A Brief Clinical Study: The Use of a Custom Guide for Scapula Free Flap Harvest and Mandibular Reconstruction.

Head and neck cancer can leave patients with significant defects requiring major reconstruction. The scapula free flap remains a relatively underused flap choice. This article examines the novel use of a custom guide for a scapula free flap in mandibular reconstruction following resection. A case file was created involving a consultant surgeon, KLS advisor, and technical team based in Belgium. A computed tomography scan of the mandible was sent electronically to render a 3-dimensional model. Custom cutting guides for resection and scapula graft harvest were fabricated. A custom plate for fixation was also developed. The scapula free flap was successfully placed using custom guides. In this case, the use of a custom guide enabled easier harvest, manipulation, and handling of the scapula free flap into the defect. The use of new technology and computer-generated guides represents a considerable shift forward into improving precision in complex surgical procedures and reducing intraoperative time. The use of a custom guide can provide an easier means to handle and manipulate one of the largest free flaps in surgery, the scapula free flap.

Modified orthopedic wire twister for fixing and removing screws in craniomaxillofacial osteosynthesis.

Internal fixation is the routinely performed surgical procedure in craniomaxillofacial surgery. At present, available kit for internal fixation includes large number of armamentarium. To overcome and reduce this, we have modified orthopedic wire twister for fixing and removing screws. This single device can replace self-holding screwdrivers with different sizes.

Competent to care. Are all doctors competent in nutrition?

Optimising nutrition is known to improve outcome in a variety of specialities from elderly care to orthopaedics. The National Institute for Health and Clinical Excellence guidelines of 2006 have provided standards to positively influence the profile of nutrition within the National Health Service. However, what role do doctors have in this process? Clearly, not all doctors are competent in nutrition. In a recent US survey only 14% of resident physicians reported feeling adequately trained to provide nutrition counselling. A lack of knowledge has also been demonstrated by general practitioners (GP). The Intercollegiate Group on Nutrition is working to improve nutritional knowledge in British medical graduates. In addition, nutritional care is now a core competency assessed in the UK Foundation Programme curriculum, which can only be a positive step. The assessment process may even influence some of the supervising consultants. What about those doctors currently practising in the UK? Recently, a questionnaire study was undertaken to look at healthcare professionals' knowledge of the benefits and risks of percutaneous endoscopic gastrostomy (PEG) feeding. Important gaps in knowledge were found that were positively correlated with whether respondents had received relevant education. Referral for a PEG was considered to be appropriate for patients with advanced dementia by 31% of the GP compared with 10% of the consultants. Only 4% of these GP had received any training in this ethically-sensitive area at a time when they may be asked to countersign consent forms for patients who lack competence. So, what is the way forward? Positive steps are being taken in the undergraduate curriculum and Foundation Programme. Perhaps it is the responsibility of those doctors with the skills and opportunities to promote good nutritional knowledge in those doctors already practising in the UK.