The pedicled occipital artery scalp flap for salvage surgery of the neck

A small group of patients with complex head and neck cancer present with problems of wound healing following radiotherapy and reconstructive surgery. Provision of skin cover to the neck in these cases is often required and presents a challenge to the reconstructive surgeon. We present the use of a pedicled scalp flap based on the occipital artery for such defects. This flap is an axial patterned scalp flap incorporating hair-bearing skin. It may be up to 15 cm wide and can reach beyond the midline of the chin. The anatomy of the flap is described and its use illustrated in three cases. This flap is a useful addition to the options for reconstruction of neck defects in patients with head and neck cancer.

The Soho nail bomb: the UCH experience. University College Hospital

This paper documents the clinical course of the casualties treated at University College Hospital, following the detonation of a terrorist nail bomb in a public house in Soho, London. The need for adequate primary debridement is paramount, including consideration of definitive primary limb amputation.

Basaloid squamous carcinoma of the buccal cavity

Basaloid-squamous carcinoma was first recognized as a separate pathologic entity in 1986. It has been described in the hypopharynx, larynx, base of tongue, and nasal cavity. We report the first case of this rare tumor occurring in the buccal cavity and review the atypical squamous cell carcinomas that occurred in these sites.

Mastoid obliteration with the temporoparietal fascia flap

Obliteration of persistently discharging open mastoid cavities is one surgical option to achieve a dry ear. All the currently described techniques involve the use of random pattern local tissue flaps or free grafts. Ten patients have undergone obliteration procedures using the vascularized temporoparietal fascia flap. This resulted in rapid epithelialization by six weeks in seven out of 10 cases. The remaining three patients have persistent non healed areas over the medial attic wall, but are not troubled by otorrhoea. The indications, technique and complications of mastoid obliteration by this axial pattern flap are described.

The King's Cross fire. Part 1: The physical injuries

Fire broke out at the end of the evening rush-hour at King's Cross Underground Station, London on the 18 November 1987. Fifty-eight people were killed or injured by the flash-over in the main ticket concourse at the top of the escalator, beneath which the fire began. Twenty-eight survivors were treated for thermal injuries of a broad spectrum of severity but with a similar pattern. The sequence of events in the initial response, the distribution of patients and the pattern of injuries with details of their management over 2 years are described. The psychological effects of the disaster on the patients involved are detailed in Part 2, the accompanying article (D. Sturgeon, R. Rosser and P. Shoenberg (1991) Burns 17, (1), 10-13).

Donor site morbidity following osteocutaneous free fibula transfer

Nine patients who had undergone free fibula transfer were reviewed to determine the incidence of donor site complications. Problems identified included distal oedema, cold intolerance, sensory loss and weakness. However, the functional deficit was not great and most patients were not troubled by their symptoms. More serious potential complications from raising this flap are considered.

Mandibular reconstruction using vascularised fibula

The osteocutaneous fibula flap has been used to reconstruct large segments of mandible in cases following ablation for cancer or radionecrosis. The bone can be cut to the appropriate shape and the fasciocutaneous flap may be used simultaneously to provide oral cavity lining or skin cover. The technique is described and its successful use in seven patients is reported with details of the complications encountered.

Comparison of laser-assisted and conventionally sutured microvascular anastomoses by bursting pressure: a reanalysis and further studies

Methods of testing the strength of microvascular anastomoses are reviewed historically, in the light of recent applications to laser-assisted microvascular anastomosis techniques. The results of two experiments using hydrostatic distension to bursting point to determine the strengths of laser-assisted and conventionally sutured anastomoses of rat arteries and veins are presented. Considerable variation of the bursting pressures was found at any given time after anastomosis, and by the third postoperative day, the sutured vessels showed a significant fall in strength to their weakest level, with not as great a fall in the laser group. The sutured vessels were stronger than were the laser-anastomosed vessels, except at 3 days and after 6 weeks, when there were no significant differences between the two types of anastomosis. Aneurysmal vessels did not always burst at lower pressures than did nonaneurysmal vessels of comparable age.

Fluid requirements of patients with burns and inhalation injuries in an intensive care unit

We have studied 9 patients with burns (20%-75%) who had inhalation injuries and compared their actual fluid requirements with their requirements calculated from the Muir and Barclay formula. All patients were resuscitated with plasma protein fraction at a rate sufficient to keep their physiological variables within the following range: heart rate less than 120/min, central venous pressure 8-12 cm H2O, urine output greater than 30-50 ml/h, systolic blood pressure greater than 90 mm Hg and diastolic blood pressure greater than 60 mm Hg. The amount of plasma protein fraction needed was 4.38 +/- 1.26 ml/kg/% burn in the first 24 h and 2.15 +/- 0.97 ml/kg/% burn in the second 24 h. This is an increase of 75% and 110% respectively above values predicted from the formula. We suggest that the observed difference is due to a combination of the presence of an inhalation injury which increases fluid requirements by approximately 30% in the first 24 h and the use of plasma protein fraction rather than the dried plasma used in the original Muir and Barclay formula.

Laser assisted microvascular anastomosis of arteries and veins: laser tissue welding

Using a milliwatt CO2 laser, a series of 160 arteries and 105 veins have been anastomosed in Wistar rats. Three stay sutures and a laser tissue welding technique were used. These were compared with a series of conventionally sutured vessels in terms of patency, speed and ease of procedure, and aneurysm formation. Patency rates of successful first time anastomoses are comparable with conventional suturing methods but the aneurysm rate is higher. Laser assisted anastomosis is faster to learn and perform than conventional suturing, but microsurgical skills are still needed. Despite the large number of variables the laser assisted technique has a high success rate, and work to minimise variables and optimise the laser parameters may improve these results.

Tracheostomal reconstruction using a fenestrated deltopectoral skin flap

Tracheostomal stenosis following laryngectomy can prevent satisfactory rehabilitation of a patient, and may be difficult to correct. A reconstructive technique using a flap within a deltopectoral flap to treat this condition is described.

Reconstruction of the middle third of mandible

The radial forearm flap is established as a suitable method of providing bone with soft tissue lining or skin cover in reconstruction of the mandible. A simple and effective method of modelling the radius to provide the appropriate contour to the anterior arch of the mandible is described.

Scalp expansion flaps

A mean 5 year review of 20 patients who had surgery for localised alopecia of the scalp is presented. The technique of using scalp expansion flaps is described and evaluated: it is associated with a low morbidity and high patient satisfaction rate; it provides an excellent one-stage procedure for intermediate size defects and, in the frontal area, for larger defects. Particular emphasis is laid on making incision lines at right angles to the direction of hair growth in order to cover stretched scars, and in performing Z-plasties when closing small scalp defects. Finally, a rationale for the treatment of localised areas of baldness according to their size is put forward.

The application of hair-bearing flaps in head and neck surgery

The history of hair-bearing flaps is presented. A study of the vascular supply of the scalp with a particular emphasis on the posterior branch of the superficial temporal artery revealed that it was possible to transpose the entire scalp or any hair-bearing flap on a long, highly mobile, narrow pedicle containing this vessel. Clinical application of this finding to postexcisional defects allowed the reconstruction of hairline, eyebrows, sideburns, and various shapes of beards and moustaches. The technique was used on 80 occasions to produce various cosmetic units and proved to be a safe procedure.

Dermatitis artefacta

An unusual case of dermatitis artefacta is presented. The patient lost the whole of the index finger of his dominant hand before the diagnosis was established. The motive was financial gain. The literature on self-inflicted disease is reviewed.