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The coronal incision revisited
British Journal of Oral and Maxillofaciai Surgery (1994) 32, 267-269 0 1994 The British Association of Oral and Maxillofacial Surgeons
Journal Abstracts Permanent Iodine-125 Implants in postoperative radiotherapy for bead and neck cancer with positive surgical margins. B. Vikvunz, M Shuntilata Head Neck 16(2): 155-157.
38 patients. This retrospective study tries to evaluate the efficacy of this approach in three treatment groups. Group 1 (14 patients) had previous proplast-teflon TMJ implants which failed; group 2 (10 patients) had inflammatory TMJ pathology without proplastteflon TMJ implants and group 3 (14 patients) had noninflammatory joint deformities and no previous proplast-teflon. The ages ranged from 3 to 55 years and follow up averaged 45 months with a range of 10 to 84 months. The specifics of the technique are discussed in the article. The authors treated these patients with a plethora of other assorted surgeries including sagittal splits on the contralateral sides, body osteotomies, subapical osteotomies and genioplasties, as well as LeFort level osteotomies. No sound conclusions can be drawn from the article relative to this technique when such a variety of treatments had been used. The authors did give criteria for success, which included significant decrease in pain, stable functional occlusion and adequate mobility. In group 1 (previous proplast-teflon grafts) 14 patients with 24 joints were reconstructed. Success was only noted in 4 patients (29%). Failures included ankylosis, unresolved pain or continued giant cell reaction and graft destruction. Group 2 (inflammatory TMJ pathology without proplast-teflon grafts previously) included 10 patients with 14 joints and had a 50% success rate. Failures included fibrous or bony ankylosis, degenerative changes or pain. Group 3 included patients with hemi-facial microsomia, fractured displaced condyles, condylar hyper or hypoplasia and previous tumors. There were 14 patients with 14 joints included in this group. Success rate was 93% with only one’failure in a S-year old with hemi-facial microsomia whose graft fractured 6 weeks post surgery. The authors do not discuss the frequency of previous surgeries in the groups. It would seem reasonable to expect a lower success rate and a change in the incidence of expected pain and function recovery in a group of patients having previous teflon proplast implants. Also this group is certainly not similar to the other groups in that it had 14 patients with 24 joints operated, where group 3 had 14 patients with 14 joints, Even though the success rate was markedly lower in group 1, I think that any surgical procedure for these patients would have been expected to have a much decreased success rate. No objective data for failure is given. This is a major criticism of the article. Donor site morbidity received scant attention in the article. They report a 10% complication rate of postsurgical clavicular fracture, but do not discuss the ramifications of this. Reading the article, one would easily imagine this a benign surgical procedure, however, the potential complications, glossed over in the article can be catastrophic to the patient. Finally, the authors condemn the procedure in the toughest cases (post-proplast-teflon reconstruction) and recommended in group 3 which would have predictably had success with a number of less potentially morbid procedures. The article is well written and interesting, however, is not a scientific approach to the problem. This is more a compendium of case studies with very little in the way of hard date and cannot yet be considered as a replacement for more traditional time tested joint reconstruction procedures. Requests for reprints: Dr Larry Wolford, 3409 Worth Street, Sammons Tower, Suite 400, Dallas, Texas 75246, USA. D. E. Frost Chapel Hill USA
This short paper describes a prospective study of 25 consecutive patients treated surgically for cancer of the upper aerodigestive tract whose resection margins at the site of the primary tumour were histologically positive. These patients were treated subsequent to surgery with conventional external beam radiotherapy from a Cobalt-60 source to both the primary site and the neck (dosages and fractionation regimens are described). Additionally permanent I-125 implantation in the area of resection was performed following the last dose of external irradiation. The method of implantation, source strength and calculated dose rates are also given. Chemotherapy was not given. Results fail to reveal any morbidity or mortality relating to the presence of the implant over a 5-year follow up. A disease-free survival rate of 75% at 1 year and 65% at 2 years is quoted. This would appear to compare favourably with local tumour control rates in other studies in which I-125 implantation was not utilised. The authors accept that a larger trial is needed to prove that local control is truly better using this technique however. The authors of this paper are both radiation oncologists which presumably explains the selected nature of their patients. However, the question that the reader of this paper is tempted to ask is why surgical treatment seems so often to be inadequate. Drs Vikram and Mishra do not stress that whilst their technique may prove occasionally useful, the best local tumour control will depend on careful pre-operative assessment and meticulous surgical technique with inter-operative histological control if appropriate, such that tumour is not left behind. A surgeon’s confidence in his re-constructive abilities will also ensure that he does not feel constrained as to the extent of his resection. N. M. Whear West Midlands
The coronal incision revisited. 17 R. Reconstr Surg 1993; 91: 185-187.
