A Comparison of Skin Graft Techniques with and without Plaster Back Slab Dressing in Reducing Donor Site Morbidity in Radial Forearm Free Flap Surgery - A Retrospective Study.

Introduction: The radial forearm free flap (RFFF) is a commonly used free flap for the reconstruction of orofacial defects because of its versatility and reliability. The donor site is closed with either split or full-thickness skin graft, and one of the common donor site morbidities is skin graft failure. Various techniques to minimise skin graft failure were reported, and we compared the skin graft techniques with and without plaster back slab dressing in the radial forearm donor site. Materials and Methods: This is a retrospective study of 75 patients who had RFFF for reconstruction of oral cavity cancer at two different tertiary teaching hospitals in the United Kingdom between April 2015 and March 2020. Thirty-nine patients from Hospital one had volar back slap, bolster dressing and crepe bandage. In contrast, 36 patients from Hospital two had only pressure dressing without a back slab. Results: The mean age of the study population was 60.65 (P = 0.274). In both groups, two patients had donor site complications. However, there was no significant difference in the donor site skin graft complications with a P = 0.662. Discussion: There was no evidence in the literature to support an ideal bandage for skin graft at the RFFF donor site. Our comparison of two techniques of skin graft dressings with and without back slap did not show any difference in the skin graft take, and the volar back slab did not add any additional benefits. The simple use of foam as a bolster dressing without a back slab is ideal for the radial forearm free flap donor site.

Reconstructing the Nasal Tip After a Human Bite: A Challenge for the Reconstructive Surgeon.

BACKGROUND: Human facial bites are uncommon and usually cause a wound that presents major challenges for the reconstructive surgeon. PURPOSE: The purpose of this study is to present the advantages and disadvantages of using a superiorly based interpolated nasolabial flap for reconstruction of a nasal tip defect. METHODS: We present a case of serious injury of the nasal tip as a result of a human bite. Early maxillofacial surgical intervention resulted in restoration of the facial anatomy and function of the structures involved. RESULTS AND CONCLUSION: We present a serious mutilating injury of the tip of the nose in a young patient as a result of a human bite. These injuries can be rather destructive and cause a facial defect which may have a significant adverse psychological impact on the patient. Because of the proximity and the skin colour match of the melolabial fold to the nose, nasolabial flaps are a very attractive and reliable reconstructive choice for nasal tip defects. The relative advantages over other reconstructive options and the limitations of an interpolated superiorly based nasolabial flap are discussed. The elaborated use of a nasolabial peninsular pedicled skin flap may deliver a very satisfactory outcome from a functional and cosmetic point of view.

Oral Cancer Treatment Through the Ages: Part 2.

PURPOSE: Understanding how oral cancer treatment evolved can pave the way for future management. The literature holds an expansive collection of historical findings regarding oral cancer, yet the authors were unable to find a comprehensive review of oral cancer treatment throughout the ages. MATERIALS: A thorough literature review was carried out using multiple scientific databases and languages, as well as examination of historical archives. Articles were included for their relevance and their findings were assimilated. RESULTS: Part two of this article considers the development of specific surgical concepts relating to head and neck cancer over the previous two centuries, including neck dissection and reconstruction, as well as exploration of non-surgical cancer therapies. CONCLUSION: This paper demonstrates historical landmarks made in oral cancer treatment and the prominent figures who pioneered them, confirming that head and neck cancer surgeons of today have valuable lessons to learn from their previous counterparts.

Oral Cancer Treatment Through the Ages: Part 1.

PURPOSE: Understanding how oral cancer treatment evolved can pave the way for future management. The literature holds an expansive collection of historical findings regarding oral cancer, yet the authors were unable to find a comprehensive review of oral cancer treatment throughout the ages. METHODS: A thorough literature review was carried out using multiple scientific databases and languages, as well as examination of historical archives. Articles were included for their relevance and their findings were assimilated. RESULTS: Part one of this article reveals a rich history of oral cancer treatment commencing in ancient times, with discussion of Egyptian, Greek and Roman practices, and travelling through the age of discovery to arrive at the dawn of scientific medicine in the 19th century. CONCLUSION: Part one demonstrates how fundamental concepts of oral cancer were discovered, and the significant impact medical innovation had on the success of oral cancer treatment.

Management of oral and maxillofacial infections in a regional unit: a seven day service?

