External carotid artery pseudoaneurysm following microvascular free flap reconstruction. The role of endovascular thrombin injection in embolization: a case report and review.

Pseudoaneurysm at the anastomosis of the free flap following ablative head and neck surgery is uncommon. We present a case of external carotid artery pseudoaneurysm in a patient who had previously undergone a subtotal glossectomy, neck dissection, and radial forearm free flap reconstruction. The traditional treatment for pseudoaneurysm has been open surgical repair. Our patient underwent successful treatment with an endovascular embolization utilizing thrombin injection of the aneurysmal sac. This case highlights the role of interventional radiology in the management of this rare but important complication of microvascular reconstructive surgery.

The use of the pectoralis major flap for advanced and recurrent head and neck malignancy in the medically compromised patient.

A retrospective review of seventy-one PPM flaps used between 1996 and 2010 primarily for oral and oropharyngeal squamous cell carcinoma presenting as either advanced stage IV primary disease (41/43), extensive recurrent (10) or metastatic (9) neck disease. The PPM flap was most commonly used following resection of the mandible (23) or the tongue/oropharynx (19). When the PPM flap was the preferred reconstruction option (54) the main indication, in addition to advanced disease, was significant medical co-morbidity (23). The majority of PPM flaps (75%) were used in the latter half of the series for an increasing number of patients in poor health with advanced disease. There was no evidence of an increase in age, ASA grade or extent of disease during this period. Approximately one quarter (17) of the flaps were used after failure of a free flap, most commonly a DCIA (7) or radial (6) flap. The 30day mortality in this group of compromised patients undergoing major surgery for advanced disease was 7% (5/71). The overwhelming majority had significant co-morbidity (94% grade 2 or higher with 63% ASA grade 3) and 90% had already undergone previous major surgery and/or radiotherapy. The 1-year, 3-year and 5-year overall survival rates were 65.5%, 39.1% and 11.0% respectively with cancer-specific survival rates of 82.0%, 65.5% and 65.5%. The majority died of disease related to the underlying co-morbidity. We recommend an aggressive approach to the surgical resection of advanced and recurrent disease but a pragmatic approach to reconstruction. The PPM major flap is reliable for reconstruction of defects of the mandible, tongue and oropharynx with a complete flap failure rate of 2.8%. Lateral defects of the mandible were managed without a plate and with an acceptable outcome in the context of limited life expectancy. This is the largest study of the use of the PPM flap for this type of patient group. The flap retains a major role in the management of advanced primary or recurrent disease, extensive metastatic neck disease and after failure of a free flap when in conjunction with significant co-morbidity.

Plasminogen activator system in oral squamous cell carcinoma.

BACKGROUND: The plasminogen activator system consists of two plasminogen activators, urokinase (uPA) and tissue (tPA); PA inhibitors (PAI-1, and -2), and a cell surface receptor for uPA (uPAR). The plasminogen activator system is involved at many stages of the metastatic cascade, including matrix remodelling, cell proliferation, and migration. AIMS: To compare tissue concentrations of the components of the plasminogen activator system in paired tumour tissue and normal tissue in patients with oral squamous cell carcinoma, and to correlate these with the histopathological grading of the tumour. METHODS: Thirty-eight paired tissue samples were analysed by enzyme-linked immunosorbent assays (ELISA; ng/mg protein) for uPA, tPA, uPAR, PAI-1, and PAI-2. RESULTS: Concentrations of uPA, uPAR, PAI-1, and PAI-2 were significantly higher in tumour than in normal oral tissue (median in uPAR tumour 1.6 (range; 0.1-7.5) ng/mg protein; normal=0.2 (0-2.3), p<0.05). There were strong correlations between the concentrations of certain components of the plasminogen activator system in particular between uPA, uPAR, and PAI-1 (p<0.05). Tissue concentrations of some components of the plasminogen activator system correlated with clinical and pathological indexes of aggression of tumours, including differentiation and T-stage. CONCLUSION: The relation between components of the plasminogen activator system, in particular uPA, uPAR, and PAI-1 in invasion, metastasis, prognosis, and survival, requires further investigation in oral squamous cell carcinomas.