&funro,
J. A. Fearon.
Plast
The authors state that whilst the straight line coronal incision is often cosmetically acceptable the resulting scar may cause the hair to part away from it, especially when wet, resulting in a very visible defect. They claim that this late problem is more likely to occur in Caucasian patients who wear their hair short or in Afro-Caribbean patients. A modified incision termed the ‘stealth incision’ is discussed, This has been &ed successfully in over 200 cases. The concept of invisibility of the scar and the shape of the stealth bomber suggested the name of the stealth approach! The potential for ,greater blood loss from this longer incision is reduced by use of the Colorado microneedle for both skin incision and subsequent dissection. This has the added advantage of eliminating the need for Ranny clips. The reader is informed that the senior author no longer shaves his patients for this approach and has not done so for 11 years with no resulting increase in morbidity. .:.,: N. M. Whear West Midlands
Sternoclavicular grafts for temporomandibular L. M. Woljbvd, D. A. Cottrell, C. Henry. 1994; 52: 119-128. Dr Wolford reports (TMJ) reconstruction
joint reconstruction. J Oral Maxillofac Surg Factors influencing combined orthognathic and rhinoplastic surgery. D. A. Cottrell, L. MY Woljord. Adult Orthodontic Orthognathic Surgery 1993; 8: 265-276.
his experience in temporomandibular joint using sternoclavicular grafts in 52 joints of 267
Journal Abstracts Permanent Iodine-125 Implants in postoperative radiotherapy for bead and neck cancer with positive surgical margins. B. Vikvunz, M Shuntilata Head Neck 16(2): 155-157.
38 patients. This retrospective study tries to evaluate the efficacy of this approach in three treatment groups. Group 1 (14 patients) had previous proplast-teflon TMJ implants which failed; group 2 (10 patients) had inflammatory TMJ pathology without proplastteflon TMJ implants and group 3 (14 patients) had noninflammatory joint deformities and no previous proplast-teflon. The ages ranged from 3 to 55 years and follow up averaged 45 months with a range of 10 to 84 months. The specifics of the technique are discussed in the article. The authors treated these patients with a plethora of other assorted surgeries including sagittal splits on the contralateral sides, body osteotomies, subapical osteotomies and genioplasties, as well as LeFort level osteotomies. No sound conclusions can be drawn from the article relative to this technique when such a variety of treatments had been used. The authors did give criteria for success, which included significant decrease in pain, stable functional occlusion and adequate mobility. In group 1 (previous proplast-teflon grafts) 14 patients with 24 joints were reconstructed. Success was only noted in 4 patients (29%). Failures included ankylosis, unresolved pain or continued giant cell reaction and graft destruction. Group 2 (inflammatory TMJ pathology without proplast-teflon grafts previously) included 10 patients with 14 joints and had a 50% success rate. Failures included fibrous or bony ankylosis, degenerative changes or pain. Group 3 included patients with hemi-facial microsomia, fractured displaced condyles, condylar hyper or hypoplasia and previous tumors. There were 14 patients with 14 joints included in this group. Success rate was 93% with only one’failure in a S-year old with hemi-facial microsomia whose graft fractured 6 weeks post surgery. The authors do not discuss the frequency of previous surgeries in the groups. It would seem reasonable to expect a lower success rate and a change in the incidence of expected pain and function recovery in a group of patients having previous teflon proplast implants. Also this group is certainly not similar to the other groups in that it had 14 patients with 24 joints operated, where group 3 had 14 patients with 14 joints, Even though the success rate was markedly lower in group 1, I think that any surgical procedure for these patients would have been expected to have a much decreased success rate. No objective data for failure is given. This is a major criticism of the article. Donor site morbidity received scant attention in the article. They report a 10% complication rate of postsurgical clavicular