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INTRODUCTION: Advanced non-melanocytic skin cancer (NMSC) in the facial region causes extensive tissue loss, possibly coverable by local flaps. Remote free flaps are the reconstructive method of choice, despite disadvantages such as color and texture mismatch, and bulkiness with regard to facial skin. MATERIAL AND METHODS: Post-ablative facial NMSC defects in four patients were reconstructed using remote free flaps, including radial forearm, scapular, parascapular, and anterolateral thigh flaps. Four months later, a split-thickness skin graft (STSG) was acquired from the retroauricular region to generate a non-cultured autologous epidermal cell (NCAEC) suspension. The flap surfaces were de-epithelialized, and the NCAEC suspension was sprayed onto the flap surface to improve the mismatch between facial and flap color. Debulking was also carried out. The aesthetic outcome was examined by photography and clinical examination 3, 6, 9, and 12 months after the first operation. RESULTS: All flaps survived the 11- to 21-month follow-up. The secondary operation was accompanied by a delay in re-epithelialization in one case. No STSG donor-site problems occurred. Follow-up photographs showed significant improvements in the color and texture of the flaps. CONCLUSIONS: Facial reconstruction with a free flap results in a mismatch of color and texture. Secondary correction of the flap surface by de-epithelialization and NCAEC application significantly improves the aesthetic outcome.

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OBJECTIVE: Microcirculation and oxygen supply in cervical skin were measured with an optical, noninvasive method in patients with or without radiotherapy before neck dissection. The course of wound healing was monitored after the surgical procedure to identify predictive factors for postoperative wound healing disorders. STUDY DESIGN: Tissue spectrophotometry and laser Doppler flowmetry were used to determine capillary oxygen saturation, hemoglobin concentration, blood flow, and blood velocity at 2-mm and 8-mm depths in the cervical skin of 91 patients before neck dissection in a maxillofacial unit of a university hospital in Munich, Germany. Parameters were evaluated for differences between patients with irradiation (24) and without (67) and patients with wound healing disorders (25) and without (66) (univariate or multivariate statistical analyses). RESULTS: Velocity at 2 mm was lower in irradiated skin (P = .016). Flow at 2 mm was higher in patients with wound healing disorders (P = .018). CONCLUSIONS: High flow values could help to identify patients at risk for cervical wound healing disorders.

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Cognitive impairment causes a delay in diagnosis and treatment of the various cancer entities, resulting in reduced surgical outcomes and patient survival. However, no investigations have been carried out as to whether an association exists between cognitive functioning and tumour size in patients with oral squamous cell carcinoma (OSCC). In this study, 46 patients with OSCC were evaluated by using a screening test for dementia, consisting of a combination of the mini-mental state examination and the clock test (81% sensitivity and 90% specificity). Test scores were correlated with tumour size according to the TNM staging system, which was categorized as being either limited (T1, T2; n=24) or advanced (T3, T4; n=22). No difference in age (P=0.172), sex (P=0.330), the percentage of drinkers (P=0.090) or the percentage of smokers (P=0.484) was evident between the groups. Patients with advanced tumour size scored significantly lower (median 5.5 of 9 possible points) when compared with those having tumours of a limited size (median 9 of 9 possible points; P=0.005). The median score of patients with T3/T4 tumours suggested the need for comprehensive neuropsychological evaluations for dementia. In conclusion, this study has demonstrated the correlation of reduced cognitive functioning in patients with advanced OSCC. As a consequence, instructions for the identification of early signs and of symptoms of oral cancer are strongly recommended for relatives and nursing staff of patients with cognitive impairment. Such patients might need immediate treatment for oral cancer but might not be able to understand the significance of their symptoms and therefore present late, often too late.

