Preliminary report: intratumoral ligation as a salvage procedure for the management of life-threatening arteriovenous malformations.

Arteriovenous malformations are rare, high flow vascular anomalies which are frequently difficult to manage. Treatment options include embolisation and/or surgery, the latter ranging from proximal ligation (now discredited) through to radical resection. The Popescu technique of intratumoral ligation was used to treat 3 patients with massive, life-threatening arteriovenous malformations which were considered unsuitable for embolisation therapy or surgical resection. The main complications experienced were soft tissue swelling and necrosis, transient peripheral nerve entrapment and haemorrhage. The preliminary results have been encouraging and suggest that effective palliation and control can be achieved; 1 patient has no clinically demonstrable recurrence nearly 3 years after surgery.

Lateral temporal bone resection for extensive pinnal malignancy. Has anything changed in forty years?

This paper offers an account of the contemporary surgical approach to advanced tumours of the external ear based on a series of 11 patients. There were eight squamous, two basal cell carcinomas and one mucoepidermoid tumour. The traditional method of excision was slightly modified by performing microsurgical dissection of the lateral part of the temporal bone rather than chisel osteotomies, and then including it en bloc with the involved soft tissues. The defect was then closed using a scalp or myocutaneous flap and this combination of otological and reconstructive expertise has proved satisfactory. Four patients are alive with no evidence of disease a mean of 4.2 (range 1.0-7.0) years from surgery: two patients who remained free of disease have subsequently died of unrelated conditions 12 and 24 months post-operatively, and in three cases death from recurrent disease occurred a mean of 1.4 (range 0.9-2.1) years after our surgery. There were two post-operative deaths. Based on the actuarial survival of 36 per cent and a successful disease clearance rate of 54 per cent, our conclusion is that the outlook of this condition has not dramatically improved since the original descriptions of the management of this problem first appeared, although intervention remains justifiable because of the potential curability and relief of symptoms.

Treatment of toxic epidermal necrolysis and a review of six cases.

Six cases of drug-induced toxic epidermal necrolysis treated in a burns unit are presented. The mean skin loss was 67.3 per cent of the total body surface area. Two patients developed renal failure and two had ocular symptoms. The mortality rate was 50 per cent, with two patients dying from septicaemia and one from respiratory and renal failure. The diagnosis of toxic epidermal necrolysis can be confirmed by skin biopsy. We recommend that this disease is treated in a burns unit so that both adequate wound care and essential intensive supportive treatment can be given. Antibiotics are indicated only for specific infections such as septicaemia or pneumonia. Steroids have been shown to increase greatly the mortality from septic complications and are not recommended. The mortality ranges from 10 per cent to 70 per cent and bad prognostic factors include increasing age, greater than 50 per cent of body surface skin loss and neutropenia.

Web neck deformity; anatomical considerations and options in surgical management.

Web neck deformity has been recognised for over 100 years and during that time there has been a large amount of literature devoted to it. There has been surprisingly little information published on the exact nature of the deformity, particularly the exact site and composition of the web and the presence or absence of any other soft tissue anomalies in the head and neck, which could modify a surgical approach. Our paper will describe the "simple" webbing found in four cases of Turner's syndrome and one case of Klippel-Feil syndrome, and discuss some of the associated features seen in these syndromes. We also review the major methods of surgical treatment and examine the role of tissue expanders in the surgical correction of this anomaly.

Carcinoma of the apocrine glands at the base of eyelashes; a case report and discussion of histological diagnostic criteria.

A review of the literature has been undertaken and the diagnostic criteria relating to this group of carcinomas found to be misleading. We encourage the reporting of all cases of apocrine carcinoma in order to draw valid conclusions regarding the behaviour and management of these unusual tumours.

Biosynthetic human growth hormone in burned patients: a pilot study.

