Anatomical restrictions in the surgical excision of scalp squamous cell carcinomas: does this affect local recurrence and regional nodal metastases?

Squamous cell carcinomas (SCCs) of the skin of the scalp have the potential for regional metastases. Microscopically, clearance may be less than the optimal dimensions. We report 101 SCCs of the scalp treated surgically under the care of a single oral and maxillofacial surgeon. Forty-two of the study patients had deep margins that were clear by less than 2mm, of whom five had margins that involved pericranium±skull. Our study demonstrated a local recurrence rate of 6% and a regional recurrence rate of 7%. All patients presented with relapse of the disease within 18 months of primary surgery. The evidence presented in this study suggests that in SCCs of the scalp, less than ideal surgical margin clearance, entirely due to anatomical restrictions, does not appear to substantially affect regional recurrence, but increases the risk of local recurrence.

The perichondrial cutaneous graft and "flip-flop" flap in facial reconstruction: a series of 41 cases.

Reconstruction of defects of the nose and eyelids can be challenging. The standard surgical options include full thickness skin grafts and local flaps. Another technique that offers a reliable and dimensionally stable one-stage reconstruction is the perichondrial cutaneous graft. The donor site is closed with the postauricular flip-flop flap. We have used these techniques in a series of 41 consecutive patients. Good or excellent aesthetic reconstructions were obtained in 39 cases, with 3 complications: 1 failed graft, and 2 small postauricular wound dehiscences. The perichondrial cutaneous graft can produce excellent cosmetic results when it is used to reconstruct complex defects of the nose and eyelid. Closure of the donor site in the conchal bowl with the flip-flop flap is a reliable and elegant technique.

A "round block" purse-string suture in facial reconstruction after operations for skin cancer surgery.

Removal of skin cancers in the head and neck region usually results in a circular or oval defect, which must be reconstructed immediately using one of several techniques. Larger defects can present a difficult aesthetic problem. The purse-string suture is particularly suited to such large defects where the skin is lax. We report 51 cases where this technique was used in the head and neck region. All defects were considerably reduced in size and some required a small skin graft to complete the reconstruction. Initially many redundant skin folds and considerable local distortion were seen but these improved with time. The technique is simple, inexpensive, and the results are satisfactory in appropriately selected cases. Comprehensive discussion to prepare patients for the gross initial distortion and the long period of retention of the suture makes the procedure acceptable to patients.

Management of first branchial cleft anomalies: report of two cases.

Embryological anomalies of the first branchial apparatus result in rare forms of developmental abnormality of the head and neck. Their presentation may be similar to other conditions and they may easily be overlooked by the unwary when considering the differential diagnosis of a parotid swelling or a neck sinus. Consequently, they may be mismanaged on one or more occasions. We encountered two patients in whom such problems arose and conclude that appropriate investigation and management by a team skill ed in surgery of this region is necessary if a satisfactory outcome is to be achieved.

Orthognathic surgery: the patients' perspective.

It is often thought that patients seek combined orthodontic and surgical treatment for predominantly aesthetic reasons, with functional concerns being secondary. To find out whether patients were more satisfied with appearance than function after treatment, all 165 patients who had orthognathic operations during the 11-year period 1983-94 were sent a questionnaire; 139 responded (84%). Rating on a visual analogue scale showed a high level of satisfaction for both appearance (mean score 6.78) and function (mean score 7.24) (Wilcoxon test, P = 0.046). This indicates that orthognathic surgery is not merely done for aesthetic reasons, but is important when combined with orthodontic treatment in correcting severe malocclusions, which appreciably improve the ability to chew.

Cross-matched blood for major head and neck surgery: an analysis of requirements.

We retrospectively analysed our blood ordering practice; the number of units of cross-matched blood requested was compared with the number transfused, in 70 patients undergoing a total of 82 ablative operations for malignant disease. Patients undergoing neck dissection alone, or excision of tumour with free revascularized flap reconstruction without neck dissection, are unlikely to require blood transfusion. Operations that include excision of tumour with primary closure and neck dissection, excision of tumour with pedicled flap reconstruction and excision of tumour with any form of flap reconstruction and neck dissection in continuity, will probably require transfusion. If atypical antibodies are present in the patient's serum on screening, cross-matched blood should always be available preoperatively. Provided that atypical antibodies are not present and that blood is available within 40 minutes from the blood bank, our results show that it is safe to adopt a policy of blood grouping and saving serum, for patients undergoing neck dissection alone, but cross-matching two or more units of blood for patients who are to have more extensive operations.

