Darryl M. Coombes

How should we manage oral leukoplakia

The aim of this article is to review the management of oral leukoplakia. The topics of interest are clinical diagnosis, methods of management and their outcome, factors associated with malignant transformation, prognosis, and clinical follow-up. Global prevalence is estimated to range from 0.5 to 3.4%. The point prevalence is estimated to be 2.6% (95% CI 1.72-2.74) with a reported rate of malignant transformation ranging from 0.13 to 17.5%. Incisional biopsy with scalpel and histopathological examination of the suspicious tissue is still the gold standard for diagnosis. A number of factors such as age, type of lesion, site and size, dysplasia, and DNA content have been associated with increased risk of malignant transformation, but no single reliable biomarker has been shown to be predictive. Various non-surgical and surgical treatments have been reported, but currently there is no consensus on the most appropriate one. Randomised controlled trials for non-surgical treatment show no evidence of effective prevention of malignant transformation and recurrence. Conventional surgery has its own limitations with respect to the size and site of the lesion but laser surgery has shown some encouraging results. There is no universal consensus on the duration or interval of follow-up of patients with the condition.

Multicentre study of operating time and inpatient stay for orthognathic surgery

Orthognathic surgery has advanced considerably since its development in the mid-twentieth century, and in most maxillofacial units mandibular and maxillary osteotomies are routine procedures. However, to enable accurate health planning and costing, and to obtain meaningful consent, it is important to have reliable data for duration of operation and inpatient stay. Virtually every aspect of orthognathic surgery has been researched, but we know of no recent studies that have looked specifically at how long the procedures take and how long patients stay in hospital. We retrospectively studied a sample of patients who had had orthognathic operations at six maxillofacial units in the United Kingdom (UK) to assess these measures. We looked at 411 operations which included 139 bilateral sagittal split osteotomies, 53 Le Fort I osteotomies, and 219 bimaxillary osteotomies. The study showed that the mean (SD) operating time for bilateral sagittal split osteotomy is 2h 6min (46min), 1h 54min (45minutes) for Le Fort I osteotomy, and 3h 27min (60min) for bimaxillary osteotomy. The duration of postoperative hospital stay was also measured. Fifty percent of patients spent one night in hospital after bilateral sagittal split osteotomy, whereas 39% and 9% of patients spent two and three nights, respectively. Forty-five percent of patients spent one night in hospital after Le Fort I osteotomy, whereas 34%, 13%, and 2% spent two, three, and four nights, respectively. Forty-one percent of patients spent two nights in hospital after bimaxillary osteotomy, whereas 34%, 21%, and 3% spent one, three, and four nights, respectively. This data provides evidence for national benchmarks.

Evidence based management of Bell's palsy

Bells palsy (idiopathic facial paralysis) is caused by the acute onset of lower motor neurone weakness of the facial nerve with no detectable cause. With a lifetime risk of 1 in 60 and an annual incidence of 11-40/100,000 population, the condition resolves completely in around 71% of untreated cases. In the remainder facial nerve function will be impaired in the long term. We summarise current published articles regarding early management strategies to maximise recovery of facial nerve function and minimise long-term sequelae in the condition.

Orthognathic surgery and related papers published in the British Journal of Oral and Maxillofacial Surgery 2008–2009

This paper provides a review of articles relating to deformity, orthognathic surgery, and distraction osteogenesis published in the British Journal of Oral and Maxillofacial Surgery during 2008 and 2009. A total of 42 papers (26 full length articles, 5 technical notes, and 11 short communications or letters to the editor) were published. It was pleasing that 62% were full length articles; this is encouraging as such papers have a high educational value and are likely to be cited in future publications.

Carcinoma of the midline dorsum of the tongue

We present a case of an 80 year old female who had previously been diagnosed with lichen planus of the tongue dorsum some 10 years previously. Due to a change in the appearance of the lesion a biopsy revealed squamous cell carcinoma of the tongue. We discuss this rare diagnosis in conjunction with the possibility of an association of squamous cell carcinoma and lichen planus.

