Two New Surgical Techniques to Refine Surgery Around the Ear: "The Inviscision" and the External Auditory Meatus Suture.

Numerous incisions around the ear have been described, and many have been used in oral and maxillofacial surgery for procedures involving the temporomandibular joint (TMJ), condylar neck, and parotid gland, as well as for rhytidectomy.1-5 Although the traditional preauricular and endaural incisions will frequently provide an excellent outcome, they will heal with a visible scar.1,4 The incision we have described aims to refine the incision to further improve this esthetic outcome. Additionally, surgical procedures around the ear have often resulted in the unpleasant and inconvenient collection of blood or surgical skin preparation in the ear canal. Although not recorded in reported studies, in our experience, patients have commonly complained of "blocked ears" for 1 to 2 weeks in the postoperative period. Although this complication represents minimal risk, it can often be difficult, once clotted or dried, to remove and will be bothersome to the patient. In addition, any packing placed in the external auditory canal (EAC) intraoperatively to mitigate the collection of blood will often and repeatedly dislodge from the EAC, requiring replacement multiple times during the procedure to the frustration of the surgeon. The techniques we have described are 2 straightforward, but innovative, surgical techniques that refine surgery around the ear to improve the esthetics and patient comfort, facilitate the surgical procedure, and increase reliable anatomic access. The modified incision we have described is predominately aimed at operations requiring access to the TMJ, condylar neck, or parotid gland. The techniques were, to the best of our knowledge, first used in our unit at the University of Maryland.

Follow-up after treatment of squamous cell carcinoma of the oral cavity: current maxillofacial practice in the United Kingdom.

Although patients are commonly reviewed after primary treatment for squamous cell carcinoma (SCC) of the oral cavity, there is little evidence about the frequency and duration of such a review. To try and obtain further information about current practice within the United Kingdom we used a structured telephone questionnaire to contact 50 units. Most of them (n=40, 80%) had developed follow-up protocols, and 38 (76%) reviewed patients for 5 years. All units examined patients monthly for the first year, and 90% of patients were seen 2-monthly for the following year. Slight variations for follow-up existed in years 3 and 4, but by the fifth year, 6-monthly review was almost universal (96%). Despite this surprising concordance, few units implemented a risk-adapted follow-up protocol that was aimed at targeting those people likely to be cured of relapsing disease.

Biodegradable fixation in oral and maxillofacial surgery.

UNLABELLED: Fixation of the maxillofacial skeleton following trauma or osteotomy surgery has been achieved by the use of titanium plates and screws for the past two decades. Advances in materials science has enabled the development of biodegradable or resorbable plates and screws for internal fixation of the maxillofacial skeleton. This paper presents the biochemistry of resorbable materials and our early experiences in their clinical applications. CLINICAL RELEVANCE: This manuscript illustrates the use of a resorbable material to fix the maxillofacial skeleton following osteotomies and trauma.

Dentigerous Cyst and Ameloblastoma of the Jaws.

AIM: To determine how many ameloblastomas were misdiagnosed as dentigerous cysts (DCs) by correlating the radiological and histopathological features of a series of both entities. METHODS AND RESULTS: Histopathology reports and radiological imaging of 135 DCs and 43 ameloblastomas were reviewed. Any clinical or radiological feature that suggested that the diagnosis of DC was wrong-for example, absence of an unerupted tooth-prompted review of the original histology. A total of 34 cases coded as DC at diagnosis were excluded; in the remaining 101 patients, the clinicoradiological and histopathological features were consistent with DC in 96 (95.0%). Review of the histology revealed that 4 patients had actually had odontogenic keratocysts (OKCs) and one a luminal/simple unicystic ameloblastoma (UA). One other OKC and 3 other ameloblastomas (1 luminal UA, 2 solid/multicystic) had originally been diagnosed as DC; these had been identified prior to the study. Of the 9 misdiagnosed patients, 6 were ≤20 years old. Clinically, DC had been the only, or one of the differential, diagnoses in 7 patients; in the other 2, the clinical diagnosis was radicular cyst. In none of the 4 misdiagnosed ameloblastomas was the radiology compatible with a diagnosis of DC. Incorrect terminology had been used on the histopathology request form in 5 of the 34 excluded cases where the clinical diagnosis was DC, despite the cyst being periapical to an erupted carious or root-filled tooth. CONCLUSIONS: The entire clinical team must ensure that a histopathological diagnosis of DC is consistent with the clinicoradiological scenario, particularly in younger patients.

Evidence based management of Bell's palsy.

Bell's palsy (idiopathic facial paralysis) is caused by the acute onset of lower motor neurone weakness of the facial nerve with no detectable cause. With a lifetime risk of 1 in 60 and an annual incidence of 11-40/100,000 population, the condition resolves completely in around 71% of untreated cases. In the remainder facial nerve function will be impaired in the long term. We summarise current published articles regarding early management strategies to maximise recovery of facial nerve function and minimise long-term sequelae in the condition.

Management of tumour spillage during parotid surgery for pleomorphic adenoma.

Over the decades parotid surgery for benign tumours has developed into a reproducible, conservative operation with low morbidity. Despite the advances tumour spillage can still occur, and its management remains controversial. Since no universal consensus exists the aim of this article is to review the approach to tumour spillage and derive a protocol for its management based on existing evidence.

The deep circumflex iliac artery perforator flap (DCIAP)--a reconstructive option for the large composite oro-mandibular cutaneous defect.

