Ian A. McGregor

The groin flap.

Summary 1.The groin flap, a single pedicled flap similar in principle to the delto-pectoral flap but exploiting the superficial circumflex iliac arterio-venous system, is described. 2.Its role in resurfacing the hand and forearm and as a substitute for the standard tube pedicle is described and its advantages in these and other roles is discussed.

Axial and random pattern flaps

Abstract 1. It is suggested that flaps in general can be divided into two groups—axial pattern flaps with an inbuilt arterio-venous system, and random pattern flaps lacking such a system. 2. The areas of skin supplied by the axial arteries of four such axial pattern flaps,i.e. their vascular territories, have been investigated and the implications of the findings, as they relate to the flaps actually raised, are discussed. 3. It is postulated, on the basis of evidence presented, that the boundaries which exist between adjoining vascular territories, including territories on each side of the midline, do not have a basis in structure in the skin but result from a dynamic pressure equilibrium existing in the blood vessels of each territory along the boundary line.

The extended role of the delto-pectoral flap

Summary 1.An extended role for Bakamjians delto-pectoral flap is described in surgery of the head and neck and surgery of the hand. 2.The role in head and neck surgery has included the primary resurfacing of defects of post-triangle mastoid, ear, parotid, full thickness of cheek, angle of mouth and chin. 3.The role in hand surgery has concerned primary resurfacing of the hand—dorsum and palm.

The theoretical basis of the z-plasty

Summary 1.Mathematical methods have been applied to the Z-plasty. 2.It has been shown that percentage lengthening depends solely on angle size. 3.With angle sizes of 30, 45, and 60 degrees the increases in length to be expected are 25, 50, and 75 per cent. 4.The factors which in practice limit the size of the Z-plasty angle are discussed.

RECONSTRUCTION OF THE THUMB BY COMPOSITE BONE-SKIN FLAP.

Summary 1.The disadvantages of the current methods of tube pedicle reconstructions of the thumb are described and the requirements for improving the method are indicated. 2.A method which meets these requirements involving the simultaneous transfer of skin and bone, followed by the immediate provision of sensation by neurovascular island transfer, is described.

Eyelid reconstruction following subtotal resection of upper or lower lid

Abstract A method of reconstruction of the eyelid is described which employs the principle of lateral advancement and incorporates a Z-plasty to eliminate tension. The method is capable of being applied to either the upper or lower eyelid and is suitable for reconstructing V-shaped defects up to two-thirds of the width of the eyelid.

Successful prophylaxis with tinidazole of infection after major head and neck surgery for malignant disease

Abstract A prospective double-blind trial of tinidazole was carried out in a group of 8 patients, each undergoing radical surgery for the removal of a large squamous cell carcinoma (SCC) of the oropharynx. In the 4 patients given tinidazole there was no wound infection, wound healing was more rapid and the foul odour associated with infection in such patients was eliminated. Post-operatively, 3 of the 4 patients given the placebo developed wound infections. Mixed cultures of gram-negative anaerobic bacilli, predominantly bacteroides, were grown from the upper drain fluids of the infected patients. Anaerobes were not isolated from the drain fluids of patients receiving tinidazole. The efficacy of tinidazole was demonstrated in these patients who are at high risk of acquiring infection because of the extensive surgery required for tumour removal and the inevitable contamination of the tissues with the diverse, resident oral flora.

The abbe flap Its use in single and double lip clefts

Summary The design of the Abbe flap and its usage in the secondary repair of single and double clefts of lip is described and some modifications of technique are discussed for use in the single cleft. A method of designing the pedicle to simplify its subsequent division is described in detail.

The pursuit of function and cosmesis in managing oral cancer

In 195 1, at the commencement of the period covered by this lecture, an article appeared in the Journal Cancer, entitled “Neck Dissection”. Its senior author was Hayes Martin, a formidable figure, who in 1934 had become Chief of the Head and Neck Service of the Memorial Hospital in New York with responsibility for the overall management of oral malignancy. As a trained surgeon one might have expected him to be biased in favour of surgery rather than radiotherapy, the two alternatives, but in the event he used radiotherapy as the primary method of treatment, both to the primary site and the neck nodes. The reason was his recognition of the prohibitive operative mortality of surgery at that time. With the surgical and anaesthetic techniques of the day and the absence of antibiotics, resection of the primary site in continuity with the neck nodes, which brought the contaminated oral cavity into continuity with the widely open neck, was unacceptably lethal in practice. Massive neck infection, wound breakdown, and even mediastinitis were regular complications. After 1940, by which time he was in a position to analyse the results of radiotherapy during the period 193&1935, results which he published in that year (Martin and Sugarbaker, 1940), his policy began to change, away from radiotherapy and towards the use of surgery. The initial move was to use surgery increasingly in treating the neck nodes, where radiotherapy had proved particularly ineffective, and by 1944 the numbers of patients whose nodes were treated surgically equalled those treated by radiotherapy. This was rapidly followed by management of the primary site by surgery, the 50 % point being reached in 1947, and by 1950, the primary treatment of over 90% of intraoral cancer patients was entirely by surgery. Having published the results of primary treatment by radiotherapy in 1940, he was in a position to compare them with his results achieved with the virtually exclusive use of surgery, and this he did in his 1951 paper in Cancer. With its forthright advocacy of primary surgical management, and in defining the form and extent of radical neck dissection, this paper marked a watershed. Indeed it would not be an exaggeration to say that it ushered in the modern approach to the surgery of oral cancer, not merely by advocating primary management by surgery, but also by introducing the concept of resection of the primary site in continuity with the neck nodes. The results he was able to produce provided an effective justification for the views he expressed so forcefully. Although it was revolutionary at the time, the paper does not strike one today as being particularly controversial, so effectively have the principles of resection which he was expounding been absorbed into routine surgical practice. The major difference between his approach and that of today concerns the manner in which he managed the intraoral defect. Throughout the entire paper there is no mention of reconstruction. In managing the defect following hemiglossectomy with hemimandibulectomy and neck dissection in continuity for cancers of the tongue and floor of mouth direct suture was presumed. What impact the paper had, and how widespread the change was in the general attitude to surgery ~lis b ois radiotherapy, cannot be assessed accurately today, but it does seem probable that it increased the role of surgical resection, in the United States at least. Quite apart from the message carried by his writings, Martin spread the gospel of surgical resection by sending his disciples far and wide throughout the country, which was probably good, but the result was also a generation of surgeons with a basic contempt for reconstruction, which was certainly bad. The remarkable fact is the extent to which the influence of his philosophy, so clearly antagonistic to reconstruction, survived his retiral in 1957. Even as late as 1971 direct closure was still the preferred method in the Memorial Hospital (Harrold, 1971) despite the general recognition elsewhere of the desirability of reconstruction.

Restoration of mandibular continuity after symphyseal osteotomy

Abstract A method of restoring bony continuity following symphyseal mandibular osteotomy is described. The method requires no oral surgical expertise and is likely to be of most value where the osteotomy has been carried out to expose an intra-oral tumour.