Exploiting the perforator concept to minimise donor site morbidity in harvesting the radial forearm free flap

Fig. 1. Propeller flap marked by reverse planning technique (note blue dot denoting position of perforator vessel). he radial forearm free flap (RFF) is a highly versatile and eliable workhorse flap but its harvest often leaves a signifiant donor site requiring soft tissue coverage. Most often this s achieved through the use of a skin graft, which aside from eing unaesthetic has been reported to fail (full or partial) ue to the poor “take” observed over the exposed flexor carpi adialis tendon. Even if the skin graft does not fail it may till cause adhesions with the underlying musculo-tendinous tructures.1,2 We describe the use of a propeller flap based on n ulnar artery perforating vessel to avoid these problems. The location and anatomy of the ulnar artery and its perorators have been well described in the literature and can be asily located using a hand-held Doppler device. These ulnar erforators have been shown to be reliable in supporting a arge skin paddle and can be used to form flaps based on the roximal, middle, and distal forearm regions.3 Flaps raised n this territory also leave donor sites that are amenable to irect closure and are aesthetically pleasing.4 Following harvest of the RFF the ulnar border of the donor ite incision in the proximal third/middle third of the forerm is elevated at the subfascial plane. Dissection precedes lnarwards until a suitable perforator is identified. Reverse lanning marks out an elliptical flap (Fig. 1) and the flap is slanded on the perforator (Fig. 2). In the case shown, the ◦ ap was rotated approximately 150 and inset into the donor ite defect (Fig. 3). The mobility of the surrounding skin of

Dynamic reanimation for facial palsy: an overview

Facial paralysis can have a profound effect on the patient from both an aesthetic and functional point of view. The symptoms depend on which branch of the nerve has been damaged and the severity of the injury. The purpose of this paper is to review currently available treatments for dynamic reanimation of a damaged facial nerve, and the goals are a symmetrical and coordinated smile. Careful selection of patients and use of the appropriate surgical technique can have excellent results.

Malakoplakia of the face: A rare but important diagnosis

Malakoplakia that presents in the head and neck is rare. We describe a case in a man who presented with a fungating mass in the periauricular skin that was thought to be a malignant tumour. Histopathological and microbiological investigations established a diagnosis of malakoplakia.

Use of cone beam computed tomography in the management of glass injuries to the face

Fig. 1. Axial cone beam computed tomogram showing two fragments of glass embedded in a patient’s face (fragments denoted by arrows). one beam computed tomography (CBCT) is an emerging ethod of imaging in maxillofacial surgery. Its advantages nclude short scanning time and a lower radiation dose than onventional CT, and it produces images with isotropic subillimetre spatial resolution and a high diagnostic quality.1 o date it has been used for dental implant planning, evalution of temporomandibular joints, and trauma of the facial keleton.2,3 We describe a new approach that uses CBCT to aid locaion of glass fragments in facial wounds. Currently this is ased on clinical examination and plain film radiographic iews that use the principle of parallax to locate the fragents. Identification of such fragments can be difficult articularly when they are small to medium in size. Stanard radiography can give an approximation of their position ut falls short of providing three-dimensional images that llow precise mapping of all fragments in the wound. The se of CBCT gives a three-dimensional image that can be eproduced to aid retrieval of even small fragments without nterference from artefacts.4 We have used CBCT to locate and assist in the removal of lass fragments from the face of a patient who was allegedly glassed” in the periorbital region on the right side of his face. NewTom 3G CBCT scanner (AFP Imaging Corporation, ew York, USA) was used to obtain images of the maxillofaial region to ascertain whether any glass fragments had been mbedded. Two fragments were identified and subsequently emoved under general anaesthetic (Figs. 1 and 2).

Europe's forgotten Cancer, what is OMF Surgery's role?

We outline the principles of management of skin cancers, and highlight the role of oral and maxillofacial surgery.