A 15-day, open trial was conducted in 12 adult burned patients of whom six were randomly allocated to form a control group and six to receive biosynthetic human growth hormone (somatropin). All were fed enterally and treated according to a standard burn protocol. The mean age, burn size, energy and nitrogen intakes were well matched in each group. The resting energy expenditures (REE) were comparable in each group and the REEs exceeded the calculated basal energy expenditures by a mean of 36.8 +/- 4.1 per cent for both groups. Blood urea values were significantly lower in somatropin-treated patients but there was no significant difference in nitrogen balance, protein oxidation or the rate of plasma protein recovery between the two groups. The basal plasma insulin concentration and basal insulinogenic index were significantly higher in somatropin-treated patients but insulin release, in response to injected glucose, was comparable in both groups. All patients had impaired glucose disposal due to insulin resistance but the area under the glucose curve increased significantly during somatropin treatment. It is concluded that somatropin administration did not significantly improve nutrition in burned patients but has been shown to exacerbate the existing insulin resistance.

Tissue expansion for head and neck reconstruction.

Tissue expansion is a new reconstructive technique with enormous potential. Although popularized over 10 years ago, its place in the management of soft tissue reconstruction for head and neck malignancy is undefined. In this paper 3 clinical cases are illustrated.

Burns to the elderly: a reappraisal.

Admissions to the McIndoe burns unit over the period 1975 to 1984 were reviewed and 123 patients over the age of sixty-five were studied in detail. Comparison with standardised mortality curves showed no difference in survival rates, but review of individual cases suggests that regular examination of elderly patients could shorten admission times and reduce the mortality by encouraging prompt identification and treatment of medical complications. Patients with burns of greater than 5% of surface area should be resuscitated with intravenous fluids as this age group is very susceptible to hypotensive renal damage. Excision of burns on or before the fifth day resulted in longer admissions and increased the number of procedures per patient. Disagreement in the recent literature on this point suggests the need for a randomised, controlled trial of early excision in the elderly patient.

Mesh grafts--an 18 month follow-up.

Thirty-four patients, who had received either sheet or mesh grafts during surgery at the McIndoe Burns Unit, were reviewed, with a minimum follow-up period of 18 months. Expert observers were able to identify 1:1.5 mesh after close examination, but no group found the cosmetic result inferior to that of sheet graft. 1:4 mesh was uniformly identified, and cosmesis was judged unsatisfactory by all observers.

Scalds in the very young: prevention or cure?

Childhood scalds are a regrettable, but common cause for admission to the McIndoe Burns Centre. A survey of the recent literature confirms that this is not a local but an international problem, and furthermore that the majority of scalds affect children less than 2 years of age. With hindsight, it is possible that a sizeable proportion of these scalds could have been prevented. Taking into account a survey carried out at Waikato, New Zealand, we should like to propose a scheme for public health education; this will be carried out by medical and nursing staff from the unit and will form the basis for a prospective study.

The degloved hand: immediate complete restoration of skin cover with a contralateral forearm free flap.

This paper describes a method of repair of a serious injury with major skin loss on both the volar and dorsal aspects of the hand and wrist using a free "forearm flap" from the opposite limb. The technique is a one-stage procedure, provides a completely variable amount of skin, the freedom to elevate the repaired hand and the opportunity to revascularise the most distal structures using the vessels incorporated in the flap.

The radial forearm flap in the management of soft tissue injuries of the hand.

Soft tissue injuries of the hand frequently require flap cover either to preserve structures damaged at the time of injury or to facilitate later reconstruction. Techniques such as the groin flap, the abdominal flap and the cross arm flap require staged procedures and until now, surgeons have had to resort to the more complicated microsurgical techniques required in free flap transfer to obtain soft tissue cover in a single-stage. The radial forearm flap makes local tissue readily available and offers a simple and effective one-stage method of soft tissue reconstruction. Surgery is confined to a single limb permitting early mobilisation and rehabilitation. The vascular anatomy of the radial forearm flap will be described and three cases presented to illustrate this technique in the management of differing soft tissue injuries of the hand.

