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BACKGROUND: Seroma formation remains a significant problem in abdominoplasty procedures--the cause of which remains to be elucidated. It has been suggested that one of the causative factors for seroma formation is the use of handheld electrocautery as opposed to scalpel for abdominal flap dissection. METHODS: Prospective trial in 102 consecutive abdominoplasty patients randomised to have abdominal flap dissection with either handheld electrocautery device on 'coagulation setting' or sharp dissection with scalpel and monopolar electrocautery forceps for haemostasis. In all other aspects the surgical technique was identical between the two groups. All drains were removed at 48 h, irrespective of drain volume. Primary outcome measure is postoperative seroma formation on clinical examination, secondary outcome measures are drain volume, weight of tissue removed, effect of liposuction and patient BMI. RESULTS: Both study groups were similar in demographics with no significant difference in weight of tissue excised, BMI, drain output or post operative complictions. There was no significant difference in seroma formation rates between the handheld electrocautery group (17.2%) and the sharp dissection group (20.1%). Overall, the seroma rate was 18.6%. Liposuction to the flanks at the time of abdominoplasty was found to significantly increase the incidence of seroma, compared to patients having abdominoplasty alone. CONCLUSIONS: Use of handheld electrocautery rather than scalpel for tissue dissection does not lead to increased seroma formation in abdominoplasty patients. Concomitant liposuction at the time of abdominoplasty increases the risk of seroma formation compared to patients having abdominoplasty alone.

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Worldwide, approximately 405 000 cases of oral cancer (OSCC) are diagnosed each year, with a rising incidence in many countries. Despite advances in surgery and radiotherapy, which remain the standard treatment options, the mortality rate has remained largely unchanged for decades, with a 5-year survival rate of around 50%. OSCC is a heterogeneous disease, staged currently using the TNM classification, supplemented with pathological information from the primary tumour and loco-regional lymph nodes. Although patients with advanced disease show reduced survival, there is no single pathological or molecular feature that identifies aggressive, early-stage tumours. We retrospectively analysed 282 OSCC patients for disease mortality, related to clinical, pathological, and molecular features based on our previous functional studies [EGFR, αvß6 integrin, smooth muscle actin (SMA), p53, p16, EP4]. We found that the strongest independent risk factor of early OSCC death was a feature of stroma rather than tumour cells. After adjusting for all factors, high stromal SMA expression, indicating myofibroblast transdifferentiation, produced the highest hazard ratio (3.06, 95% CI 1.65-5.66) and likelihood ratio (3.6; detection rate: false positive rate) of any feature examined, and was strongly associated with mortality, regardless of disease stage. Functional assays showed that OSCC cells can modulate myofibroblast transdifferentiation through αvß6-dependent TGF-ß1 activation and that myofibroblasts promote OSCC invasion. Finally, we developed a prognostic model using Cox regression with backward elimination; only SMA expression, metastasis, cohesion, and age were significant. This model was independently validated on a patient subset (detection rate 70%; false positive rate 20%; ROC analysis 77%, p < 0.001). Our study highlights the limited prognostic value of TNM staging and suggests that an SMA-positive, myofibroblastic stroma is the strongest predictor of OSCC mortality. Whether used independently or as part of a prognostic model, SMA identifies a significant group of patients with aggressive tumours, regardless of disease stage.

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BACKGROUND: The anterolateral thigh flap is becoming the flap of choice for reconstruction of soft tissue defects. By applying the chimaeric principle, we describe a technique to achieve primary donor-site closure in the use of the anterolateral thigh for the reconstruction of very large defects. METHODS: A long anterolateral thigh flap is marked out using standard points of reference. At least two separate cutaneous perforator vessels are identified on hand-held Doppler and dissected in a retrograde fashion back to the descending branch of the lateral circumflex femoral artery. The skin paddle is then divided between the two cutaneous perforators to give two separate paddles with a common vascular supply. The skin paddles can now be stacked side by side on a flap inset, effectively doubling the width of the flap, whilst still allowing for primary donor-site closure. RESULTS: We have used this flap to reconstruct chest-wall and extremity defects on six patients (mean age: 28.6 years; range: 24-35 years). The largest defect was 30x18cm and the smallest 11x12cm in diameter. In each case, the width of the defect was too great to allow for direct closure of the donor site had a conventional anterolateral flap design been used. There were no cases of flap failure or re-exploration, and in all cases the donor site was closed primarily. CONCLUSIONS: The split-skin paddle anterolateral thigh flap provides bespoke cover for large soft tissue defects with improved morbidity and cosmesis of the donor site.

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Free tissue transfer has revolutionized the management of complex head and neck defects. Perforator flaps represent the most recent advance in the development of free flap surgery. These flaps are based on perforating vessels and can be harvested without significant damage to associated muscles, thereby reducing the postoperative morbidity associated with muscle-based flaps. Elevation of perforator flaps requires meticulous technique and can be more challenging than raising muscle-based flaps. Use of a Doppler device enables reliable identification of the perforating vessels and aids in the design of free-style free flaps, where the flaps are designed purely according to the perforator located. The major advantage of free-style free flaps is that an unlimited number of flaps can potentially be designed on much shorter pedicles. The anterolateral thigh flap is the most commonly used perforator flap in head and neck reconstruction. Its use is described in detail, as is use of other less common perforator flaps. This article also describes head and neck reconstruction in a region-specific manner and gives a short-list of suitable flaps based on the location of the defect.