The provision of a seven-day National Health Service (NHS) has been proposed as a means to halt the weekend delay in treatment that has been described in some studies. We tested the emergency services in the Oral and Maxillofacial Surgery Department at Northampton General Hospital to find out whether they provided a seven-day service. Data were collected prospectively and retrospectively for all patients admitted to the Oral and Maxillofacial Department at Northampton General Hospital with infections of the head and neck during a period of 29months (January 2014-May 2016). Duration of hospital stay and waiting time for operation were compared for weekday and weekend admissions to find out if there were changes in either outcomes or waiting times. The severity of infection between the two periods was also assessed using the serum C reactive protein (CRP) concentration as a marker. A total of 293 patients were admitted with head and neck infections, and the mean (range) duration of stay for those admitted on weekdays was 3 (1-14) days and for patients admitted at a weekend was 3 (1-17) days (p=0.14). However, the waiting times for operation were significantly longer during the week (mean (range) 0.6 (0-8) days) than at the weekend (0.5 (0-3) days, p=0.04). We know of no other published studies about provision of a seven-day service in oral and maxillofacial surgery. Our results show that we are already working to that standard, and this raises the question of whether any changes are required to current practice in the NHS, with their associated costs and upheaval.

Head and neck nonmelanoma cutaneous malignancy treatment in a skin cancer referral center.

OBJECTIVE: The purpose of our study was to determine the level of accuracy provided by clinical diagnosis in head and neck cutaneous malignancy as confirmed by histopathologic examination of the specimen in a skin cancer referral center. Positive predictive value was selected as a reliable measure of diagnostic accuracy. We also aimed to audit our surgical outcomes and record and present the completeness of excision, the rates of recurrence and metastasis, and the reconstructive method. STUDY DESIGN: We reviewed the electronic charts of 867 consecutive patients with skin tumors and calculated the positive and negative predictive values of clinical diagnosis. RESULTS: The positive predictive value was 91% for basal cell carcinoma and 78.8% for squamous cell carcinoma. Of the 178 histologically diagnosed squamous cell carcinomas, 15 were metastatic. CONCLUSIONS: In a skin cancer referral center, expert clinical diagnosis may safely overcome the need for preoperative biopsy. Relying on clinical diagnosis to formalize a treatment plan for head and neck nonmelanoma skin cancer is safe and efficient. This is more reliable in cases of basal cell carcinoma compared with suspected squamous cell carcinomas.

Management of Self-Harm Injuries in the Maxillofacial Region: A Report of 2 Cases and Review of the Literature.

Clinicians face numerous challenges when managing psychiatric patients who self-inflict injuries within the maxillofacial region. In addition to a complex clinical examination, there are both surgical and psychiatric factors to consider, such as the risk of damaging vital structures, the exacerbation of the patient's psychiatric status, and the long-term psychosocial and esthetic sequelae. We present 2 cases of adolescents who repeatedly self-inflicted wounds and/or inserted foreign bodies (FBs) into the face, scalp, and neck. The different treatment modalities were based on full evaluation of the patient's clinical, medical, and diagnostic test findings coupled with a psychiatric assessment. The decision for conservative management or surgical intervention was made according to the presence and location of the FBs, degree of hemorrhage, signs and symptoms of infection, and unpleasant scars that could lead to long-term psychological impairment. In most cases, the FBs were removed and the wounds were toileted and closed under local or general anesthesia. We advocate a holistic approach via a multidisciplinary team, which is deemed essential to provide the highest quality of care for patients to reduce the risk of further relapses. Lastly, a satisfactory esthetic outcome is always paramount to achieve long-term psychological and physical welfare.

Among Patients Undergoing Ablative Treatment for Oral Cancer, Does the Provision of Oral Rehabilitation Improve the Quality of Life? A Review of the Current Literature.

PURPOSE: The impact of oral cancer and its treatment is well documented; therefore, oral rehabilitation (OH; eg, with prosthetics, osseointegrated implants, etc) can be indicated to restore some level of form, function, and well-being. The purpose of this study was to review the current literature and evaluate the impact of OH on quality of life (QoL) after ablative surgery. MATERIALS AND METHODS: A systematic literature search was conducted using EMBASE, MEDLINE, and PsychINFO. The study population was composed of all articles published from 2000 to 2015. To be included, studies had to use validated, specific head and neck QoL measurements (European Organization for Research and Treatment of Cancer QoL Head and Neck Module or University of Washington QoL Questionnaire). Only 8 articles met these inclusion criteria. In this review, OH was the primary predictor variable and QoL was the primary outcome variable. RESULTS: The 8 articles reviewed used a range of designs, including 1 randomized controlled trial, 3 prospective cohort studies, 3 case series, and 1 single-measurement cross-sectional descriptive study. Sample sizes were small (n = 26 to 102), and there was limited randomization and control of intervention and comparator groups. The overall level of evidence was weak. All studies showed a link between OH and QoL, but the results varied in significance (P < .01 to P = .95). CONCLUSION: Overall, there appears to be improvement in QoL to varying degrees after OH. However, a more systematic use of QoL measurements is needed before any definitive conclusions can be drawn.