Frontonasal encephalocele--"long nose hypertelorism".

Two varieties of frontonasal encephalocele are presented, with variations in the surgical technique necessitated by the different anatomical findings. The encephalocele pushes the nasal skeleton posteriorly and caudally and widens the distance between the medial orbital walls. This causes the long nose and the telecanthus. In this variety of frontonasal encephalocele, hypertelorism is uncommon. There may be absence of dura in relation to the encephalocele. The suggested method of correcting the deformity involves a combined intracranial and extracranial approach. The nasal skeleton is mobilized and placed in its correct position and the telecanthus is corrected. All skull defects are bone grafted. Correcting the deformity at an early age is recommended.

Post-irradiation sarcoma of the lower lip.

This report records the occurrence of an irradiation induced fibrosarcoma of the lower lip which appears to be the first case documented in this site. The problems associated with the histopathological diagnosis of such lesions are discussed and the value of electronmicroscopical examination of spindle cell sarcomas stressed.

The radial forearm flap: a versatile method for intra-oral reconstruction.

The radial forearm flap is ideal for intra-oral reconstruction, offering thin, pliable predominantly hairless skin to replace oral mucosa. The vascularity of the area allows considerable variation in the design of this fasciocutaneous flap and offers the possibility of including bone as an osteocutaneous flap. Furthermore, the vascular anatomy of the flap simplifies the technical aspects of free tissue transfer. Based on ten clinical cases the design of the flap is described and its versatility in differing clinical situations is illustrated. The advantages of this method of intra-oral reconstruction are discussed and evaluated.

Survival after replantation.

Over a seven-year period in one unit performing replantation surgery 63 parts were replanted in 49 patients with an overall survival rate of 60%, which represents a worthwhile salvage of tissue otherwise not available for reconstruction. As the median operation time was eight hours (range 5-22) the implication of providing such prolonged operative procedures on the resources of the Health Service must be seriously considered. Yet there is a failure of awareness among the medical profession of the possibilities of such treatment, and potentially viable parts may be being discarded.

Pain and dysphagia in patients with squamous carcinomas of the head and neck: the role of perineural spread.

Clinical and pathological features of perineural spread have been investigated in patients with squamous carcinomas at several sites in the head and neck. In 100 surgical cases, the clinical and pathological findings were congruent in 76%. Combined clinical and histological evidence of perineural invasion was recorded in 33% and the overall incidence of nerve involvement detected morphologically was 44%. Perineural infiltration was demonstrated histologically in 51% of major excisions from the buccal cavity and in 34% of resections from the oropharynx, hypopharynx and cervical oesophagus. The neurological findings were dominated by hypoaesthesia, dysaesthesia and referred pain - mainly in the territories of cranial nerves V and IX. Multiple and/or sequential nerve involvement was occasionally seen. No correlation was established between nerve invasion and metastasis to regional lymph nodes. Long-distance infiltration of nerve trunks, and multiple involvement, are grave prognostic features.In 17 terminal patients submitted to autopsy, 65% had combined clinical and pathological evidence of perineural spread and the overall incidence of nerve involvement detected morphologically was 88%. Sensory changes again predominated. Multiple nerve involvement was observed in 35%. An apparently new `dysphagia syndrome' is described in 4 patients with oropharyngeal carcinomas in whom gross mechanical obstruction was simulated by a combination of perineural spread of tumour into the ipsilateral vagal trunk, sometimes accompanied by segmental infarction, variable invasion of the sympathetic chain, and `splinting' of the pharynx by local fibrosis and tumour in the soft tissues of the neck. Short-term palliation was achieved in these patients with high-dose steroids.

An interpositional elastomeric cap for metacarpophalangeal joint perichondrioplasty in rheumatoid arthritis.

A new interpositional elastomeric cap was developed and used for perichondrioplasty in six rheumatoid metacarpophalangeal joints. Adequate cartilage formation occurred, and the joint contours were more normal than those achieved by previous methods.