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Extremely large chest wall defects may result following salvage oncological surgery. Typically these defects involve a large skin defect combined with a variable resected area of underlying muscle and ribs. In situations where the skin defect is very large the use of a large latissimus dorsi flap may require skin grafting to the donor site if a myocutaneous flap is used or to the recipient defect if a muscle-only flap is used. Alternatively a transverse rectus abdominis flap is a second option but in certain cases this may not be available. We describe the use of a free anterolateral thigh flap to reconstruct a chest wall defect and demonstrate the principle of side-to-side stacking of separate skin paddles to achieve skin closure of a massive defect whilst permitting primary closure of the donor site. The principle of turbocharging components of a chimaeric flap is also described.

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Thirteen patients with large ameloblastomas of the mandible underwent segmental mandibulectomy and immediate reconstruction, with simultaneous placement of osseointegrated implants. All patients received palatal mucosal grafts around the dental implants 6 to 10 months after surgical treatment and received implant-supported prostheses another 1 to 2 months later. There were five female and eight male patients, with a mean age of 32 years (range, 17 to 50 years). The mean length of the mandibular defect was 8.8 cm (range, 5 to 13 cm). All free fibula flap procedures were successful, with no reexplorations or partial flap losses. There was no clinical or radiographic evidence of failure during the osseointegration process for any implant. With functional occlusal loading, the marginal bone loss around the implants was less than 1.5 mm in a mean follow-up period of 40 months (range, 18 to 70 months). There were no recurrences during that time. The technique described allows improved access to the bone at the time of reconstruction, immediate assessment of alveolar ridge relationships, and accurate fixation of the implant-fibula construct. The advantages of this procedure include a reduced risk of recurrence with segmental resection, reliable mandibular reconstruction, and reduction of the number of surgical procedures, allowing full oral rehabilitation in a shorter time. It is concluded that segmental mandibulectomy and immediate vascularized fibula osteoseptocutaneous flap reconstruction, with simultaneous placement of osseointegrated implants, represent an ideal treatment method for large ameloblastomas of the mandible.

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Choking is a serious problem in pharyngoesophageal reconstruction, which may occur following tumor ablation of the pharynx or following corrosive injury involving the epiglottis and other parts of the upper airway. To prevent choking and the risk of severe pulmonary complications, patients have to give up oral intake and assume feeding via jejunostomy for the rest of their lives. After reconstruction of the esophagus, eight patients experienced frequent choking and aspiration. With a free jejunal flap, the inlet for food could be separated from the route of the upper airway by a diversion technique. The jejunum segment was transferred microsurgically to reconstruct the cervical esophagus, with its inlet at the buccogingival sulcus. There were no surgical complications related to either the free jejunal flap transfer or the donor site. Postoperatively, patients require re-education of their pattern of swallowing, but after the rehabilitation period all patients reported a satisfactory oral intake through the reconstructed esophagus to the abdomen without choking. There were no episodes of aspiration following reconstruction. With this new method to create a separate food pathway, patients can resume oral intake safely without choking and without permanent jejunostomy. This technique offers a useful solution for patients who suffer from recurrent choking and aspiration following injury or ablation of the pharynx.

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A technique for vaginal reconstruction is described that uses a pedicled jejunal flap. A neovagina was constructed using a segment of jejunum based on the fourth branch of the superior mesenteric artery. This provided an excellent result with adequate length, without the need for a lubricator or stent. Hypersecretion has not been observed.

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Malocclusion may result after free fibula flap reconstruction of the mandible, because of inadequate positioning of the temporomandibular joint, inaccurate contouring of the reconstruction plate, or subsequent fracture of a miniplate. Factors that alter the vascularity of the transplanted fibula may also result in a delayed presentation of malocclusion. Seven cases are presented, in which primary surgical treatment consisted of segmental mandibulectomy and reconstruction with a free fibula osteoseptocutaneous flap. Fixation was achieved with a reconstruction plate in five cases and a miniplate in two cases. Malocclusion was corrected with an osteotomy performed at the junction of the fibula and the native mandible. The new osteotomy sites were fixed with miniplates and maintained with intermaxillary fixation. Complete bony union was achieved at the osteotomy sites. The correction of malocclusion was successful in all cases, and all patients have resumed a normal diet. This report demonstrates that osteotomy and realignment of the mandible are effective for the secondary correction of malocclusion after mandibular reconstruction with the free fibula osteoseptocutaneous flap.