Recovery of sensation in the skin of non-innervated radial flaps after subfascial and suprafascial dissection.

We compared the extent of recovery of sensation in 40 non-innervated radial free flaps, 20 of which had been raised subfascially and 20 suprafascially. We found no significant difference in sensory recovery between the two groups. The mean extent of sensory recovery was light touch (68%); sharp touch (84%); warm (29%) and cold (40%) temperature; and static (25%) and moving (31%) two-point discrimination. Nearly all the flaps responded to at least one stimulus (excluding two-point discrimination) and half of them to three or more. Sharp touch sensation in the flap was similar to that in the surrounding tissues and light touch was less sensitive. There was no dysaesthesia. Recovery was not related to sex, age, alcohol consumption, or site of reconstruction. Smoking and radiotherapy had a slight effect.

The matrix metalloproteinase system in oral squamous cell carcinoma.

BACKGROUND: The matrix metalloproteinase (MMP) system is responsible for degradation of tissue in both normal and pathological processes, including tumour invasion and metastasis. AIM: To compare tissue concentrations of components of the MMP system between tumour tissue and normal tissue in patients with oral squamous cell carcinoma, and to correlate concentrations with pathological grade of tumour. METHODS: Thirty-eight paired tissue samples from tumours and normal tissue were analysed by three laboratory techniques: firstly, enzyme linked immunosorbent assays (ELISA) in ng/mg protein for MMP-1, MMP-3, and tissue inhibitors of metalloproteinases (TIMPs) -1 and -2. Secondly, gelatinase activity assays to measure concentrations of total and endogenous active gelatinases, MMP-2 and MMP-9 (ng/mg protein). And thirdly to use quenched fluorescent substrate hydrolysis to measure total MMP activity (pM/min). RESULTS: The concentration of all MMPs was significantly higher in tumour than in normal oral tissue (p < 0.05, Mann-Whitney U-test). Tissue concentrations of some of these factors correlated with clinical and pathological indices of aggressiveness of tumours, including T-stage, N-stage, tumour differentiation, and anatomical level of involved nodes. However, the study was not powered to show statistical significance. CONCLUSION: It is the balance between proteinases and their inhibitors that controls tissue degradation at each stage of tumour invasion and metastasis. Measurement of MMPs in oral mucosal biopsy samples may establish the invasive potential of tumours at their initial presentation.

Repair of radial free flap donor site by full-thickness skin graft from inner arm.

Sixty-two consecutive patients had 63 radial free flaps taken and the donor site repaired with either a full-thickness or split-skin graft. A full-thickness graft was harvested from the inner upper arm in 53 patients (85%). The donor site was assessed using a visual analogue scale, tactile sensitivity, and the Vancouver scar assessment score. All donor sites healed without complications except for two minor wound dehiscences. Both patients and surgeons rated the aesthetic outcome as good. The advantages included; single operation site; simple execution; thin hairless graft, good colour match and an inconspicuous scar causing minimal morbidity.

The Leicester radiotherapy bite block: an aid to head and neck radiotherapy.

We describe the construction of a custom-made bite block to be used during external beam radiotherapy to the oral cavity. The bite block is made with standard maxillofacial prosthetic techniques and materials. The design allows accurate and reproducible positioning of the perioral tissues to aid planning of radiotherapy and treatment. The compressibility of this device improves comfort for the patient, while it is in use.

Alcohol, tobacco and paan use and understanding of oral cancer risk among Asian males in Leicester.

