Biomedical subjects
Publications and source records attributed to N M Breach.
The malignant Triton tumour is a malignant schwannoma with rhabdomyoblastic differentiation. This is the first report of this type of rare, aggressive sarcoma arising in the maxilla and only the third report of this type of pathology arising outside the context of von Recklinghausen's disease. Aspects of clinical and histopathological diagnosis are mentioned.
There are many different flaps available for head and neck reconstruction. The latissimus dorsi myocutaneous flap has been widely used in this unit on 80 occasions in the past three years, both as a pedicled and as a free microvascular flap following the excision of head and neck malignancy, the commonest pathology being intraoral squamous cell carcinoma. There were nine cases of complete or substantial flap loss requiring a further reconstructive procedure. Few of the patients who underwent total glossectomy suffered from overspill or aspiration and the fistula rate was low. Reference is made to the anatomy and the technique of raising this versatile flap which provides a large volume of tissue and has been particularly useful following total glossectomy when combined with a hyoid hitch.
A retrospective study was made of 64 patients who underwent free flap reconstructive surgery following resection of neoplasms, mainly in the head and neck region, over a period of approximately 4 years, from 1983 to 1987, in the Royal Marsden Hospital, London. A brief history of free flap surgery is presented, followed by a description of the anaesthetic technique used, and the results of the study. The various ways in which anaesthetic management may influence the results of surgery are discussed.
A case is presented of the successful closure of a colono-cutaneous fistula in the neck, which developed twenty-one years after pharyngo-laryngectomy. A pectoralis major muscle flap and a delto-pectoral skin flap were used.
Myocutaneous and fascio-cutaneous flaps have enabled single stage combined surgical resections and reconstructive procedures to be carried out for locally advanced, non-metastatic carcinoma of the external genitalia. The need for delayed repair procedures with their associated morbidity and prolonged hospital stay is minimised. Functional loss resulting from the removal of the supporting muscle is rarely a problem.
Experience in the use of free vascularised tissue flaps in reconstruction following major head and neck resections for malignant disease has been described. The benefits of the use of free flaps are improved function and cosmesis with more rapid rehabilitation and reduced in-patient stay in a group of patients, many of whom had a limited life expectancy. The disadvantages of this technique are the need for special equipment and for medical and nursing staff trained and experienced in this type of work.
In a series of 24 patients treated for squamous carcinoma of the oral cavity and oropharynx, 26 mandibular reconstructions using 27 grafts or flaps were performed. Reconstruction was immediate in 23 cases and delayed in three. There were five 'simple' bone grafts, 10 pedicled compound myocutaneous flaps, and 12 vascularized free compound flaps. Operative mortality was 12% and complication rate 65%, but 70% of the grafts survived till death or follow-up of the patients. Three 'simple' bone grafts failed and were removed. Three of five compound pectoralis major flaps failed along with one of five pedicled compound latissimus dorsi flaps. Only one vascularized free compound flap was lost. The major cause of graft failure was intra-oral suture line dehiscence exposing the bone to saliva. Under these circumstances, bone graft necrosis occurred when blood supply to the bone was poor--viz. 'simple' grafts and compound pectoralis major flaps. The vascularized free compound flaps were most reliable but the need for jaw preservation where possible and better patient selection are recognized.
Acral lentiginous melanoma has not previously been reported in the English literature. It is a rare tumour occurring nearly always on the palmar and plantar surfaces and has only recently been recognised as a separate histological group of melanoma. Diagnosis can be difficult both clinically and histologically, and is often delayed. An illustrative case is presented and the world literature is briefly reviewed.
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A study was undertaken of the effects of heterografts (lyophilized porcine skin or bovine dermis) on the healing of split-skin graft donor sites. When compared with a petrolatum gauze dressing, no advantages were found. Some disadvantages developed, however, which led us to discontinue their use.
By using a technique in which the hair-bearing skin of the axilla is undermined through three small incisions the eccrine glands can be methodically removed. The resulting scarring is minimal and is aesthetically acceptable. In a series of 25 patients (50 axillae) 23 were totally cured of their hyperhidrosis. The remaining 2 patients were sufficiently improved not to require any further treatment. The technique may be undertaken under either local or general anaesthesia.
The use of the pre-auricular region as a donor site for full-thickness skin grafts is described. It provides a valuable source of skin for the medial canthal-nose, eyelid-cheek areas, providing a good colour and texture match.
Five patients with sternoclavicular swellings are described. The group presents a variety of diagnoses which highlight the need for thorough investigation and appropriate management of swellings around the sternoclavicular joint. Although frequently assumed to be benign, this series demonstrates the potential occurrence of malignant disease, and the dangers of pursuing a simple conservative course. Conversely, a substantiated benign diagnosis may avoid the use of unnecessary surgical treatment.