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Free flaps in skull base reconstruction are indicated for providing an effective separation of the intracranial cavity from the oronasal space, for eliminating a dead space, and for the treatment of established wound complications such as dural exposures and cerebrospinal fluid leaks. Seven patients with cranial base defects underwent reconstructions using a free vastus lateralis muscle flap. In two cases, a vastus lateralis flap was raised to incorporate the anterolateral thigh skin as a myocutaneous flap. In four cases, a free flap was indicated for reconstruction following tumor ablation, and in three cases, for the resolution of wound or cerebrospinal fluid leak complications following previous cranial base surgery. All flaps were successful, with no partial failures. In those patients undergoing tumor ablative surgery, the cranial cavity was effectively sealed from the oronasal cavity. Patients with established wound complications following previous cranial base surgery had a complete resolution of their symptoms. This report discusses the suitability of the vastus lateralis flap for skull base reconstruction in terms of the availability of adequate muscle volume to fill dead space, vascularized fascia to augment dural repairs, and the freedom to use skin if required for internal lining or external skin cover. This flap also provides an extremely long pedicle, allows simultaneous flap harvest, and has low donor site morbidity.

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This report outlines a microsurgical technique for total esophageal reconstruction in situations in which conventional methods using stomach or colon are not available. Eleven patients with corrosive injury and one patient following tumor resection underwent total esophageal reconstruction in a two-stage procedure. In the first stage, skin flaps or free jejunal transfers were used for the cervical reconstruction. In the second stage, supercharged pedicled jejunum flaps placed subcutaneously were used for thoracic esophageal replacement. The study included one male and 10 female patients, with a mean age of 38.4 years. The mean follow-up period was 78.9 months. All patients had one or more complications that required revisional surgery. Pedicled myocutaneous flaps were used to close fistulas or chronic wounds in four patients. The cervical skin tube in two patients and the jejunum in another two patients required shortening because of redundancy. Four patients had dysphagia caused by neck contractures, which were released. Two patients developed pharyngoesophageal strictures that required further free skin flaps for release. Two patients had reflux because of blind pouches arising from the original esophagus and required thoracotomy for removal. At long-term follow-up, all patients are fully rehabilitated and have resumed an oral diet with significant weight gain. Compared with lifelong jejunostomy feeding and its associated psychosocial disadvantages, the authors' experience demonstrates that the application of microsurgical techniques to fully reconstruct the esophagus is of considerable benefit to this difficult patient group.

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Free thin anterolateral thigh flaps combined with cervicoplasty were used in a series of seven patients undergoing reconstruction for previous burn injury from September of 2000 to May of 2001 at Chang Gung Memorial Hospital. This method uses a suprafascial dissection technique to provide a thin flap to improve cervical contour. Neck contractures had resulted from flame burns in six patients and from a chemical burn in one patient. The mean age was 32.7 years (range, 22 to 45 years). The size of excised scar ranged from 10 x 2 cm to 26 x 5 cm (mean, 19.7 x 3.3 cm). The size of flaps ranged from 11 x 5 cm to 26 x 8 cm (mean, 21.3 x 6.5 cm). Average operative time was 6 hours. Average hospital stay was 10 days. All flaps survived, with one flap sustaining partial marginal loss. The donor site was closed primarily in five cases and by using a split-thickness skin graft in two cases. At a mean follow-up time of 5 months, the functional improvement was measured as follows: a mean increase in extension of 30 degrees (preoperatively, 95 degrees; postoperatively, 125 degrees), a mean increase in rotation of 18 degrees (preoperatively, 59 degrees; postoperatively, 77 degrees), and a mean increase in lateral flexion of 12.5 degrees (preoperatively, 26.5 degrees; postoperatively, 39 degrees). The average cervicomandibular angle was improved by 25 degrees (preoperatively, 145 degrees; postoperatively, 120 degrees). This series demonstrates that the use of free thin anterolateral thigh flaps combined with cervicoplasty provides a one-stage reconstruction with a thin, pliable flap that achieves good cervical contour with low donor-site morbidity.

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The goal of this study was to prospectively assess the long-term results of ruby laser depilation in 346 consecutive patients who underwent hair removal at 402 anatomical sites. The patients were treated using a ruby laser, with mean power ranging from 8.6 J to 15.7 J according to skin type. Results were assessed using two outcome measures-the percentage reduction in hair density and the hair-free interval. The median reduction in hair density was 55 percent (range, 0 to 100 percent) at a median time of 1 year after the last treatment session. The median hair-free interval was 8 weeks. Patients underwent a median number of four treatment sessions. Forty-three of the 346 patients were treated at more than one anatomical site. Of the sites treated, 75 percent reduction in hair density was achieved in 22 percent, 90 percent reduction was achieved in 2.2 percent, and complete depilation was achieved in only 0.7 percent. Darker colored hair was more effectively treated. Treatment efficacy was not affected by anatomical site, with the exception of the faces of male patients, which were found to be particularly resistant to treatment. There was a significant correlation between the number of treatments given and the outcome. The overall complication rate was 9.0 percent (36 of 402 sites) with respect to pigmentary changes and blistering, but varied according to Fitzpatrick skin type. The complication rate was highest in skin types V and VI (24.7 percent), with no complications in skin type I. Although a greater than 50 percent reduction in hair density was achieved in half of the 346 patients treated, complete depilation was achieved in only an extremely limited number of patients.

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