Extensive bony metastases from facial metatypical basal cell carcinoma: a case report.

Metastatic basal cell carcinoma (BCC) is rare. We treated a 44-year-old woman with an extended facial metatypical BCC in whom staging showed no local or distant metastases, but one year after resection, we diagnosed a local recurrence. Re-staging, using a fludeoxyglucose positron emission tomography-computed tomogram, (FDG PET-CT) showed suspected accumulations of FDG in the whole axial skeleton. Bone punch biopsy examination confirmed extensive bony metastases, and after resection of the relapse, we began her on a systemic treatment with a Hedgehog-pathway inhibitor (vismodegib), which resulted in partial remission.

Is there an ideal way to close the donor site of radial forearm free flaps?

Radial forearm free flaps (RFFF) are the "workhorse" of reconstructive head and neck surgery, but have considerable morbidity at the donor site. The aim of this study was to review current publications about the incidence and type of morbidity and the different techniques used for closure of the site. We screened the MEDLINE database to find relevant papers using the terms "RFFF head and neck" and "RFFF donor site". Abstracts were filtered, and the full texts studied carefully. We found 1056 publications during the period 1982-2017 of which 389 were studied in full, and 39 studies were finally included in the review. We found four main methods of closure of the donor site: full-thickness skin grafts (FTSG); split-thickness skin grafts (STSG); modified techniques for raising the flap and closure of the wound by local flaps; and others (such as allografts, expanders, and vacuum bandages). For STSG and FTSG the preparation of the donor site seems to be a relevant factor. Special attention should be paid to the coverage of the flexor tendons. FTSG give better aesthetic results than STSG. Closure by local flaps may achieve primary closure of the donor site without a third surgical site, but the techniques are limited by the amount of tissue required at the site of the defect. The most common side effects are disorders of wound healing such as exposed tendons. To avoid exposure of the tendons, flexor tendons should be covered with muscle bellies when STSG are used. It is still not clear whether many other reported side effects (such as impairment of sensitivity) are induced by raising the flap or closing the donor site. There is an argument for closure of individual donor sites independently, but there is no one method of closure for all donor sites, because each has its specific disadvantages and complications.

Optical coherence tomography characteristics of different types of big bubbles seen in deep anterior lamellar keratoplasty by the big bubble technique.

PurposeTo define optical coherence tomography (OCT) characteristics of type-1, type-2, and mixed big bubbles (BB) seen in deep anterior lamellar keratoplasty.MethodsHuman sclero-corneal discs were obtained from UK (30) and Canada (16) eye banks. Air was injected into corneal stroma until a BB formed. UK samples were fixed in formalin before scanning with Fourier-domain (FD-OCT). One pair of each type of BB was scanned fresh. All BB obtained from Canada were scanned fresh with time-domain (TD-OCT). For each OCT machine used, type-1 BB from which Descemets membrane (DM) was partially peeled, were also scanned. The morphological characteristics of the scans were studied.ResultsFD-OCT of the posterior wall of type-1 (Dua's layer (DL) with DM) and type-2 BB (DM alone) both revealed a double-contour hyper-reflective curvilinear image with a hypo-reflective zone in between. The anterior line of type-2 BB was thinner than that seen with type-1 BB. In mixed BB, FD-OCT showed two separate curvilinear images. The anterior image was a single hyper-reflective line (DL), whereas the posterior image, representing the posterior wall of type-2 BB (DM) was made of two hyper-reflective lines with a dark space in between. TD-OCT images were similar with less defined component lines, but the entire extent of the BB could be visualised.ConclusionOn OCT examination the DM and DL present distinct features, which can help identify type-1, type-2, and mixed BB. These characteristics will help corneal surgeons interpret intraoperative OCT during lamellar corneal surgery.

[News in Retinal Imaging]. / Neuerungen in der retinalen Bildgebung.

New developments in retinal imaging have revolutionised ophthalmology in recent years. In particular, optical coherence tomography (OCT) provides highly resolved and well reproducible images and has rung in a new era in ophthalmological imaging. The technology was introduced in the early 1990 s, and has rapidly developed. There have been improvements in resolution, sensitivity and processing speed. There have also been developments in functional processing. OCT angiography is the first application in routine clinical work.

[Ocular perfusion pressure and its relevance for glaucoma]. / Der okuläre Perfusionsdruck und seine Bedeutung für das Glaukom.

Ocular perfusion pressure is defined as the difference between arterial and venous pressure in ocular vessels. In practice, mean arterial pressure is used to substitute for arterial pressure in ocular vessels while intraocular pressure gives an estimate for ocular venous pressure. This results in a value that is easy to calculate and which is of importance since several studies have shown that it is correlated to the prevalence, incidence and progression of primary open angle glaucoma. Today, ocular perfusion pressure is used to estimate individual risks. Since no target value for ocular perfusion pressure can be defined, direct therapeutic intervention is difficult. Still, it has to be kept in mind that lowering intraocular pressure automatically leads to an increase in ocular perfusion pressure. The present article also points out problems and limitations in the concept of ocular perfusion pressure and suggests possible solutions for these problems in the future.

