- Email: [email protected]
P50 Use of palatal mucosal grafts for upper and lower eyelid reconstruction – a case report
Posters / British Journal of Oral and Maxillofacial Surgery 48 (2010) S25–S55
implants, which is more conservative and allows for greater preservation of buccal bone volume, therefore allowing the same site to be used for implant placement at a later date. P46 ADIA – a revolution in dental implantology audit software N.J. Perkins1 , S. Byfield2 , K. Joshi3 . 1 St. Helen’s Dental Practice, Cumbria; 2 James Hull Dental Care, The Raglan Suite, Harrogate; 3 Dental Focus Web Design, UK ADIA (Association of Dental Implantology Audit) is an innovative web-based audit program that was launched in July 2008. It is available free of charge to ADI members (www.adi.org.uk/ profession/membership/adia.htm), and there are over 300 members currently using this bespoke software. There are many benefits to clinicians of using ADIA including: (1) Meeting GDC audit recommendations (‘Training Standards in Implant Dentistry for General Dental Practitioners’, 2008); (2) Auditing their success rates (e.g. implant system, implant position, grafted/non-grafted sites, practice location) and providing data on any complications; (3) Monitoring the progress of implant patients on their treatment journey (e.g. implants waiting to be loaded; recalls); (4) Enabling secure patient data sharing for surgeon, prosthodontist and technician. The next phase of development for ADIA will involve a background audit, which will be able to provide anonymised data for the United Kingdom on a range of implant systems and clinical variables (e.g. success rates for immediate vs. delayed implant placement, onlay grafting vs. GBR techniques; trends towards implant types, lengths, and diameters in various sites). There has been interest in ADIA from Europe and the USA, and as the software continues to evolve, it has the potential to become a global audit program. This type of software may also find innovative applications in other disciplines in medicine and dentistry, including Oral and Maxillofacial Surgery. The purpose of this poster is to provide an overview of the ADIA audit software for those Oral and Maxillofacial Surgeons (and trainees) who have an interest in dental implantology. P47 How to reduce Did Not Attend (DNA) rates and achieve treatment targets in a NHS Foundation Hospital in the UK L.H.H. Cheng, A. Walton, H. Conway, D. James, F. Canning, P. White, S. Franklin, V. Harrison, A. Ezsias, E. Ali, S. Ratcliffe, R. Qureshi. Department of Oral and Maxillofacial Surgery, Homerton University Hospital, London, UK Introduction: 18 week targets have become the common aim and daily reference among hospital managers and clinicians. In order to achieve waiting list targets and to maximise theatre utilisation in our expanding service, we have appointed a dedicated Booked Admission Officer (BAO) to reduce DNA rates and enhance efficiency of our service. Materials and Methods: Data collected from Electronic Patient Records before and after the appointment of a dedicated BAO. Results: With the establishment of neck lump, facial skin cancer, lumps and bumps, thyroid, oral/dental clinics, the total number of surgery performed increased 7 fold from 167 in 2006 to 1,189 in 2008. A further 60% increase was expected in 2009 to 1,897 cases. The DNA rates before and after the appointment of BAO were 30% and 7% respectively. This also led to a significant increase in theatre utilisation and improved use of resources. Discussion: Patient DNA is contributed to by an inefficient booking system, insufficient or lack of communication with patient and
S37
carers, and patient choice. Good team-working between clinicians and managers is key to achieve waiting list targets. By reducing DNA rates and increasing theatre utilisation, 11 week targets have been achieved and we are now aiming at a 5 week target. Conclusions: The creation of a dedicated BAO working along side clinicians is essential to ensure low DNA rates and high theatre utilisation which are basic ingredients to further reducing the waiting time targets to 5 weeks in our hospital. P48 A technical note: Torus palatinus exposure for surgical reduction J. Christou, G. Gillan, A. Qureshi, P. Hardee. Whipps Cross University Hospital, London, UK The long established surgical technique for exposure of the torus palatinus is the localised antero-posterior incision over the torus. This can be a fiddly task