Omar Ahmed

Z-plasty modification of ulnar-based fasciocutaneous flap for closure of the radial forearm flap donor defect.

The radial forearm flap is a commonly used method of intra-oral reconstruction, but problems with the donor site are not uncommon. In an attempt to avoid complications, Elliot et al described the use of an ulnar-based flap to obtain direct closure. Where it was not possible to close the proximal defect using V-Y closure, the use of a split skin graft was recommended. We describe a modification of their technique that can potentially obviate the need of a split skin graft when proximal closure is not possible.

Merkel cell carcinoma of the head and neck: challenges in implementing best practice.

ObjectiveMerkel cell carcinoma (MCC) is a rare, aggressive skin tumor. Controversies regarding optimal management persist due to inadequate data and knowledge regarding tumor biology. Head and neck MCC increases both oncological and reconstructive challenges, compounded by predominantly elderly patients. We review our practice and outcomes, review evidence, and discuss the difficulties in delivering best practice management. MethodsAll patients with primary head and neck MCC, managed by a single multidisciplinary team between January 2001 and December 2010, were identified through retrospective analysis of a pathology coding database. A literature review was performed. ResultsTwenty patients, with a mean age of 83.5 years (40–99 years) and presenting with mean symptom duration of 5 months, had primary tumors involving the nose (n = 2), periorbital region (n = 5), cheek (n = 6), and the temple and scalp (n = 7). Mean tumor size was 2.1 cm (range, 0.5–7.5 cm). Reconstructive techniques were direct closure (n = 8), skin grafting (n = 7), local flaps (n = 4), and free anterolateral thigh flap (n = 1). Two (10%) patients presented with nodal disease. Eight (40%) patients re-presented with nodal recurrence at a mean of 7 months with 6 undergoing salvage neck dissections. Adjuvant radiotherapy was completed in 5 cases, and chemotherapy used for palliation in 1 case. Most of the patients declined radiotherapy due to adverse effects or frailty. ConclusionsOur series demonstrates the profound challenges in managing head and neck MCC, including tailoring definitive primary treatment and current consensus management to elderly patients. Regional nodal assessment and management remains crucial to achieving this goal.

Sentinel bruising in metastatic malignant melanoma

Previous reports illustrate the potential for metastatic malignant melanoma to present with ‘bruises’ that were found, on histological analysis, to be directly related to cutaneous tumour deposits. We wish to report a contrary case of bruising without cutaneous neoplasia as a sentinel feature of the nodal spread of malignant melanoma. Our patient, a 57-year-old male, initially presented in late 2006 with an ulcerated (4.5 mm Breslow thickness, Clarke’s IV) melanoma over his left scapula, which was widely excised and closed directly. Staging investigations showed no evidence of metastatic disease. A routine 3-monthly followup was subsequently performed, but he brought forward his appointment in October 2007, due to concern over axillary bruising. He admitted to a 3-week history of an enlarging mass in his left axilla but only became alarmed on developing sudden, spontaneous bruising of the skin overlying this mass. He denied history of any trauma. Examination revealed an ovoid mass in the medial wall of the axilla, highly suspicious of malignant lymphadenopathy. Overlying it was the sentinel 2 1 cm bruise (Figure 1). However, the affected skin was clearly mobile over, and separate from, the underlying mass. The patient’s platelet count and coagulation screen were normal and medications were non-contributory. The patient underwent left axillary lymphadenectomy 3 days thereafter, and the main tumour mass was found to be at least 2 cm in width, and easily separable, both surgically and histologically, from the overlying subcutaneous skin flap, and with no obvious tumour haematoma extending into the skin. The ‘bruise’ overlying the nodal mass was not excised, but a 3-mm punch biopsy revealed no evidence of malignancy within that skin. Furthermore, the bruise disappeared spontaneously within 3 days of the surgery. Five of the 45 lymph nodes recovered, including the main mass, contained metastatic malignant melanoma with extracapsular spread. At the time of lymphadenectomy, a further pigmented lesion was noted on the posterior aspect of the ipsilateral

Transoral robotic surgery for residual and recurrent oropharyngeal cancers: Exploratory study of surgical innovation using the IDEAL framework for early‐phase surgical studies

The purpose of this study was to identify the role of transoral robotic surgery (TORS) in the management of residual and recurrent oropharyngeal cancer.