Professor Carrie Newlands

Two cases of benign lymphoid hyperplasia (BLH) of the palate are reported. The histologic appearances are those of a benign or reactive lymphoid aggregate and correlate well with other published accounts of this lesion. Using a battery of antileukocyte antibodies suitable for formalin-fixed tissue, analysis of the antigenic profile of oral BLH has been performed. The results indicate its benign nature: the germinal centres show tingible-body macrophages and polyclonal light chain restriction, the mantle zones are composed of both mature and immature B-cells, and the extramantle zones contain both B- and T-lymphocytes, plasma cells, macrophages, polymorphonuclear leukocytes and eosinophils. The histologic and immunohistochemical features are those of a benign rather than malignant proliferation of lymphocytes. This is in agreement with published accounts of long-term follow-up, which have found no correlation between BLH in the mouth with either malignant association or malignant transformation.

We report a case of adenosquamous carcinoma that arose in the maxillary alveolus of a 61-year-old woman, metastasized rapidly to submandibular and deep cervical lymph nodes, and caused death in spite of surgery and radiotherapy. Our case highlights the aggressive behavior associated with this tumor when it occurs in the oral cavity and at most other body sites. In addition, the oral adenosquamous carcinoma may not be as rare as the small number of reported cases might suggest because the adenocarcinoma component may form a very small proportion of the tumor as in our case, and the histopathologic criteria for diagnosis are not clearly established. Thus some cases of adenosquamous carcinoma may not be recognized as such. This underlines the important role of the histopathologist in the diagnosis of oral cancer by the recognition of specific subtypes of cancer and their associated prognostic significance.

Process mapping in industry is a well-established tool to improve efficiency. It is defined as a quality improvement technique that breaks down a process, or task, into its individual components, or steps, then analyses it. Lean principles are used to reduce waste and produce consistently good outcomes. Improving the operative efficiency of orthognathic surgery has many benefits. There is increasing demand for this complex surgery, and patients have appropriately high expectations with relation to their outcome. There are also increasing pressures for hospitals to reduce costs. In a recent paper by our group (Bowe et al, in press), we have published operating times for orthognathic procedures that are significantly shorter than in previously available series, with an average time for a bimaxillary osteotomy of 2 hours and 19 mins. Through observation of the senior authors' uniform technique, refined from experience of over 2,000 cases, a bimaxillary osteotomy was broken down into individual steps, all arranged in a process-mapped template with which to increase efficiency and results. We show here the multiple small operative efficiencies we have developed, and the Lean surgical principles which we use. This has enabled us to reduce the operative time of these common procedures, without compromising outcomes. This study presents an approach to process map bimaxillary orthognathic operations and shows how the application of Lean principles improves operative efficiency, and produces consistent results. (C) 2020 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

This is the third of three articles that give an overview of the current evidence for management of the neck and parotid in patients with cutaneous cancers of the head and neck. In this paper we discuss Merkel cell carcinoma (MCC) and review the latest evidence for management of the regional nodes. Crown Copyright (C) 2019 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons. All rights reserved.

The 8th edition of TNM (tumour, node and metastasis) has numerous and important changes compared with the 7th edition. Public Health England and the Royal College of Pathologists, U.K., have adopted the 8th edition of TNM (TNM8) published by the Union for International Cancer Control for skin cancer staging. These changes will have an impact on the management and commissioning of melanoma and nonmelanoma skin cancer (NMSC). The T1-T3 categories for NMSC staging require the clinician to measure the maximum dimension (usually diameter) of every potential invasive cancer. For squamous, basal and adnexal carcinomas, but not Merkel cell carcinoma (MCC), the T1-T3 categories are defined by new 20-mm and 40-mm divisions based on the maximum dimension of the lesion. In addition, new risk factors upstage T1 or T2 to T3. For melanoma, mitotic index no longer influences separation of pathological stage (pT1). There is a new, additional stratification level at 08-mm Breslow thickness. Subdivision pT1b, with a negative sentinel lymph node biopsy (SLNB) of pN0, is now stage IA compared with the previous IB. For MCC, SLNB is now included specifically in the pN staging system. The pT1 subdivision requires clinical information as to whether histologically involved nodes were clinically occult or detectable. For both melanoma and MCC the clinician must state whether the lymph nodes are occult or clinically detectable. Eyelid carcinoma continues to have a staging system different from that in general skin and the system is substantially revised in TNM8.

