Outcome analysis of patients with craniofacial resection: Hong Kong experience.

BACKGROUND: The aim of this study was to evaluate the clinical outcome of patients who underwent craniofacial resection for tumour in the anterior skull base at the University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong between January 1993 and June 2003. METHODS: A retrospective review was conducted. The duration of follow up ranged from 1.7 to 119 months (median, 41.8 months). The setting was a tertiary referral centre. Thirty-nine patients, 23 males and 16 females, aged 8-79 years were included. Thirty-four patients had malignant tumour and five patients had benign pathology. The tumour pathology was diversified. Nineteen patients had no treatment before the surgery, and the remaining 20 patients had received surgery, radiotherapy or combined treatment before resection. Patients were given postoperative irradiation and/or chemotherapy depending on the pathology of the tumour and the extent of the disease and clearance at the time of surgery. RESULTS: There was no operative mortality. Complications occurred in 10 patients and among them, three required reoperation. The other complications were managed successfully with conservative measures. The 5-year actuarial disease-free survival for patients with benign and malignant pathology was 100 and 77.6%, respectively. For patients with malignant pathology, 5-year actuarial disease-free survival was 90% when the resection margin was negative at surgery. However, the survival dropped to 53.6% when the resection margin was involved macroscopically. CONCLUSION: Craniofacial resection was an appropriate surgical approach with acceptable morbidity in selected patients with tumour located at the anterior skull base. Complete excision of malignant tumour could achieve 90% 5-year disease-free actuarial survival.

Microvascular reconstruction of the hepatic artery in live donor liver transplantation: experience across a decade.

HYPOTHESIS: Hepatic arterial anastomosis by means of a microvascular technique can be performed with a high success rate in live donor liver transplantation in adult recipients. DESIGN: Retrospective analysis of data collected prospectively. SETTING: Tertiary referral center. PATIENTS: From September 28, 1993, through December 23, 2002, 28 children received left lateral segment grafts (n = 23) or left lobe grafts (n = 5), and 124 adults received left lobe (n = 6) or right lobe (n = 118) grafts. Microvascular technique was used for hepatic arterial anastomosis. Attention was paid to exposure, orientation of the axis of arterial ends, and matching of size. Long microinstruments were used for arterial ends deeply located inside an adult's abdominal cavity. An average of 16 stitches was used for a vessel anastomosis 3 mm in diameter. INTERVENTIONS: Intraoperative and postoperative Doppler ultrasonography were performed. MAIN OUTCOME MEASURES: Hepatic artery thrombosis rate. RESULTS: All hepatic arterial anastomoses were patent after reconstruction. Complications occurred in 3 patients. They had hepatic arterial thrombosis at 19 days, 25 days, and 3 months after liver transplantation. The overall complication rate was 2%. CONCLUSION: With attention to exposure, appropriate instruments, and experience, a low complication rate of 2% can be achieved in hepatic arterial anastomosis by using a microvascular technique, even in adult patients with the liver graft situated deeply in the abdominal cavity.

Use of 1,320 nm Nd:YAG laser for wrinkle reduction and the treatment of atrophic acne scarring in Asians.

