the inner surface of the cheek 40%. There was no reported major complication; and only one patient suffered a reactionary haemorrhage that required re-exploration to secure the bleeder. A single procedure was adequate in most patients (80%), only 20% of patients required revision of the scar at the donor site or release of the tongue. The overall aesthetic results were either very satisfactory or satisfactory in the majority of patients (90%). Two patients were not satisfied with the final aesthetic results, one suffered from ectropion and the other had a donor site wound healing problem. The functional results (deglutition, speech) were satisfactory in most patients (70%), all were edentulous. CONCLUSION: An inferiorly based pedicled NLF is a reliable flap for the reconstruction of small and medium sized defects in the oral cavity. The flap can be best utilised for old edentulous and high risk patients where it can be used as a single stage procedure which is particularly useful in those types of patients. The flap can be safely combined with neck dissection even when the facial artery was ligated.

Immediate breast reconstruction with expander assisted latissimus dorsi flap after skin sparing mastectomy.

BACKGROUND AND PURPOSE: The latissimus dorsi myocutaneous flap (LDMF) used to be the standard practice for breast reconstruction; however, with the increased use of tissue expanders and the development of the transverse rectus-abdominis myocutaneous flap for autologous tissue breast reconstruction, its use has decreased. To reassess the role of the LDMF in breast reconstruction, a prospective study was performed to evaluate women who had a skin sparing mastectomy followed by immediate reconstruction with a latissimus dorsi flap and tissue expander implant. PATIENTS AND METHODS: Twenty-five women with early breast cancer underwent immediate latissimus dorsi myocutaneous flaps with tissue expander after skin sparing mastectomy. The oncologic safety of skin sparing mastectomy, the postoperative aesthetic results and complications were evaluated. RESULTS: Between May 2003 and April 2005, 25 consecutive women diagnosed with breast cancer underwent skin sparing mastectomy and expander assisted immediate latissimus dorsi breast reconstruction. Their median age was 42 years, ranging from 34 to 48 years. The procedure duration ranged from 2.5 to 6 hours, with a median of 3.9 hours, however, expansion was completed by 4 months (range 1 to 8 months). Patients were discharged 7 days after surgery with a range of 5 to 15 days. The complication rate was low, manifesting with skin flap necrosis in 12%, wound infection in 4%, and port site extrusion in 4%. There was no flap loss. With the exception of seroma formation, the donor site morbidity was low (seroma 40%, hematoma 4%, back pain 8%, and limited arm movement 4%). No local recurrence was recorded. The aesthetic result of surgery was rated as excellent in 20%, good in 60%, fair in 24%, and poor in 4% of cases. The duration of post-operative follow up was 14.7 months, ranging from 6 to 24 months. CONCLUSIONS: Skin sparing mastectomy and immediate breast reconstruction is an oncologically safe technique. The use of latissimus dorsi myocutaneous flap with tissue expansion has proved to be an effective and aesthetic method of immediate breast reconstruction after skin sparing mastectomy.

Pleurodesis as a palliative treatment of advanced lung cancer with malignant pleural effusion.

PURPOSE: This study was conducted to evaluate the success rate of management of advanced. Lung cancer patients with malignant pleural effusion comparing talc powder with tetracycline for pleurodesis. PATIENTS AND METHODS: We report 60 patients with lung cancer associated with malignant pleural effusion treated in the department of surgery NCI, Cairo University, between January. 1998 and February, 2003. Patients were Divided Into Three Groups: Group I: Pleurodesis using tetracycline (20 patients). Group II: Pleurodesis using talc slurry (20 patients). Group III: Pleurodesis using talc insufflation (20 patients). Good response to pleurodesis is defined as no pleural fluid re-accumulation or minimal pleural fluid re-accumulation not causing symptoms or requiring further aspiration for one month. RESULTS: There were 34 males and 26 females, mean age was 54 years with range of 42-66 years, right sided effusion was present in 32 patients (53%) and left sided in 28 patients (47%). Pathological subtypes were adenocarcinoma in 32 patients, squamous cell carcinoma in 18 and undifferentiated carcinoma in 10 patients. In group I, 12 patients (60%) showed good response to intrapleural tetracycline, 15 patients (75%) responded in group II, while 17 patients (85%) showed good response in group III. Post pleurodesis complications included, fever, chest pain and empyema. CONCLUSION: It is concluded from this study that thoracoscopic talc insufflation was an effective, easy and low cost method for producing pleurodesis in patients with recurrent malignant pleural effusion and proved to be better than talc slurry and tetracycline.