OBJECTIVES: To determine use of alcohol, tobacco and paan among males from the various Asian communities in Leicester; and assess their knowledge and attitudes towards oral cancer risk factors and prevention. Also, to determine any differences regarding habits and attitudes between first and second generation Asians. DESIGN: Volunteers completed a confidential, bilingual questionnaire regarding alcohol, tobacco and paan use and also knowledge about oral cancer risk factors and preventive measures. SETTING: Participants were recruited from sources that included GPs' surgeries, sixth form colleges and places of worship. SUBJECTS: Asian males, i.e. those of Indian, Pakistani, Bangladeshi or Sri Lankan origin; over the age of 16 years and resident in Leicester. MAIN OUTCOME MEASURES: Quantitative figures were obtained from the questionnaires as to the frequency of alcohol, tobacco and paan use and responses regarding oral cancer knowledge, risk factors and preventive measures. RESULTS: The principal Asian community groups in Leicester were Hindu, Sikh, Muslim and Jain. Significant differences were found in males from these groups with regards to habits and oral cancer awareness. Muslim males use tobacco and paan more than the other groups but avoid alcohol. Sikh males drink more alcohol (especially spirits) than the other groups but their use of tobacco and paan is low. Habits of Hindu and Jain males are variable. However, approximately 10% of both 1st and 2nd generation Hindu males combine all three habits of alcohol, tobacco and paan; and are thus considered to be at high risk of developing oral cancer. Seven percent of 1st generation Hindu males were found to chew paans containing tobacco which are strongly associated with oral cancer. More 2nd generation Jains drank alcohol than the 1st generation, and a greater proportion of Hindu, Sikh and Jain 2nd generation males drink spirits than their older counterparts. Knowledge of oral cancer risk factors and preventive measures were variable, the lowest level of knowledge being among the 1st generation Sikh group. Few volunteers realised the risk of alcohol drinking in the aetiology of oral cancer. CONCLUSION: The 'Asian' community in Leicester is not homogeneous, but consists of distinct community groups; each with their own cultural beliefs, habits and attitudes. Knowledge of these differences can be used to provide appropriate health education programmes suitably targeted to reduce the use of the known risk factors for oral cancer.

Traumatic medial malleolar fracture of a fibula flap donor leg.

A 50-year-old male presented with a T4 N0 squamous cell carcinoma of the floor of the mouth and alveolus. Treatment included a partial mandibulectomy with a free osteocutaneous fibula flap reconstruction. He made a good postoperative recovery and was given adjuvant radiotherapy. No problems were reported with the donor site or ankle. Five months after harvesting the flap the patient sustained a fracture of the medial malleolus having jumped over a ditch playing golf. This was treated successfully with a below knee plaster of Paris cast. The interosseous membrane was not ruptured in the accident indicating that the distal fibula left in situ was adequate to maintain the integrity of the mortice. A degree of ankle instability may be present after fibula flap harvest which is only revealed by athletic activity.

Ameloblastoma--a diagnostic problem.

A 50-year-old female was referred by her dental practitioner. She had a periapical radiolucency associated with the lower right second premolar tooth. The tooth was root treated and subsequently apicected. Tissue curetted at the time of surgery was shown to be a solid ameloblastoma which was managed initially by marginal excision. Histopathological examination of the resection specimen demonstrated tumour at the inferior margin. A segmental resection of the mandible with an immediate reconstruction using a free tissue transfer of the iliac crest was therefore performed. The case shows the need for vigilance in dealing with periapical pathology and underlines the importance of sending all tissue specimens for histopathological analysis.

Oropharyngeal morbidity following transoral approaches to the upper cervical spine.

The transoral approach to the upper cervical spine is now well established. Oropharyngeal complications have not previously been critically assessed. In the present study, the overall complication rate was 31.6%. This dropped to 15.4% in those patients who did not undergo splitting of the soft palate. The complication rate of 75% in the split soft palate group means that this procedure should be discontinued where it is not absolutely necessary.

Oral rehabilitation with implant-retained prostheses following ablative surgery and reconstruction with free flaps.