and iatrogenic soft tissue trauma to the muco-periosteal flap frequently occurs. Herein, we describe a technique for suture-retained flap retraction which enables the solo surgeon to perform the operation effectively. This brief technical note offers the reader a simple change to the commonly practised method with generous access to the torus but reduced iatrogenic trauma to the mucosa. P49 Implementing of the ‘WHO Surgical Safety Checklist’ in an outpatients setting – an audit D. Hani, P.K. Sedani, P. Hardee, C. Bridle, N. Ali, N. Nasser. Whipps Cross University Hospital, UK Introduction: Wrong site surgery is a preventable adverse event; however, such events do occur. Oral and Maxillofacial Surgeons, Dental and Medical Practitioners should maintain their duty of care towards patients by maintaining high standards and prioritising safety. The error of a wrong tooth extraction accounted for 83 per cent of serious untoward incidents in oral and dental treatments. Following an incident of a wrong tooth extraction in our department, it was felt that a change in practice was required to minimize the risk of further serious untoward incidents. Methods: An Outpatients Surgical Safety Checklist was instituted and white boards, on which the teeth to be extracted were marked clearly in every surgical setting to prevent a repeat mishap. The Outpatients Surgical Safety Checklist was adapted from World Health Organisation Surgical Safety Checklist published in 2008. We are probably one of the first hospital departments to have implemented this checklist in an Out-Patient setting. A Prospective Audit was designed to assess and to investigate the compliance of all members of staff with the new checklist. Results: A total of 382 Surgical Checklists were collected for a period of two months. All forms were found to be fully completed by all members of staff correctly. This resulted in 100% compliance with the guidelines. Conclusions: Compliance with the WHO Surgical Checklist ensures patients safety and prevents mistakes using the The Swiss cheese model of safety. P50 Use of palatal mucosal grafts for upper and lower eyelid reconstruction – a case report S. Saraf, N. Fanaras, A. Majumdar. Milton Keynes General Hospital and Luton and Dunstable Hospital, UK Grafts are used in eyelid reconstruction to augment eyelid tissues that are inadequate. Skin is replaced with relative ease, but the
S38
Posters / British Journal of Oral and Maxillofacial Surgery 48 (2010) S25–S55
tarsus and conjunctiva are much more difficult to reconstruct. The purpose of this well illustrated case report is to remind the facial reconstructive surgeon of the versatility, abundance and accessibility of the palatal mucosa which replaces the conjunctiva and tarsus with a single layer and retains its firmness after transplantation. A forty-nine year old man with an anophthalmic socket experienced difficulty in wearing his ocular prosthesis due to loss of inferior fornix depth and inadequate upper lid length. After failure of conventional reconstructive methods the inferior fornix was reconstructed successfully with palatal mucosal grafts. The upper lid length was restored in stages with the use of full thickness skin graft and the hard palate mucosal graft to enable retention of the ocular prosthesis. Keywords: Hard palate mucosal grafts, composite upper eyelid reconstruction, inferior fornix reconstruction. P51 The use of Tie-lok to secure endotracheal tube in challenging tracheostomy cases L.H.H. Cheng, A. Ezsias, L. Tham, R. Ghosh, D. Watson, C. Peters, E. Ali, S. Ratcliffe, S. Levy, C. Heron. Oral & Maxillofacial Surgery, Intensive Care and Tracheostomy Team, Homerton Hospital, London, UK Introduction: The use of adjustable flange tracheostomy tubes for patients with short thick neck have been well established. When the adjustable flange tracheostomy tube could not reach the trachea or when there was no smaller tube for downsizing procedure, endotracheal tube (ETT) have been used to secure artificial airway. We report 2 cases using Tie-lok drain ties to secure the ETT on neck skin. Case 1: 75 year old lady with an adjustable flange tracheostomy tube became dislodged towards the tracheal window. An ETT was inserted and secured on skin with an adhesive impermeable tape and then 2 Tie-lok ties. Case 2: 65 year old lady who had 2 previous tracheostomy was not suitable for percutaneous tracheostomy due to a deviated step-wise stenotic trachea. An adjustable flange