fracture, but do not discuss the ramifications of this. Reading the article, one would easily imagine this a benign surgical procedure, however, the potential complications, glossed over in the article can be catastrophic to the patient. Finally, the authors condemn the procedure in the toughest cases (post-proplast-teflon reconstruction) and recommended in group 3 which would have predictably had success with a number of less potentially morbid procedures. The article is well written and interesting, however, is not a scientific approach to the problem. This is more a compendium of case studies with very little in the way of hard date and cannot yet be considered as a replacement for more traditional time tested joint reconstruction procedures. Requests for reprints: Dr Larry Wolford, 3409 Worth Street, Sammons Tower, Suite 400, Dallas, Texas 75246, USA. D. E. Frost Chapel Hill USA
This short paper describes a prospective study of 25 consecutive patients treated surgically for cancer of the upper aerodigestive tract whose resection margins at the site of the primary tumour were histologically positive. These patients were treated subsequent to surgery with conventional external beam radiotherapy from a Cobalt-60 source to both the primary site and the neck (dosages and fractionation regimens are described). Additionally permanent I-125 implantation in the area of resection was performed following the last dose of external irradiation. The method of implantation, source strength and calculated dose rates are also given. Chemotherapy was not given. Results fail to reveal any morbidity or mortality relating to the presence of the implant over a 5-year follow up. A disease-free survival rate of 75% at 1 year and 65% at 2 years is quoted. This would appear to compare favourably with local tumour control rates in other studies in which I-125 implantation was not utilised. The authors accept that a larger trial is needed to prove that local control is truly better using this technique however. The authors of this paper are both radiation oncologists which presumably explains the selected nature of their patients. However, the question that the reader of this paper is tempted to ask is why surgical treatment seems so often to be inadequate. Drs Vikram and Mishra do not stress that whilst their technique may prove occasionally useful, the best local tumour control will depend on careful pre-operative assessment and meticulous surgical technique with inter-operative histological control if appropriate, such that tumour is not left behind. A surgeon’s confidence in his re-constructive abilities will also ensure that he does not feel constrained as to the extent of his resection. N. M. Whear West Midlands
The coronal incision revisited. 17 R. Reconstr Surg 1993; 91: 185-187.
&funro,
J. A. Fearon.
Plast
The authors state that whilst the straight line coronal incision is often cosmetically acceptable the resulting scar may cause the hair to part away from it, especially when wet, resulting in a very visible defect. They claim that this late problem is more likely to occur in Caucasian patients who wear their hair short or in Afro-Caribbean patients. A modified incision termed the ‘stealth incision’ is discussed, This has been &ed successfully in over 200 cases. The concept of invisibility of the scar and the shape of the stealth bomber suggested the name of the stealth approach! The potential for ,greater blood loss from this longer incision is reduced by use of the Colorado microneedle for both skin incision and subsequent dissection. This has the added advantage of eliminating the need for Ranny clips. The reader is informed that the senior author no longer shaves his patients for this approach and has not done so for 11 years with no resulting increase in morbidity. .:.,: N. M. Whear West Midlands
Sternoclavicular grafts for temporomandibular L. M. Woljbvd, D. A. Cottrell, C. Henry. 1994; 52: 119-128. Dr Wolford reports (TMJ) reconstruction
joint reconstruction. J Oral Maxillofac Surg Factors influencing combined orthognathic and rhinoplastic surgery. D. A. Cottrell, L. MY Woljord. Adult Orthodontic Orthognathic Surgery 1993; 8: 265-276.
his experience in temporomandibular joint using sternoclavicular grafts in 52 joints of 267