Ablative surgery of the oral tissues may result in significant facial deformity, poor oral function, and psychologic detriment. Immediate surgical reconstruction with vascularized free flaps has become increasingly popular, but the oral rehabilitation of these patients with conventional dental prostheses is usually unsuccessful. The results and clinical experiences of treating a group of 17 patients with ablative surgery, immediate reconstruction with free flaps, and restoration with mandibular implant-retained prostheses are presented after follow-up periods of 6 months to 7 years. Most patients expressed a high degree of satisfaction with their prostheses. General principles and guidelines for the provision of this effective treatment modality are discussed.

The superiorly based pharyngeal flap: a modification of the transoral approach to the upper cervical spine.

The transoral approach has become a well established method of gaining access to the upper cervical spine. The use of a superiorly based pharyngeal flap rather than the more usual midline longitudinal incision is decribed. This flap improves exposure of the operative field which simplifies the subsequent neurosurgical procedure.

Aesthetic lip splits.

Both upper and lower lip splits, usually with osteotomy of the underlying jaw, improve access to the deep structures of the head and neck. A simple modification to the midline lip split is to incorporate a chevron in both the peri-oral skin and vermilion margin. The advantages are: accurate wound closure, no straight line contracture and a broken line of the peri-oral scar. This improves the aesthetic result of the healed lip.

Oral rehabilitation with endosteal implants and free flaps.

Current management of oral cancer following tumour resection includes reconstruction of the surgical defect with free vascularized flaps and rehabilitation of orofacial form and function with the aid of endosteal implants. The choice of flap for reconstruction influences the use of implants, and further hard- and soft-tissue surgery is frequently required to enhance the success of oral rehabilitation.

The functional case for miniplates in maxillofacial surgery.

A review is presented of the application of miniplates in maxillofacial surgery, with an emphasis on maxillofacial trauma. The advantages are highlighted, particularly in relation to functional considerations, including jaw function, weight loss, and pulmonary function. Miniplates are considered to be the best treatment for patients with maxillofacial fractures.

Should endoscopic stenting be the initial treatment of malignant biliary obstruction?

Forty-two patients with biliary obstruction caused by a stricture had a diagnostic ERCP with subsequent insertion of a straight 10G endoprosthesis. These patients represented 70% of a cohort in which stent insertion had been attempted. The majority (63%) had pancreatic carcinoma, but 22% had malignant hilar obstruction. Five patients (12%) died within a few days of stent insertion; ERCP may have contributed to two deaths. Jaundice was relieved in all survivors. Median hospital stay was 6 days (range 2-32 days). After further investigation, nine patients were thought to be potentially curable and underwent laparotomy. Late complications after stent insertion alone included cholangitis (26%) and recurrent jaundice (28%). Only one patient developed gastric outlet obstruction and needed a gastroenterostomy. Median survival in the endoprosthesis group was 11 weeks (range 2-84 weeks). Survival was longer for patients with bile duct (14 weeks) rather than hilar strictures (6 weeks). Median survival after subsequent surgery was 40 weeks (range 4-80 weeks) with two long-term survivors. This study confirms that ERCP and stent insertion is a useful initial treatment for obstructive jaundice due to a biliary stricture, being both diagnostic and therapeutic. Subsequent evaluation for curative surgery is not precluded and in the majority of cases worthwhile palliation may be achieved by stenting alone.

Maxillofacial trauma in severely injured patients.

A study was made of maxillofacial trauma in seriously injured patients to determine the likely role of oral and maxillofacial surgeons working in the regional trauma centres proposed by the Royal College of Surgeons of England. There were 153 patients, aged 70 years or less, who sustained major trauma (injury severity score 16 or more) and were admitted directly to the accident departments of the Bristol Royal Infirmary or Derriford Hospital, Plymouth during 1989. Maxillofacial injuries occurred in 50 (33%) of these patients with lacerations present in 39, burns in 1 and facial bone fractures in 28 (18%); soft tissue abrasions and contusions were excluded. The aetiology, patterns of injury, surgical treatment and outcome were reviewed. The implications for the provision of maxillofacial surgical services in regional trauma centres is discussed.