tracheostomy tube was used but the locking ring became loose and the tube was dislodged. As there was no smaller adjustable flange tracheostomy tube, a paediatric ETT was used and secured with 2 Tie-lok ties. Discussion: The security of artificial airway is paramount to maintain airway in challenging necks. The adhesive tapes only provide temporary anchorage to skin. Tie-lok drain tie provides an alternative to sticky tapes with good grip and good skin hygiene maintenance. Conclusion: In unusual cases of using EET instead of ordinary tracheostomy tube, the security of the tube can be achieved by using Tie-lok drain ties. They provide a strong, slip-free grip to the ETT which is simple to use and maintain. P52 Use of tissue patch sealant film for treating chylous leak after major neck surgery L.H.H. Cheng, S. Heaton, G. Parker, all volunteer crew members. Bart & the London, and Homerton Hospitals, London and the Africa Mercy, Mercy Ships, UK Introduction: Chylous fistula is a rare but well recognized and serious complication following major neck surgery. Surgical exploration is often required after failed medical management in high fistula output. We report the use of Tissue Patch sealant film
on 2 patients as an adjunct to ensure effective seal to potential sources of chylous leak. Case Report 1: An African lady presented with an extensive left supraclavicular teratoma. It was excised and she developed a lower neck swelling. Surgical exploration revealed chylous leaks from 2 inferior and one mid cervical regions. They were ligated, oversewn and Tissue Patch Dural applied over 2 inferior leaks. Reexploration was required for further supraclavicular swelling and chylous leak was identified from a dilated mid cervical lymphatic channel. The other 2 previous leaks were dry. Case Report 2: A Caucasian gentleman with metastatic carcinoma of the neck underwent surgical investigation and was found to have primary tonsillar carcinoma. After neck dissection, he developed high output chylous leak despite medical treatment. Chylous leak was identified, oversewn and Tissue Patch 3 was applied. His neck remained dry and received postoperative chemoradiotherapy. Discussion: The Tissue Patch sealant film has been used to provide adhesive seal after dural repair, thoracic and liver surgery. The film conforms well with irregular surfaces of the soft tissue bed. It is biodegradable and safe to use. Conclusion: Tissue Patch sealant film has been found to be a useful adjunct to ensure effective seal to the potential sources of chylous leak after major neck surgery. P53 Is Desflurane superior to Sevoflurane in maximising theatre throughput and surgical training in busy day case oral and maxillofacial surgical operating theatre? L.H.H. Cheng, A. Mulcahy, H. Drewery, A. Rose. Barts and the London NHS Trust, London, UK Introduction: Oral and Maxillofacial and Anaesthetic training time is pressurised, consequently, trainees need to operate on as many patients as possible in shortened training time. Surgeons and anaesthetists are increasingly being scrutinised as to their efficiency of their theatre list. We therefore compared using Desflurane versus Sevoflurane as an anaesthetic agent to reduce anaesthetic turn round and recovery time. Method: 82 patients listed for Oral & Maxillofacial Surgical Day Surgery Unit at the Royal London Dental Hospital were given Desflurane or Sevoflurane by two consultant anaesthetists. Results: See the table.
Time between turning off anaesthetic agent and removal of laryngeal mask/tracheal tube Turn round time between cases Time between arriving at recovery and leaving the hospital
Average time (range), minutes Desflurane Sevoflurane
Student t test t p
9 (3–23)
9 (1–17)
0.393
10.7 (0–20)
21.68 (10–46)
4.5
<0.0001
79.4 (46–133)
66.79 (42–110)
2.64
0.01
0.7
Discussion: In a climate where anaesthetists are single handed and income generation for the Trust, an increase in the number of theatre cases are encouraged. The profile of Desflurane should theoretically allow increased number of patient on the list because of faster turn round time. Conclusion: The superior pharmacological profile of Desflurane is demonstrated in the turn around data which infers that the anaesthetist is delaying starting the subsequent case in the Sevoflurane group comparing with the Desflurane group, even when the airway device been removed. This implies that the quality of first stage recovery is better in the Desflurane group.