BACKGROUND AND OBJECTIVES: The role of 1,320 Nd:YAG in non-ablative skin rejuvenation in Asians is has not been established. Furthermore, no study has investigated the effectiveness of 1,320 Nd:YAG laser in the treatment of atrophic scarring in Asians. The objective of our study was to investigate the effectiveness of 1,320 Nd:YAG laser in wrinkle reduction and the treatment of atrophic acne scarring in Asians. STUDY DESIGN/MATERIALS AND METHODS: Twenty-seven female patients were included in the study: seven were treated for acne scarring and the others for wrinkle reduction. A 1,320 nm Nd:YAG laser (Cooltouch II, Roseville, CA) was used to treat both the cheeks and forehead for the patients with wrinkles, and both cheeks only for patients with atrophic acne scarring. All patients received treatment in the post-auricular areas. A spot size of 10 mm was used, and three passes were performed (two pre-cooling and one post-cooling). Patients were treated monthly for 6 months. All patients were subjectively assessed before and after their last treatment sessions using a structured questionnaire, and objectively assessed by the use of clinical photographs for by independent observers. A cutometer was used to assess viscoelasticity, and biopsies were taken at the post-auricular site for assessment by a pathologist. RESULTS: The overall degree of patients' satisfaction was rated as 4.9 (range 0-9.8) for wrinkle reduction and 4 (range 0-10) for acne scarring. In terms of objective assessment by independent observers, the degree of improvement was considered to be mild or no change in most cases. The independent pathologist who assessed the degree of improvement in terms of increased collagen production detected no change in 8 patients, mild improvement in 9, and moderate improvement in 10. There was also improvement in term of epidermal thickness in 13 cases. Assessment by viscoelasticity indicated a significant degree of improvement in most parameters in both groups of patients. Blistering occurred in five cases, all in the central facial areas, and post-inflammatory hyperpigmentation occurred in three cases. All cases of PIH resolved after the use of 4% hydroquinoine. There was no scarring or hypopigmentation. CONCLUSIONS: The 1,320 nm Nd:YAG laser is effective for wrinkle reduction and atrophic acne scar improvement, but to further enhance the clinical outcome a combination approach with another device such as IPL and a surgical technique such as subcision is necessary.

Salvage of recurrent head and neck squamous cell carcinoma after primary curative surgery.

PURPOSE: The efficacy of salvage treatment of recurrent head and neck squamous cell carcinomas (HNSCC) after primary curative surgery was evaluated. METHODS: The management outcome of 377 patients who had recurrent squamous cell carcinoma of oral cavity, oropharynx, hypopharynx, and larynx after primary curative surgery was reviewed. RESULTS: The surgical salvage rates of recurrence were 29% local, 30% tracheostomal, 56% unilateral nodal recurrence of previously undissected neck, 32% of unilateral neck recurrence after prior neck dissection, and 11% lung metastasis. The 5-year tumor-free actuarial survival rates of those patients who received surgical salvage was 35% for local recurrence, 32% for unilateral nodal recurrence of the previously undissected neck, and 18% for nodal recurrence of the previously dissected neck. One patient of six with tracheostomal recurrence salvaged with surgery and one patient of six with lung metastasis salvaged with lobectomy survived without tumor at 5 years. There was no 5-year survivor of all patients salvaged with other nonsurgical methods. The mean survival of patients without surgical salvage was 6 months. CONCLUSIONS: There was a moderate chance of cure after surgical salvage of locoregional recurrent HNSCC. Surgical salvage was, however, only feasible for early recurrent tumor. Close follow-up surveillance of early recurrence is essential after primary treatment of patients.

Safe tracheostomy for patients with severe acute respiratory syndrome.

OBJECTIVES/HYPOTHESIS: Severe acute respiratory syndrome (SARS) caused by coronavirus has become an epidemic affecting many regions worldwide. Fourteen percent to 20% of patients require endotracheal intubation and ventilator support. Some of these patients may require tracheostomy subsequently. This procedure, when performed without protection, may lead to infection of the medical and nursing staff taking care of the patient. STUDY DESIGN: Based on clinical information of three patients. METHODS: The authors carried out an emergency tracheostomy and changed the tracheostomy tube for one patient and performed elective tracheostomy in another two patients. RESULTS: No medical or nursing staff member was infected after carrying out the procedure while taking all the precautions and wearing the appropriate protective apparel. CONCLUSION: The authors have prepared guidelines for performing a safe tracheostomy under both elective and emergency conditions. Surgeons who might be involved in performing the tracheostomy should become familiar with these guidelines and the appropriate protective apparel.

Role of skin cooling in improving patient tolerability of Q-switched Alexandrite (QS Alex) laser in nevus of Ota treatment.