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OBJECTIVES: To compare perioperative problems and outcomes of reconstructive surgery with microvascular flaps of a group of older (≥ 70) and younger adults (20-69). DESIGN: Prospective clinical cohort study. SETTING: Maxillofacial surgical unit of a university teaching hospital in Munich, Germany. PARTICIPANTS: Two hundred fifteen people with head and neck carcinoma (older: n = 54, mean age 75.8, range 70-96; younger: n = 161, mean age 55.5, range 20-69) who underwent surgery between 2007 and 2009. MEASUREMENTS: Participant characteristics: age, sex, American Society of Anesthesiologists (ASA) status, tumor type, preoperative radiation or chemotherapy, medical comorbidities. Surgical variables: flap type, type of reconstruction (primary/secondary), length of operation (minutes). Postoperative variables: length of stay (minutes) on intensive care unit (ICU), reasons for ICU stay longer than 1,500 minutes (surgical or medical), length of hospitalization (days), and reasons for hospitalization longer than 20 days (surgical or /medical). Short-term outcome within 30 days: revisions, flap success, overall complication rate, mortality. RESULTS: Older adults had a higher ASA class (P < .001) and shorter duration of surgery (P = .02). Age as an independent factor prolonged stay on ICU (P = .008) and was associated with a higher complication rate (P = .003) but had no influence on length of hospitalization, flap success, need for revisions, or mortality. CONCLUSION: Although higher rates of peri- and postoperative difficulties must be expected when microvascular reconstructive surgery is considered for older adults, careful surgical technique, adequate postoperative surveillance, and immediate management of complications can facilitate outcomes comparable with those for younger adults.

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BACKGROUND: The radial forearm free flap (RFFF) is commonly used in reconstructive surgery. With respect to the maxillofacial region, several venous anastomotic techniques (e.g., single or double anastomoses) have been described, but the debate as to which alternative is preferable is ongoing. A complicating factor is the unpredictable anatomical situation in patients undergoing secondary operation. No recommendations are available for the surgical strategy in such cases. We present a standard operating procedure (SOP) applicable for secondary reconstructions, postulating double anastomoses as the method of choice, and evaluate its efficacy. METHODS: The following parameters were retrospectively analyzed for 120 patients with secondary (41; 34.2%) or primary (79; 65.8%) reconstruction following the instructions of SOP and compared between the study groups: age; sex; history of radiotherapy; side of the donor arm; flap size; preparation and use of the cephalic vein and reasons for its non-inclusion; included venae comitantes; recipient veins; arterial anastomoses; revisions, flap survival, and mortality within thirty days after operation. RESULTS: The method of choice was applicable in 26 (63.4%) secondary and 52 (65.8%) primary reconstructions (no difference; P = 0.841), resulting in 100% flap viability in both groups. In the remaining cases, single venous anastomoses were performed, resulting in 73.3% flap viability in secondary and 100% in primary reconstructions. Flap survival in secondary reconstructions was significantly higher when double anastomoses were conducted (P = 0.012). CONCLUSIONS: The results suggest the necessity of double venous anastomoses in secondary maxillofacial reconstructions with RFFF.

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The vascularised fibula flap has been used in mandibular reconstruction for three decades. An e-survey of pre-operative lower limb evaluations being utilised by UK maxillofacial head and neck surgeons was carried out in order to gauge if there was any uniformity in practice. Our results show that routine pre-operative evaluation is the expected standard but the modalities used vary among the different units. The results compare favourably with previous published figures.

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Injuries resulting from the use of angle grinders are numerous. The most common sites injured are the head and face. The high speed disc of angle grinders does not respect anatomical boundaries or structures and thus the injuries produced can be disfiguring, permanently disabling or even fatal. However, aesthetically pleasing results can be achieved with thorough debridement, resection of wound edges and careful layered functional closure after reduction and fixation of facial bone injuries. A series of penetrating facial wounds associated with angle grinder use are presented and the management and prevention of these injuries discussed.

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The term inflammatory pseudotumour is given to a group of benign lesions, which are comprised of spindle myofibroblasts and chronic inflammatory cells. They rarely present out with the orbit in the head and neck and can appear sinister in their clinical and radiological presentation. Local resection is curative, whilst steroids and radiotherapy can be helpful adjuncts. Accurate histological diagnosis is essential to avoid radical and disfiguring resections being undertaken.

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The development of ischaemia in the hand after harvest of a radial forearm flap is extremely rare. Previous cases have been caused by anatomical anomalies or conditions that may have been detectable by ultrasonography. We report the development of ischaemia after harvest of a radial forearm flap despite a normal preoperative Allen's test and a normal Doppler ultrasound scan, in a non-smoker with no evidence of peripheral vascular disease. Angiographic appearances suggested that the ischaemia may have been secondary to an incomplete superficial palmar arch. This case highlights the potential for development of ischaemia despite normal preoperative investigations, with obvious ramifications for obtaining consent.

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