implants, which is more conservative and allows for greater preservation of buccal bone volume, therefore allowing the same site to be used for implant placement at a later date. P46 ADIA – a revolution in dental implantology audit software N.J. Perkins1 , S. Byfield2 , K. Joshi3 . 1 St. Helen’s Dental Practice, Cumbria; 2 James Hull Dental Care, The Raglan Suite, Harrogate; 3 Dental Focus Web Design, UK ADIA (Association of Dental Implantology Audit) is an innovative web-based audit program that was launched in July 2008. It is available free of charge to ADI members (www.adi.org.uk/ profession/membership/adia.htm), and there are over 300 members currently using this bespoke software. There are many benefits to clinicians of using ADIA including: (1) Meeting GDC audit recommendations (‘Training Standards in Implant Dentistry for General Dental Practitioners’, 2008); (2) Auditing their success rates (e.g. implant system, implant position, grafted/non-grafted sites, practice location) and providing data on any complications; (3) Monitoring the progress of implant patients on their treatment journey (e.g. implants waiting to be loaded; recalls); (4) Enabling secure patient data sharing for surgeon, prosthodontist and technician. The next phase of development for ADIA will involve a background audit, which will be able to provide anonymised data for the United Kingdom on a range of implant systems and clinical variables (e.g. success rates for immediate vs. delayed implant placement, onlay grafting vs. GBR techniques; trends towards implant types, lengths, and diameters in various sites). There has been interest in ADIA from Europe and the USA, and as the software continues to evolve, it has the potential to become a global audit program. This type of software may also find innovative applications in other disciplines in medicine and dentistry, including Oral and Maxillofacial Surgery. The purpose of this poster is to provide an overview of the ADIA audit software for those Oral and Maxillofacial Surgeons (and trainees) who have an interest in dental implantology. P47 How to reduce Did Not Attend (DNA) rates and achieve treatment targets in a NHS Foundation Hospital in the UK L.H.H. Cheng, A. Walton, H. Conway, D. James, F. Canning, P. White, S. Franklin, V. Harrison, A. Ezsias, E. Ali, S. Ratcliffe, R. Qureshi. Department of Oral and Maxillofacial Surgery, Homerton University Hospital, London, UK Introduction: 18 week targets have become the common aim and daily reference among hospital managers and clinicians. In order to achieve waiting list targets and to maximise theatre utilisation in our expanding service, we have appointed a dedicated Booked Admission Officer (BAO) to reduce DNA rates and enhance efficiency of our service. Materials and Methods: Data collected from Electronic Patient Records before and after the appointment of a dedicated BAO. Results: With the establishment of neck lump, facial skin cancer, lumps and bumps, thyroid, oral/dental clinics, the total number of surgery performed increased 7 fold from 167 in 2006 to 1,189 in 2008. A further 60% increase was expected in 2009 to 1,897 cases. The DNA rates before and after the appointment of BAO were 30% and 7% respectively. This also led to a significant increase in theatre utilisation and improved use of resources. Discussion: Patient DNA is contributed to by an inefficient booking system, insufficient or lack of communication with patient and
S37
carers, and patient choice. Good team-working between clinicians and managers is key to achieve waiting list targets. By reducing DNA rates and increasing theatre utilisation, 11 week targets have been achieved and we are now aiming at a 5 week target. Conclusions: The creation of a dedicated BAO working along side clinicians is essential to ensure low DNA rates and high theatre utilisation which are basic ingredients to further reducing the waiting time targets to 5 weeks in our hospital. P48 A technical note: Torus palatinus exposure for surgical reduction J. Christou, G. Gillan, A. Qureshi, P. Hardee. Whipps Cross University Hospital, London, UK The long established surgical technique for exposure of the torus palatinus is the localised antero-posterior incision over the torus. This can be a fiddly task and iatrogenic soft tissue trauma to the muco-periosteal flap frequently occurs. Herein, we describe a technique for suture-retained