BACKGROUND: The development of a high-energy laser device with very short pulse duration has revolutionized the treatment of nevus of Ota. Nevertheless, patients still suffer from complications that range from the pain and swelling that occur immediately after laser surgery to post-operative pigmentary changes and scarring. However, the simultaneous use of skin surface cooling and laser surgery may limit the damage of non-target tissue. OBJECTIVES: To assess whether epidermal cooling reduces the pain and swelling that commonly occur after laser treatment for nevus of Ota. STUDY DESIGN/PATIENTS AND METHODS: Thirty-seven patients with nevus of Ota were recruited from a dermatology outpatient clinic. Before treatment, the research nurse used an ink pen to divide the lesions into two halves. Half of each lesion was treated with a Q-switched Alex laser system that had a cool sapphire plate in contact as a mean of skin cooling. The other half was treated with the same laser, but with the cooling device switched off. Immediately after treatment, and again 1 week later, the patients answered a questionnaire, which assessed the symptoms that are associated with laser surgery. Dose assessment was performed in each half of the nevus to obtain the optimal fluence that could be used for the treatment of nevus of Ota before the entire half was treated. RESULTS: There was no difference in terms of the optimal fluence that was used, but in terms of immediate pain the patients associated the side that was treated with the cooling plate with a significantly lesser degree of pain than the non-cooled side (P = 0.001). Eighty two percent of the patients preferred the cooled side to the non-cooled side. CONCLUSIONS: Pre- and post-operative skin cooling is effective in improving the tolerability of nevus of Ota patients to Q-switched laser treatment. However, the use of cooling during laser treatment of nevus of Ota did not allow the use of higher fluence.

Prognostic factors of clinically stage I and II oral tongue carcinoma-A comparative study of stage, thickness, shape, growth pattern, invasive front malignancy grading, Martinez-Gimeno score, and pathologic features.

PURPOSE: This study aims at evaluation of the different prognostic models, including stage, tumor thickness, shape, malignancy grading of tumor invasive front, Martinez-Gimeno score, and pathologic features in the prediction of subclinical nodal metastasis, local recurrence, and survival of early T1 and T2 oral tongue squamous cell carcinoma. The results will have important implication for the management of patients. PATIENTS AND METHODS: Seventy-two clinically T1 and T2 glossectomy specimens of oral tongue carcinoma were serially sectioned in 3-mm thickness for the evaluation of various pathologic features. The prognostic value in the prediction of subclinical nodal metastasis, local recurrence, and survival of different models were compared. RESULTS: Among all the tumor parameters and predictive models being evaluated, tumor thickness was the only significant factor that had significant predictive value for subclinical nodal metastasis, local recurrence, and survival. With the use of 3-mm and 9-mm division, tumor of up to 3-mm thickness has 8% subclinical nodal metastasis, 0% local recurrence, and 100% 5-year actuarial disease-free survival; tumor thickness of more than 3 mm and up to 9 mm had 44% subclinical nodal metastasis, 7% local recurrence, and 76% 5-year actuarial disease-free survival; tumor of more than 9 mm had 53% subclinical nodal metastasis, 24% local recurrence, and 66% 5-year actuarial disease-free survival. CONCLUSIONS: Tumor thickness should be considered in the management planning of patients with early oral tongue carcinoma.

Current reconstruction options following tumour extirpation in head and neck surgery.

The reconstruction of defects in the head and neck region has remained a challenging problem for head and neck surgeons. The amount of tissue loss may be extensive or the tissue destruction may involve composite elements. It is important to consider both the functional and aesthetic aspects while planning the reconstruction. The application of microvascular free tissue transfer allows the selection of the most appropriate tissue for reconstruction of the defect created following tumour extirpation. As these free tissues bring in new blood supply, wound healing is usually not a problem even if the region had received previous radiotherapy. Despite all the benefits associated with microvascular free tissue transfer these procedures remain associated with a small chance of failure. The application of pedicle tissue for reconstruction for certain defects still has a role in reconstruction of the head and neck region. The selection of the appropriate method and suitable tissue for reconstruction depends on the experience of the surgeon. Contemporary head and neck surgeons should consider all the reconstructive options before deciding on the optimal reconstruction method after adequate tumour resection.