Imaging of retinal ganglion cells in glaucoma: pitfalls and challenges.

Imaging has gained a key role in modern glaucoma management. Traditionally, interest was directed toward the appearance of the optic nerve head and the retinal nerve fiber layer. With the improvement of the resolution of optical coherence tomography, the ganglion cell complex has also become routinely accessible in the clinic. Further advances have been made in understanding the structure-function relationship in glaucoma. Nevertheless, direct imaging of the retinal ganglion cells in glaucoma would be advantageous. With the currently used techniques, this goal cannot be achieved, because the transversal resolution is limited by aberrations of the eye. The use of adaptive optics has significantly improved transversal resolution, and the imaging of several cell types including cones and astrocytes has become possible. Imaging of retinal ganglion cells, however, still remains a problem, because of the transparency of these cells. However, the visualization of retinal ganglion cells and their dendrites has been achieved in animal models. Furthermore, attempts have been made to visualize the apoptosis of retinal ganglion cells in vivo. Implementation of these techniques in clinical practice will probably improve glaucoma care and facilitate the development of neuroprotective strategies.

Ocular perfusion pressure and ocular blood flow in glaucoma.

Glaucoma is a progressive optic neuropathy of unknown origin. It has been hypothesized that a vascular component is involved in glaucoma pathophysiology. This hypothesis has gained support from studies showing that reduced ocular perfusion pressure is a risk factor for the disease. The exact nature of the involvement is, however, still a matter of debate. Based on recent evidence we propose a model including primary and secondary insults in glaucoma. The primary insult appears to happen at the optic nerve head. Increased intraocular pressure and ischemia at the post-laminar optic nerve head affects retinal ganglion cell axons. Modulating factors are the biomechanical properties of the tissues and cerebrospinal fluid pressure. After this primary insult retinal ganglion cells function at a reduced energy level and are sensitive to secondary insults. These secondary insults may happen if ocular perfusion pressure falls below the lower limit of autoregulation or if neurovascular coupling fails. Evidence for both faulty autoregulation and reduced hyperemic response to neuronal stimulation has been provided in glaucoma patients. The mechanisms appear to involve vascular endothelial dysfunction and impaired astrocyte-vessel signaling. A more detailed understanding of these pathways is required to direct neuroprotective strategies via the neurovascular pathway.

A novel, microscope based, non-invasive laser Doppler flowmeter for choroidal blood flow assessment.

Impaired ocular blood flow is involved in the pathogenesis of numerous ocular diseases like glaucoma or AMD. The purpose of the present study was to introduce and validate a novel, microscope based, non-invasive Laser Doppler Flowmeter (NI-LDF) for measurement of blood flow in the choroid. The custom made NI-LDF was compared with a commercial fiber optic based laser Doppler flowmeter (Perimed PF4000). Linearity and stability of the NI-LDF were assessed in a silastic tubing model (i.d. 0.3 mm) at different flow rates (range 0.4-3 ml/h). In a rabbit model continuous choroidal blood flow measurements were performed with both instruments simultaneously. During blood flow measurements ocular perfusion pressure was changed by manipulations of intraocular pressure via intravitreal saline infusions. The NI-LDF measurement correlated linearly to intraluminal flow rates in the perfused tubing model (r = 0.99, p < 0.05) and remained stable during a 1 h measurement at a constant flow rate. Rabbit choroidal blood flow measured by the PF4000 and the NI-LDF linearly correlated with each other over the entire measurement range (r = 0.99, y = x∗1.01-12.35 P.U., p < 0.001). In conclusion, the NI-LDF provides valid, semi quantitative measurements of capillary blood flow in comparison to an established LDF instrument and is suitable for measurements at the posterior pole of the eye.

Microbiological stability of biodiesel-diesel-mixtures.

The biodegradation of rapeseed oil methyl ester (RME) in pure and in mixtures with diesel fuel was investigated. Higher ratio of diesel fuel in the mixture resulted in higher count of bacteria. Fungal growth was advanced by higher RME contents. The growth of microorganisms gained from soil was strongest in B 20 (20 vol.% biodiesel and 80 vol.% diesel fuel) mixtures followed by B 5 (5 vol.% biodiesel and 95 vol.% diesel fuel) mixtures and pure RME. The formation of free fatty acids (FFA) in the RME sample was measured according to DIN EN 14214. The content of FFA in inoculated RME samples rose from 0.08 mass% to 0.344 mass% at the beginning. The oxidation stability of inoculated samples of B 20, B 5 and pure RME decreased faster than the oxidation stability of blank samples. An optical evaluation showed the formation of turbidity. Partly, the formation of sediment was observed, especially in B 20 and B 5 samples.

