Utility of preoperative colour flow Doppler assessment of perforator anatomy in medial sural artery perforator (MSAP) free flaps.

PURPOSE: It is known that the vascular perforators upon which the medial sural artery perforator (MSAP) flap is based are subject to considerable variation. This study seeks to evaluate the use of colour flow Doppler (CFD) as an imaging technique to establish the presence of suitable vessels, the discriminatory findings from that imaging, the rate of flap abandonment and flap complications. METHODS: All patients undergoing MSAP in our institution since 2015 had a pre-operative CFD using a standardised technique. A prior group of 22 patients not having CFD acted as a control group. Data were  collected prospectively. RESULTS: Fourteen patients had CFD. In one patient, no suitable vessels were found. In 13 patients, vessels of suitable size and position were identified, which then correlated precisely with operative findings. Three had suitable vessels in one leg only. No flaps in the CFD group were abandoned. One flap in the CFD group was partially lost. One flap in the prior control group was abandoned. CONCLUSIONS: CFD provided reliable discriminatory information to decide on flap suitability/which leg and correlated precisely with operative findings, with no flap abandonment. Flap survival rate was very high.

Factors determining postoperative length of stay and time to resumption of feeding following free flap reconstruction for oral cancer.

Microvascular free tissue transfer reconstruction following resection of oral cancer is commonly chosen as the first line of treatment due to its superior functional outcomes. Multiple patient and surgical factors impact the length of postoperative stay, and the time taken for patients to recommence oral feeding. This study aimed to identify factors that increase the length of stay and time to resumption of feeding. We retrospectively evaluated 100 cases from March 2015 to October 2020, and identified variables associated with increased length of stay (LOS) and time to resumption of feeding in univariate and multivariate analyses. Factors found to be associated with increased LOS in multivariate analysis were increasing age, elective tracheostomy, tumours originating from the floor of the mouth and mandible, a longer operating time, and use of fibular free flaps (p<0.05). Tracheostomy, increasing age, and female gender were strongly associated with delays in resumption of some types of oral feeding, and an integrated critical care unit (ICCU) stay of two or more days was associated with a longer time to resumption of free fluids. This information can be used to anticipate extensions to typical LOS, to produce cost analyses, develop individual patient risk stratification, manage patient expectations, and target the use of enhanced recovery programmes.

Bilateral hypoglossal nerve damage due to the use of the harmonic focus scalpel.

We describe the case of a 68-year-old man who presented with an anterior floor of mouth squamous cell carcinoma and underwent bilateral neck dissection. Subsequently, the patient developed permanent bilateral hypoglossal palsies, causing significant dysphagia, dysarthria and breathing difficulties. Hypoglossal nerve damage from surgical causes is uncommon, occurring in only 0.42% of functional neck dissections. However, it is the bilateral and permanent features of this case which make it unique. This injury may have been caused by incorrect use of the Harmonic Focus scalpel. Therefore, we discuss the literature demonstrating that the Harmonic Focus scalpel causes more lateral thermal damage than alternative tools, and the widely accepted 3 mm safety limit is not enough to protect important surrounding structures. This case report aims to highlight the need for proper training and specific identification of the hypoglossal nerve to prevent this rare and debilitating complication occurring in future patients.

An unusual case of myiasis.

Myiasis-the feeding of fly larvae on living mammals, may have various clinical presentations depending on the tissues or organs involved. Myiasis is a common travel associated skin disorder as a consequence of short visits to developing countries. It is the fourth most common travel associated disease. The most common clinical manifestations of fly larvae infestation include inflammatory and allergic reactions. Ear, eye and respiratory tract infestations are not uncommon and the human botfly Dermatobia hominis is the most recognised causative organism. We present an unusual case report of a myiasis in the upper lip of a patient admitted under the maxillofacial team at South Manchester Hospital.

Rectal ulceration caused by the anti-anginal nicorandil: Case report of a preventable complication.

The association of the anti-anginal drug nicorandil with oral and anal ulceration is becoming more widely recognised, but there are no reports of isolated nicorandil-induced rectal ulceration. Awareness of this condition is poor, and patients often undergo unnecessary surgery for a condition which resolves on stopping the medication.We report a case of nicorandil-induced rectal ulceration causing rectal bleeding. The patient was spared surgery after awareness of the link with this drug.This diagnosis should be considered in patients with unexplained gastrointestinal ulceration after exclusion of serious underlying causes. We hope this report will increase awareness amongst physicians and surgeons of this reversible condition.