Is there any benefit in surgery for potentially malignant disorders of the oral cavity?

Oral epithelial dysplasia grading is currently recognised as the most useful prognostic indicator for predicting conversion of potentially malignant disorders of the oral cavity to squamous cell carcinoma. It is also used as a basis for deciding management options. However, the diagnosis of oral epithelial dysplasia is subjective and thus unreliable. Surgery is currently recommended for removal of high-risk lesions; however, the evidence for its success is lacking, and in some cases, there have been reports of increased recurrence of malignancy following surgical excision. Molecular and genetic markers have been identified and show promising results in identifying which potential malignant disorders are at risk of malignant transformation. The current evidence available for prognosis of potential malignant disorders and its treatment is based on observational and retrospective data. No randomised control trials have been conducted to date to assess the efficacy of surgery in oral epithelial dysplasia. Until good quality evidence is available from well-designed randomised control trials, experts still recommend the surgical removal of potential malignant disorders which are regarded as high risk.

Acquisition of microvascular suturing techniques is feasible using objective measures of performance outside of the operating room.

The aim of this study was to determine the effectiveness of a microsurgical simulation course on a group of novice surgeons. The study also aimed to see whether a device to measure manual dexterity (Imperial College Surgical Assessment Device, ICSAD), a global rating scale and an end product assessment tool could be used to objectively measure performance. Thirty surgeons were recruited to take part and were evenly split into novice, intermediate, and expert groups. The novice group took part in a one-week microsurgical course. The assessment of performance was done with the surgeon anastomosing a harvested rat aorta. They were assessed using ICSAD, which records number of hand movements, distance moved by hands and time. The assessment was also video recorded and later watched by two assessors. The procedure performance was scored using a global rating scale and the final anastomosis was scored using an end product assessment tool. The novice surgeons took the assessment at the beginning and at the end of the course. The intermediate and expert group performed the assessment once to use as a comparison to the novice group. By the end of the course the novices performed significantly better in all parameters in comparison to their pre course assessment. The novice group performed similarly to the expert group in their end of course assessment in four out of the five assessment parameters. Simulation using objective measures of performance can be used to effectively to train a group of novice microsurgeons.

Paraumbilical fat graft for the correction of contour deformity following parotidectomy and prevention of Frey syndrome.

Following parotidectomy, patients develop retromandibular hollowing. A case series of patients for whom a free paraumbilical graft was used to reconstruct the parotid bed defect is presented here. This graft is harvested through a supra/sub-umbilical or suprapubic incision. Over-correction of approximately 50% is required due to atrophy and resorption with time. The graft is harvested with the overlying dermis and the graft should not be filleted, as this can cause necrosis. An antibiotic membrane is placed between the graft and the underlying bed and the graft is secured with Vicryl sutures. Since 1997, 130 patients have been treated successfully with this method. Regarding complications, nine patients developed a seroma, four developed a haematoma, two suffered graft liquefaction, and one suffered an infection with frank suppuration and loss of the graft. However, no complications have been noted in the most recent 70 patients. The incidence of Frey syndrome also appeared to be reduced. The paraumbilical fat graft appears to be a successful and reliable method of correcting facial defects after a superficial or total parotidectomy. The graft can also be used to correct temporal defects and has the added advantage of reducing Frey syndrome.

The use of foam sclerotherapy to treat low-flow vascular malformations of the head and neck.

Liquid sclerotherapy, laser and surgery have been used in the treatment of head and neck vascular anomalies with variable success for many years. A multidisciplinary team consisting of plastic surgery, maxillofacial surgery and interventional radiology currently treats such lesions by converting liquid sclerosant into foam. Foam sclerotherapy is currently used successfully to treat varicosities of the lower limbs and in this study, we present four cases in which 3% sodium tetradecyl sulfate has been used to treat low-flow vascular malformations in the head and neck.

Is there a therapeutic role for cranioplasty?

Cranioplasty is often undertaken as a joint neurosurgical and maxillofacial procedure. The principal aims remain to improve cosmesis and to protect the underlying brain. We report two cases of cranioplasty with subsequent improvement in neurological function and discuss the possible therapeutic role of cranioplasty.

Cutaneous sinuses of dental origin.

We report a case of a cutaneous sinus related to a non-vital lower premolar. The case was misdiagnosed by non-dentally trained medical staff and subsequent treatment proved ineffective. Following referral to an Oral and Maxillofacial clinic the correct cause was established. Correct treatment was followed by rapid resolution of signs and symptoms. This case highlights the need for healthcare professionals dealing with such patients to be aware of the dentition as a cause for cutaneous sinuses in the head and neck region. Those professionals not dentally qualified should enquire about dental pain and consider referral to the dental practitioner or a specialist department for further evaluation. Even those with a dental background can be fooled and a through history and examination is paramount, supplemented by special investigations were appropriate.