flap retraction which enables the solo surgeon to perform the operation effectively. This brief technical note offers the reader a simple change to the commonly practised method with generous access to the torus but reduced iatrogenic trauma to the mucosa. P49 Implementing of the ‘WHO Surgical Safety Checklist’ in an outpatients setting – an audit D. Hani, P.K. Sedani, P. Hardee, C. Bridle, N. Ali, N. Nasser. Whipps Cross University Hospital, UK Introduction: Wrong site surgery is a preventable adverse event; however, such events do occur. Oral and Maxillofacial Surgeons, Dental and Medical Practitioners should maintain their duty of care towards patients by maintaining high standards and prioritising safety. The error of a wrong tooth extraction accounted for 83 per cent of serious untoward incidents in oral and dental treatments. Following an incident of a wrong tooth extraction in our department, it was felt that a change in practice was required to minimize the risk of further serious untoward incidents. Methods: An Outpatients Surgical Safety Checklist was instituted and white boards, on which the teeth to be extracted were marked clearly in every surgical setting to prevent a repeat mishap. The Outpatients Surgical Safety Checklist was adapted from World Health Organisation Surgical Safety Checklist published in 2008. We are probably one of the first hospital departments to have implemented this checklist in an Out-Patient setting. A Prospective Audit was designed to assess and to investigate the compliance of all members of staff with the new checklist. Results: A total of 382 Surgical Checklists were collected for a period of two months. All forms were found to be fully completed by all members of staff correctly. This resulted in 100% compliance with the guidelines. Conclusions: Compliance with the WHO Surgical Checklist ensures patients safety and prevents mistakes using the The Swiss cheese model of safety. P50 Use of palatal mucosal grafts for upper and lower eyelid reconstruction – a case report S. Saraf, N. Fanaras, A. Majumdar. Milton Keynes General Hospital and Luton and Dunstable Hospital, UK Grafts are used in eyelid reconstruction to augment eyelid tissues that are inadequate. Skin is replaced with relative ease, but the
S38
Posters / British Journal of Oral and Maxillofacial Surgery 48 (2010) S25–S55
tarsus and conjunctiva are much more difficult to reconstruct. The purpose of this well illustrated case report is to remind the facial reconstructive surgeon of the versatility, abundance and accessibility of the palatal mucosa which replaces the conjunctiva and tarsus with a single layer and retains its firmness after transplantation. A forty-nine year old man with an anophthalmic socket experienced difficulty in wearing his ocular prosthesis due to loss of inferior fornix depth and inadequate upper lid length. After failure of conventional reconstructive methods the inferior fornix was reconstructed successfully with palatal mucosal grafts. The upper lid length was restored in stages with the use of full thickness skin graft and the hard palate mucosal graft to enable retention of the ocular prosthesis. Keywords: Hard palate mucosal grafts, composite upper eyelid reconstruction, inferior fornix reconstruction. P51 The use of Tie-lok to secure endotracheal tube in challenging tracheostomy cases L.H.H. Cheng, A. Ezsias, L. Tham, R. Ghosh, D. Watson, C. Peters, E. Ali, S. Ratcliffe, S. Levy, C. Heron. Oral & Maxillofacial Surgery, Intensive Care and Tracheostomy Team, Homerton Hospital, London, UK Introduction: The use of adjustable flange tracheostomy tubes for patients with short thick neck have been well established. When the adjustable flange tracheostomy tube could not reach the trachea or when there was no smaller tube for downsizing procedure, endotracheal tube (ETT) have been used to secure artificial airway. We report 2 cases using Tie-lok drain ties to secure the ETT on neck skin. Case 1: 75 year old lady with an adjustable flange tracheostomy tube became dislodged towards the tracheal window. An ETT was inserted and secured on skin with an adhesive impermeable tape and then 2 Tie-lok ties. Case 2: 65 year old lady who had 2 previous tracheostomy was not suitable for percutaneous tracheostomy due to a deviated step-wise stenotic trachea. An adjustable flange tracheostomy tube was used but the locking ring became loose