The deep circumflex iliac artery (DCIA) flap is often used for mandibular reconstruction but it is bulky and causes additional donor-site morbidity because of the inclusion of an "obligatory internal oblique muscle". Large composite segmental mandibular resections that consist of floor of mouth, subtotal tongue, and adjacent facial skin are a challenge in terms of reconstruction. They often require 2 free flaps or a free scapular flap and both have disadvantages. The deep circumflex iliac artery perforator (DCIAP) flap with a cutaneous component overcomes the disadvantages. We describe reconstructions with DCIAP flaps in 3 patients with large mandibular composite segmental defects. We report our experience of the flap and discuss some of the difficulties we encountered and the points we learned perioperatively.

Aberrant common carotid artery -- a surprise for the unwary.

An aberrant common carotid artery is a rare anatomical anomaly. We report a case of an aberrant carotid artery running across the trachea in a patient undergoing total thyroidectomy. This rare anomaly may make a tracheostomy, a particularly hazardous procedure.

Lost tribe? Awareness of oral and maxillofacial surgery (OMFS) among the general public.

OMFS has important links with other disciplines in medicine and dentistry. Therefore it is important that people are aware of this speciality. A study was devised to determine the awareness of OMFS among the general public and to improve their understanding. A questionnaire was distributed among the participants attending a dental practice. 100 participated and the mean age was 42.5 years. Only 17% were aware of OMFS. 96% recognised the duty of OMFS practitioner while 74% did agree dual qualification was necessary. 68% identified hospital as the main place of work and 61% thought that the training was 5-6 years long. This study confirms that awareness of OMFS among general public remains low and much needs to be done to improve it.

Dynamic reanimation for facial palsy: an overview.

Facial paralysis can have a profound effect on the patient from both an aesthetic and functional point of view. The symptoms depend on which branch of the nerve has been damaged and the severity of the injury. The purpose of this paper is to review currently available treatments for dynamic reanimation of a damaged facial nerve, and the goals are a symmetrical and coordinated smile. Careful selection of patients and use of the appropriate surgical technique can have excellent results.

How should we manage oral leukoplakia?

The aim of this article is to review the management of oral leukoplakia. The topics of interest are clinical diagnosis, methods of management and their outcome, factors associated with malignant transformation, prognosis, and clinical follow-up. Global prevalence is estimated to range from 0.5 to 3.4%. The point prevalence is estimated to be 2.6% (95% CI 1.72-2.74) with a reported rate of malignant transformation ranging from 0.13 to 17.5%. Incisional biopsy with scalpel and histopathological examination of the suspicious tissue is still the gold standard for diagnosis. A number of factors such as age, type of lesion, site and size, dysplasia, and DNA content have been associated with increased risk of malignant transformation, but no single reliable biomarker has been shown to be predictive. Various non-surgical and surgical treatments have been reported, but currently there is no consensus on the most appropriate one. Randomised controlled trials for non-surgical treatment show no evidence of effective prevention of malignant transformation and recurrence. Conventional surgery has its own limitations with respect to the size and site of the lesion but laser surgery has shown some encouraging results. There is no universal consensus on the duration or interval of follow-up of patients with the condition.

Europe's forgotten cancer, what is OMF surgery's role?

We outline the principles of management of skin cancers, and highlight the role of oral and maxillofacial surgery.

Malakoplakia of the face: a rare but important diagnosis.

Malakoplakia that presents in the head and neck is rare. We describe a case in a man who presented with a fungating mass in the periauricular skin that was thought to be a malignant tumour. Histopathological and microbiological investigations established a diagnosis of malakoplakia.

Multicentre study of operating time and inpatient stay for orthognathic surgery.

Orthognathic surgery has advanced considerably since its development in the mid-twentieth century, and in most maxillofacial units mandibular and maxillary osteotomies are routine procedures. However, to enable accurate health planning and costing, and to obtain meaningful consent, it is important to have reliable data for duration of operation and inpatient stay. Virtually every aspect of orthognathic surgery has been researched, but we know of no recent studies that have looked specifically at how long the procedures take and how long patients stay in hospital. We retrospectively studied a sample of patients who had had orthognathic operations at six maxillofacial units in the United Kingdom (UK) to assess these measures. We looked at 411 operations which included 139 bilateral sagittal split osteotomies, 53 Le Fort I osteotomies, and 219 bimaxillary osteotomies. The study showed that the mean (SD) operating time for bilateral sagittal split osteotomy is 2h 6min (46min), 1h 54min (45minutes) for Le Fort I osteotomy, and 3h 27min (60min) for bimaxillary osteotomy. The duration of postoperative hospital stay was also measured. Fifty percent of patients spent one night in hospital after bilateral sagittal split osteotomy, whereas 39% and 9% of patients spent two and three nights, respectively. Forty-five percent of patients spent one night in hospital after Le Fort I osteotomy, whereas 34%, 13%, and 2% spent two, three, and four nights, respectively. Forty-one percent of patients spent two nights in hospital after bimaxillary osteotomy, whereas 34%, 21%, and 3% spent one, three, and four nights, respectively. This data provides evidence for national benchmarks.

Synchronous unilateral pleomorphic adenomas in the parotid gland: report of a case.

A 45 year old man presented with a swelling on the right side of his face of 12 months duration. Subsequent magnetic resonance imaging (MRI) scans revealed he did in fact have two discrete tumours of his right parotid gland. Following a superficial parotidectomy and dissection of the deep lobe, histopathology revealed both tumours to be pleomorphic adenomas. We discuss the clinicopathological findings and implications in contemporary surgical management of parotid neoplasms.

Carcinoma of the midline dorsum of the tongue.

We present a case of an 80 year old female who had previously been diagnosed with lichen planus of the tongue dorsum some 10 years previously. Due to a change in the appearance of the lesion a biopsy revealed squamous cell carcinoma of the tongue. We discuss this rare diagnosis in conjunction with the possibility of an association of squamous cell carcinoma and lichen planus.