Psychological distress in patients attending an oncology clinic after definitive treatment for maxillofacial malignant neoplasia.

Although management of malignant tumours of the mouth and salivary glands generally involves joint consultation with radiotherapists in dedicated oncology clinics, patients' preferences or psychological needs in this environment have not been investigated prospectively, particularly for those on long-term review after treatment. In this prospective study, therefore, psychometric data were collected from a series of 40 consecutive review patients by questionnaires completed on the day of consultation. The following established psychometric tests were used: the Hospital Anxiety and Depression Scale and the General Health Questionnaire. Patients' reactions to duration of consultation, advice given, opportunity to ask questions, and number of staff present were also investigated by a standard structured questionnaire. Forty-seven per cent of patients exhibited symptoms of psychiatric disturbance; 33% were anxious, and 15% were depressed, preoccupation with physical symptoms being the most frequent problem. Explanations of continuing physical symptoms were particularly highly valued because these were often wrongly interpreted by the patients as evidence of recurrence. No patient objected to the presence of students and only one to the presence of more than 10 members of staff. However, 18% requested one-to-one discussion in addition.

Audit of antibiotic policy and wound infection in neck surgery.

Neck surgery on 100 consecutive patients in a unit with an established antibiotic policy was studied. An infection rate of 3% was recorded, comparing well with previously published studies. There were no major sequelae in the infected cases. A policy of no perioperative antibiotics for 'clean' surgery for benign disease, cefuroxime for 'clean' surgery for malignant disease and cefuroxime plus metronidazole for 'clean contaminated' surgery is vindicated.

A simple method for fixation of mandibular fractures.

A useful but underused technique of mandibular fixation is described. Its main advantages over more traditional techniques are that it is easily and rapidly applied, suitable for both children and adults, and generally well tolerated. The method can be employed where only a few teeth are present and in displaced fractures together with an intraosseous buccal plate wire. It is a method that can be recommended for use in nonmaxillofacial units and in areas where only basic equipment and facilities are available.

Trends in the aetiology of maxillofacial fractures in the United Kingdom (1977-1987).

A survey was undertaken to assess changes in the aetiology of maxillofacial fractures in the United Kingdom between 1977 and 1987, using data which had been collected in British departments of Oral and Maxillofacial Surgery. Data were available from units serving 17 million people and included details of patients from a broad spread of rural and urban areas. Analysis of data from the 27 maxillofacial units able to supply details from both 1977 and 1987 showed an overall increase of 20% in numbers of patients with maxillofacial fractures, though a trend towards fewer severe injuries was also a feature over the same period. Numbers of patients injured in road accidents had decreased by 34%, numbers of patients injured in assaults had increased by 47% whilst numbers of patients injured in all other ways had increased by 39%.

Primary bone cyst of the mandibular condyle.

Cysts of the mandibular condyle are rare and their diagnosis and treatment can be difficult. A case in a young girl is described where the histology was that of a solitary bone cyst but the presentation and behaviour more closely resembled an aneurysmal bone cyst.

Parotid gland malignancy presenting as temporomandibular joint pain or dysfunction.

Temporomandibular joint pain and dysfunction is a common complaint and a frequent cause of referral to oral and maxillofacial surgeons. The importance of considering malignant disease in the differential diagnosis is illustrated by the following cases of parotid gland neoplasia which were referred as temporomandibular joint dysfunction.

Metastatic renal clear cell carcinoma of the jaws. Two cases illustrating clinical and pathological diagnostic problems.

Two cases of metastatic renal clear cell carcinomas of the mandible are presented in which the jaw symptoms preceded the discovery of the primary lesions. Their presentation mimicked vascular abnormalities both clinically and on special investigations and both required biopsy, one of which was a major excision, for diagnosis. The histological differential diagnosis of metastatic renal clear cell carcinoma from other clear cell tumours arising in the orofacial tissues can also be difficult, often requiring specialised knowledge and techniques. These points illustrate that the differential diagnosis of a pulsatile soft tissue jaw tumour developing below intact mucosa and eroding bone, should include metastatic tumour as well as vascular anomaly, vasoformative tumour, extra nodal lymphoma and primary bone tumour.

Carbon fibre reinforced osteotomy wafers.

The incorporation of carbon fibres into acrylic occlusal osteotomy wafers enhances their strength, sufficient to allow a considerable reduction in size and thickness. The method and its application are briefly described.