and the tube was dislodged. As there was no smaller adjustable flange tracheostomy tube, a paediatric ETT was used and secured with 2 Tie-lok ties. Discussion: The security of artificial airway is paramount to maintain airway in challenging necks. The adhesive tapes only provide temporary anchorage to skin. Tie-lok drain tie provides an alternative to sticky tapes with good grip and good skin hygiene maintenance. Conclusion: In unusual cases of using EET instead of ordinary tracheostomy tube, the security of the tube can be achieved by using Tie-lok drain ties. They provide a strong, slip-free grip to the ETT which is simple to use and maintain. P52 Use of tissue patch sealant film for treating chylous leak after major neck surgery L.H.H. Cheng, S. Heaton, G. Parker, all volunteer crew members. Bart & the London, and Homerton Hospitals, London and the Africa Mercy, Mercy Ships, UK Introduction: Chylous fistula is a rare but well recognized and serious complication following major neck surgery. Surgical exploration is often required after failed medical management in high fistula output. We report the use of Tissue Patch sealant film
on 2 patients as an adjunct to ensure effective seal to potential sources of chylous leak. Case Report 1: An African lady presented with an extensive left supraclavicular teratoma. It was excised and she developed a lower neck swelling. Surgical exploration revealed chylous leaks from 2 inferior and one mid cervical regions. They were ligated, oversewn and Tissue Patch Dural applied over 2 inferior leaks. Reexploration was required for further supraclavicular swelling and chylous leak was identified from a dilated mid cervical lymphatic channel. The other 2 previous leaks were dry. Case Report 2: A Caucasian gentleman with metastatic carcinoma of the neck underwent surgical investigation and was found to have primary tonsillar carcinoma. After neck dissection, he developed high output chylous leak despite medical treatment. Chylous leak was identified, oversewn and Tissue Patch 3 was applied. His neck remained dry and received postoperative chemoradiotherapy. Discussion: The Tissue Patch sealant film has been used to provide adhesive seal after dural repair, thoracic and liver surgery. The film conforms well with irregular surfaces of the soft tissue bed. It is biodegradable and safe to use. Conclusion: Tissue Patch sealant film has been found to be a useful adjunct to ensure effective seal to the potential sources of chylous leak after major neck surgery. P53 Is Desflurane superior to Sevoflurane in maximising theatre throughput and surgical training in busy day case oral and maxillofacial surgical operating theatre? L.H.H. Cheng, A. Mulcahy, H. Drewery, A. Rose. Barts and the London NHS Trust, London, UK Introduction: Oral and Maxillofacial and Anaesthetic training time is pressurised, consequently, trainees need to operate on as many patients as possible in shortened training time. Surgeons and anaesthetists are increasingly being scrutinised as to their efficiency of their theatre list. We therefore compared using Desflurane versus Sevoflurane as an anaesthetic agent to reduce anaesthetic turn round and recovery time. Method: 82 patients listed for Oral & Maxillofacial Surgical Day Surgery Unit at the Royal London Dental Hospital were given Desflurane or Sevoflurane by two consultant anaesthetists. Results: See the table.
Time between turning off anaesthetic agent and removal of laryngeal mask/tracheal tube Turn round time between cases Time between arriving at recovery and leaving the hospital
Average time (range), minutes Desflurane Sevoflurane
Student t test t p
9 (3–23)
9 (1–17)
0.393
10.7 (0–20)
21.68 (10–46)
4.5
<0.0001
79.4 (46–133)
66.79 (42–110)
2.64
0.01
0.7
Discussion: In a climate where anaesthetists are single handed and income generation for the Trust, an increase in the number of theatre cases are encouraged. The profile of Desflurane should theoretically allow increased number of patient on the list because of faster turn round time. Conclusion: The superior pharmacological profile of Desflurane is demonstrated in the turn around data which infers that the anaesthetist is delaying starting the subsequent case in the Sevoflurane group comparing with the Desflurane group, even when the airway device been removed. This implies that the quality of first stage recovery is better in the Desflurane group.