A study to investigate changes in the microbiology and antibiotic sensitivity of head and neck space infections.

BACKGROUND AND OBJECTIVES: Due to a growing concern regarding antibiotic resistance, we aim to investigate if there has been a change in the microbiology and antibiotic sensitivity of head and neck space infections over the last 30-40 years. PATIENTS AND METHOD: A retrospective study was undertaken of 100 patients admitted for inpatient management of head and neck infections. A literature search of the data from the last 30-40 years was performed for comparative purposes. RESULTS: There were 57 male and 43 female patients (average age 37 years). The most common infections were of odontogenic (67) and skin (14) origin. The submandibular (69%) and buccal (60%) spaces were more commonly involved. Sixty-six cases had multiple space involvement. Seventy-eight cases had swabs taken for microbiology culture and sensitivity, with 67 (85.9%) having microorganisms isolated. Fifty (74.6%) of these were aerobic infections and 17 (25.4%) anaerobic. Bacteria were isolated in 64 (95.5%) cultures. 70.1% of the bacteria were gram positive. Gram-positive cocci were isolated in 65.4% of cultures. The most common bacteria isolated were streptococcus. 73.4% of the bacteria were sensitive to amoxicillin and 81.3% sensitive to both amoxicillin and metronidazole. 15.6% were resistant to penicillin, which were Staphylococcus aureus from skin infections. CONCLUSION: Comparing our results with a review of the literature shows no significant change in the microbiology and antibiotic sensitivity of odontogenic head and neck infections over the last 30-40 years. Amoxicillin is still shown to be an effective empirical drug for odontogenic head and neck infections.

The clinical relevance of microbiology specimens in head and neck space infections of odontogenic origin.

It is common surgical practice to take a specimen for microbial culture and sensitivity when incising and draining infections of odontogenic origin in the head and neck. We aimed to find out if routine testing has any therapeutic value. We retrospectively studied 90 patients (57 male and 33 female) admitted to Northampton General Hospital for treatment of odontogenic infections, and reviewed admission details, antimicrobial treatment, microbiological findings and their sensitivity or resistance, and complications. Specimens were sent from 72 (80%) patients of which 61 (85%) were infected. The most commonly isolated organism was Streptococcus viridans. Interim reports were published after a mean of 3 days (range 1-4), and 94% of patients were discharged within a mean of 2 days (range 0-9) postoperatively. Almost 95% of patients were discharged before results were available, and there were no reported complications. We therefore suggest that microbial culture has little therapeutic value in the management of these patients. With culture and sensitivity tests costing £25 - £30, omission of this practice in the case of uncomplicated (single tissue space) odontogenic infections could save resources in the National Health Service without affecting the care of patients.

Microbiological examination and antibiotic sensitivity of infections in the head and neck. Has anything changed?

Because of the growing concern about antibiotic resistance, we aimed to investigate whether the microbiological picture and antibiotic sensitivity of infections in the head and neck have changed in the last 30-40 years. We retrospectively studied 150 patients admitted for inpatient treatment of infections in the head and neck, and searched published reports from the last 30 - 40 years for comparison. There were 85 male and 65 female patients (mean age 39 years, range 1-95). Most infections originated from the teeth (n = 111) and skin (n = 16), and the submandibular (69%) and buccal (67%) spaces were involved most often. Multiple spaces were involved in 94 patients. Swabs were taken for culture and sensitivity in 102 cases, and microorganisms were isolated in 91 (89%), of which 67 (74%) were aerobic infections and 24 (26%) were anaerobic. Bacteria were isolated in 87 (96%) cultures of which 60 (69%) were Gram-positive. Gram-positive cocci were isolated in 62% of cultures. The most common bacteria isolated were streptococci. Seventy percent of the bacteria were sensitive to amoxicillin and 84% to amoxicillin and metronidazole; 14% (Staphylococcus aureus from infections of the skin) were resistant to penicillin. A comparison of our results with those found in previous reports shows no significant change in the microbiological picture and antibiotic sensitivity of odontogenic infections in the head and neck over the last 30 - 40 years. Amoxicillin still treats these infections effectively.