Catenin expression in T1/2 carcinomas of the floor of the mouth.

Reduction of the expression of catenin is a crucial step in the pathogenesis, progression and prognosis of many epithelial cancers including squamous cell carcinomas (SCCs). Catenin expression in oral carcinomas was evaluated in relation to clinico-pathological features in order to determine its value as a prognostic marker. Eighty-five patients with histologically proven T1/2 squamous cell carcinoma of the oral floor who underwent surgical treatment were eligible for the study. A tissue microarray consisting of multiple representative tissue cores of each carcinoma was composed. The expression levels of alpha, beta and gamma-catenins were determined immunohistologically. Correlation between clinical features and the expression of catenin proteins was evaluated statistically using Kaplan-Meier curves, log-rank tests and chi(2)-tests. Loss of alpha-catenin expression in carcinoma of the floor of the mouth correlated significantly with poor prognosis (P=0.05). Conversely, significantly reduced rates of lymph-node metastases were observed in alpha- and beta-catenin-positive T1 and T2 SCCs. Loss of gamma-catenin expression indicated a reduced survival rate in nodal-negative tumours (P=0.02). Catenin expression in carcinomas of the floor of the mouth seems to be a predictive parameter in the prognosis of T1 and T2 SSCs.

Aneurysmal bone cyst of the mandible: a case report.

The case of a 6-year-old boy with a rapid growing mass in the right angle of the mandible that clinically and radiographically resembled a malignant lesion is presented. The biopsy specimen showed an aneurysmal bone cyst. The patient was treated surgically via extraoral approach including immediate mandibular reconstruction with with iliac crest bone. The literature is briefly reviewed.

[CleftData. Program for minimal documentation of lip-jaw-palate clefts]. / CleftData. Programm zur Minimaldokumentation der LKG-Spalten.

BACKGROUND: The aim of the German Study Group on Cleft Lip and Palate-Craniofacial Deformities is to develop a precise system for documentation of cleft lip and palate patients which is suitable for use in PC-databases. DOCUMENTATION: In cooperation with the medical disciplines involved in the therapy such as otolaryngology, oral and maxillofacial surgery, orthodontics and speech therapy a system of documentation was developed with regard to the international classification of diseases (ICD) and the operating procedures system (OPS). Malformations are classified with the LAHS coding system. In addition to this concept of minimal documentation photographic images in standardized projections are stored. Furthermore, each operative procedure is documented by its date and the anatomic region of malformation treated without details of operative methods or descriptions of other procedures. SOFTWARE: On behalf of the German Study Group on Cleft Lip and Palate a software to meet these purposes was developed called CleftData. Based on a relational Access database it is equipped with SQL connectivity enabling its use on all hard- and software-systems.

[Surgical procedures in mouth, jaw and facial surgery in Thiel embalmed body donors]. / Operative Verfahren der Mund-, Kiefer- und Gesichtschirurgie an nach Thiel fixierten Körperspenden.

METHODS: This study investigates whether human cadavers embalmed according to Thiel can be used for research and education in oral-maxillo-facial surgery. Different surgical approaches were tested on such cadavers. The usability of the specimen was judged jointly by anatomists and surgeons. Color, structure, and consistency of the different tissues were comparable to vital conditions. Thiel's embalming technique applied to human cadavers provides an optimal basis for research and for basic and postgraduate medical education.

[Evaluating form and function of the nose after open rhinoplasty in unilateral lip-maxillopalatal clefts]. / Beurteilung von Form und Funktion der Nase nach offener Rhinoplastik bei einseitigen Lippen-Kiefer-Gaumen-Spalten.

Secondary septorhinoplasty in patients with cleft lip and palate (CLP) is performed to improve nasal form and function. The purpose of this study was to compare the initial findings and the surgical outcome in 30 patients with unilateral CLP. Open rhinoplasty was carried out to correct nasal deformity. Nasal soft tissue analysis was done by measurement of standardized raster photographs of the nose and lateral teleradiography. Deviations from the ideal form regarding nasal symmetry, nasal width, and alar base line were determined. The nasal profile was assessed by measuring the nasofacial and nasolabial angle, the angle between the upper lip and the Frankfurt horizontal plane (FHP), and the angle between the columella and the FHP. Nasal patency was evaluated by rhinomanometry. The overall flow (cm3/s) was determined and the flow of the cleft side and non-cleft side compared. Evaluations were made immediately before and 6 months after surgery. In the frontal plane, nasal symmetry was significantly improved and the alar form adjusted. The deep position of the columella was corrected. The acute nasofacial angle and the drooping ala were not significantly improved. An increase in the overall flow and correction of the quotient cleft/non-cleft side was achieved by the surgical procedure. In this study, aesthetically and functionally relevant findings were objectified and can be used for quality control.