Changes in demographics of patients undergoing third molar surgery in a hospital setting between 1994 and 2012 and the influence of the National Institute for Health and Care Excellence guidelines.

PURPOSE: To evaluate changes in demographics of patients undergoing third molar surgery (TMS). MATERIALS AND METHODS: This retrospective study used the World Health Organization's International Classification of Diseases, Tenth Revision codes F091 and F093 to generate data on patients (N = 10,447) undergoing TMS from 1994 through 2012 at the authors' institution. The data is described in terms of mean, median, mode and were analyzed using analysis of variance and the Student t test. RESULTS: Fewer female patients were treated after implementation of the National Institute for Health and Care Excellence (NICE) guidelines. The mean patient age increased from 29 years (1994) to 36 years (2012), with the median increasing from 27 to 31 years (P < .001). There was a significant difference in the age of patients treated before and after the introduction of the NICE guidelines (P < .001). CONCLUSIONS: The increase in age appears to be influenced by the NICE guidelines. Given the increased risk of complications in older patients, consideration should be given to the removal of a similarly impacted, asymptomatic, contralateral third molar without obvious radiographic relation to the inferior dental canal, if a young patient is undergoing general anesthesia.

Leiomyosarcoma of the tongue with multiple metastases: a case report and review of literature.

Leiomyosarcoma of the tongue is an extremely rare malignant mesenchymal neoplasm and only 25 cases have been described in the English-language literature, 22 of which were primary lesions. A case is presented of a 54-year-old female patient diagnosed with primary leiomyosarcoma of the tongue with lung and multiple soft tissue metastases. This case is especially unusual because widespread soft tissue metastases resulted, involving the lung and skeletal muscle in 3 separate sites. Unfortunately, curative treatment was not possible. Chemotherapy using a combination of ifosfamide and doxorubicin was, therefore, provided as palliation, with a good response after a 3-week cycle of therapy. Currently available literature on primary and secondary leiomyosarcoma of the tongue was reviewed for a better understanding of this rare mesenchymal neoplasm. To the investigators' knowledge, there are no other reported cases in the literature that have previously been managed with chemotherapy alone.

Multiple synchronous cutaneous squamous cell carcinomas of the head and neck: a case report.

Cutaneous squamous cell carcinoma (CSCC) is the second most common skin cancer in whites, with a relatively low metastatic potential and a general amenability to local treatment. However, patients with high-risk CSCC is more likely to develop local and distant metastases that could be fatal. We present a case of an 82-year-old white man who initially presented with a solitary squamous cell carcinoma (SCC) of the scalp and subsequently developed more than 40 primary CSCC lesions and metastases to the right parotid lymph nodes and thoracic vertebrae within 14 months of the primary diagnosis. Our report highlights the challenges that aggressive SCC can bring in the elderly population and describes some of the treatment modalities of CSCC.

Mandibular fracture in a child resulting from a dog attack: a case report.

Dog attacks are extremely frequent and are thought to be responsible for an average of 250,000 minor injuries and emergency unit attendances each year. Children in particular are more likely to experience dog-bite injuries with 5-9-year olds most susceptible. The majority of injuries are to the head region, with the lips, cheeks, and nose often affected. Most injuries experienced are confined to the soft tissues; nevertheless, maxillofacial fracture is a potential albeit rare complication. The incidence of facial fractures in relation to dog bites is unknown; however, some have estimated that facial fractures could occur in 5% of dog attacks. However mandibular fracture following a dog bite is extremely rare, with review of the literature only identifying three cases. We present a further case in which a five-year-old sustained numerous soft-tissue lacerations to the face and hand, together with fracture of the mandibular symphysis following a dog attack. The fracture was successfully repaired using open reduction and internal fixation with titanium plates and screws. The case emphasises that although maxillofacial fracture is rare, it may occur following a dog bite and that thorough and systematic examination of the facial skeleton is crucial to exclude the presence of such injuries.

Protection of the patient's hair with a standard swimming cap during major maxillofacial operations.

During maxillofacial operations there is inevitably a lot of blood shed, which soils the patients hair. The cleaning of blood stained hair is a laborious and time-consuming task, particularly after a long operation. To prevent this we advocate using a standard swimming cap to protect the hair.