Clinical relevance of erbB-1 and -2 oncogenes in oral carcinomas.

To gain a better understanding of molecular changes in oral squamous cell carcinomas, we tested fresh tumour specimens from 110 patients for erbB-1 and -2 oncogene aberrations using the competitive differential polymerase chain reaction. The significance of established tumour characteristics such as TNM stage, differentiation and oncogene aberrations for tumour progression were analyzed. ErbB-2 amplification with a gene copy number > 1.6 in tumour tissue and erbB-1 deletion with a gene copy number < 0.4 in tumour-surrounding mucosa are of clinical relevance and indicate an early tumour recurrence or metastasis (p < 0.05). In T1/T2 tumours an erbB-2 gene dosage study allows differentiation between tumours with high or low risk for early progression. In a multivariate statistical analysis T stage (p < 0.01) and erbB-2 amplification in tumour material (p < 0.05) were independent prognostic variables.

Chemosensitivity testing of oral cancer cells treated with a p185neu-specific agent.

The amplification and overexpression of the erbB-2 oncogene and its involvement in tumorigenesis makes this receptor an appropriate target for specific agents directed towards tumor cells. The purpose of this study was to evaluate the in vitro effect of the bacterially produced recombinant immunotoxin scFv(FRP5)-ETA on the protein synthesis and adenosine triphosphate (ATP) reduction in oral squamous cell carcinoma (OSCC) cells. This agent recognizes the erbB-2 receptor and inhibits protein synthesis in receptor-overexpressing cells. OSCC cells were selected for this study, and amplification and expression levels of the erbB-2 receptor were determined. Cell suspensions were cultured for 6 d with various concentrations of scFv(FRP5)-ETA (1-1000 ng/ml). A431 and MDA-MB468 cell lines were used as controls. Chemosensibility of tumor cells was measured by [3H]leucine incorporation assay and by an ATP luminescence assay. In OSCC cells with amplification and overexpression of erbB-2 inhibition, up to 92% of protein synthesis and 90% of ATP reduction was observed when cells were exposed to 1,000 ng/ml immunotoxin. In OSCC cells showing a deletion of erbB-2 and in erbB-2-negative MDA-MB468 cells, protein synthesis was inhibited by 22% and 8%, respectively. These results indicate that the effectiveness of a recombinant immunotoxin targeting erbB-2 receptors in OSCC cells depends on the level of erbB-2 amplification and expression, that it is highly specific for tumor cells expressing these receptors, and that a dose-dependency can be observed.

Rehabilitation with dental implants of oral cancer patients.

The aim of this study was to evaluate the risks and complications of rehabilitation with dental implants after tumour surgery and radiotherapy. After a disease-free survival of 18 months, 29 patients who had undergone oral cancer treatment were rehabilitated with dental implants. The complication rate of implants in irradiated, non-irradiated and grafted bone was analyzed at least 3 years after implant placement. In the healing period, 28.6% of the implants in irradiated bone and 8.4% in non-irradiated bone showed soft tissue complications. Of the implants, 26.7% in the irradiated and 14.7% in the non-irradiated mandibular bone were lost in the first 36 months after placement. Thirty-one point two percent of implants inserted in non-irradiated bone grafts were affected and did not osseointegrate. Of 109 inserted implants, 70 were suitable for prosthetic rehabilitation. There are high complication rates after implant placement in oral cancer patients. Irradiation adversely affects soft tissue healing. Osseointegration is frequently disturbed, especially when implants were placed in non-vascularized bone grafts.

[Regeneration of mouth mucosa in the buccal plane following graft procurement for reconstruction of bulbar urethral stenoses]. / Regeneration der Mundschleimhaut im Planum buccale nach Entnahme zur Rekonstruktion von bulbären Urethrastenosen.

The use of free buccal mucosal grafts in the treatment of urethral strictures has become very popular. In 1996 and 1997 we harvested free buccal mucosal grafts up to 7 cm long and 4 cm wide from 12 patients who underwent urologic surgery for urethral strictures. In 2 patients the donor site was closed primarily by sutures. Four patients received Lyodura and another 4 patients received Syspurderm as temporary wound coverage. In 2 patients Ethisorp patches were used. Donor site pain was judged by the patients on a visual analogue scale during the first postoperative week. The 2 patients who received the Ethisorp patches complained of more intense pain, probably caused by the rigidity of the material. In all patients regeneration of the donor site mucosa was good. During the follow-up period of 4-18 months scar formation at the lower vestibulum was noticed as the only complication. Permanent limitation of mouth opening, stenosis of the parotid duct or hypesthesia did not occur.