Although several studies have reported the use of reinnervated microvascular free flaps for oro-pharyngeal reconstruction, it has been known for some time that non-innervated flaps demonstrate spontaneous sensory recovery. This study sought to evaluate the degree of such spontaneous recovery in 50 radial forearm flaps used for mucosal reconstruction of head and neck ablative defects. The recovery of sensation to pinprick, light touch and temperature was tested a mean of 38 months (range 15–71) after surgical insetting. Two-point discrimination was also sought. Although 18 flaps (36%) remained anaesthetic, partial recovery in one or more modalities was present in 28 patients (56%). A recovery in all modalities of sensation in at least two-thirds of the flap area was recorded in 4 patients (8%). The mean 2-point static discrimination for fascio-cutaneous flaps was 18.9 mm.

ObjectivesWe aimed to determine the prevalence of low back pain (LBP) in sport, and what risk factors were associated with LBP in athletes.DesignSystematic review with meta-analysis.Data sourcesLiterature searches from database inception to June 2019 in Medline, Embase, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Web of Science and Scopus, supplemented by grey literature searching.Eligibility criteriaStudies evaluating prevalence of LBP in adult athletes across all sports.ResultsEighty-six studies were included (30 732, range 20–5958, participants), of which 45 were of ‘high’ quality. Definitions of LBP varied widely, and in 17 studies, no definition was provided. High-quality studies were pooled and the mean point prevalence across six studies was 42%; range 18%–80% (95% CI 27% to 58%, I2=97%). Lifetime prevalence across 13 studies was 63%; range 36%–88% (95% CI 51% to 74%, I2=99%). Twelve-month LBP prevalence from 22 studies was 51%; range 12%–94% (95% CI 41% to 61%, I2=98%). Comparison across sports was limited by participant numbers, study quality and methodologies, and varying LBP definitions. Risk factors for LBP included history of a previous episode with a pooled OR of 3.5; range 1.6–4.0 (95% CI 1.9 to 6.4). Statistically significant associations were reported for high training volume, periods of load increase and years of exposure to the sport.ConclusionLBP in sport is common but estimates vary. Current evidence is insufficient to identify which sports are at highest risk. A previous episode of LBP, high training volume, periods of load increase and years of exposure are common risk factors.

Tuberculosis (TB) of the temporomandibular joint (TMJ) is rare and misdiagnosis is common. We describe an unusual case of the disease in a 27-year-old Zimbabwean woman. (C) 2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

This overview is the first of 2 articles on the current evidence for management of the neck and parotid in cutaneous cancers of the head and neck. In this paper we discuss cutaneous squamous cell carcinoma (SCC) and review the latest evidence for management of the regional nodes. (C) 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

The incidence of skin cancer is increasing and surgery is the mainstay of management. The James Lind Alliance (JLA) priority setting partnership (PSP) was designed to address research uncertainties in skin cancer surgery. We report the outcome and top ten research priorities from the JLA PSP in skin cancer surgery.

Absorbable or non-absorbable sutures can be used for superficial skin closure following excisional skin surgery. There is no consensus among clinicians nor high-quality evidence supporting the choice of suture. The aim of the present study was to determine current suture use and complications at 30 days after excisional skin surgery. An international, prospective service evaluation of adults undergoing excision of skin lesions (benign and malignant) in primary and secondary care was conducted from 1 September 2020 to 15 April 2021. Routine patient data collected by UK and Australasian collaborator networks were uploaded to REDCap©. Choice of suture and risk of complications were modelled using multivariable logistic regression. Some 3494 patients (4066 excisions) were included; 3246 (92.9 per cent) were from the UK and Ireland. Most patients were men (1945, 55.7 per cent), Caucasian (2849, 81.5 per cent) and aged 75-84 years (965, 27.6 per cent). The most common clinical diagnosis was basal cell carcinoma (1712, 42.1 per cent). Dermatologists performed most procedures, with 1803 excisions (44.3 per cent) on 1657 patients (47.4 per cent). Most defects were closed primarily (2856, 81.9 per cent), and there was equipoise in regard to use of absorbable (2127, 57.7 per cent) or non-absorbable (1558, 42.2 per cent) sutures for superficial closure. The most common complications were surgical-site infection (103, 2.9 per cent) and delayed wound healing (77, 2.2 per cent). In multivariable analysis, use of absorbable suture type was associated with increased patient age, geographical location (UK and Ireland), and surgeon specialty (oral and maxillofacial surgery and plastic surgery), but not with complications. There was equipoise in suture use, and no association between suture type and complications. Definitive evidence from randomized trials is needed.

Sentinel lymph node biopsy (SLNB) is an accurate staging procedure for malignant melanoma but its use in patients with melanoma of the head and neck has been questioned in the past because of a perceived record of poor safety and accuracy. Technical improvements have sought to redress this. Vital structures and variable lymphatic pathways can make its use in the head and neck challenging. In our study we have examined the data and the experiences of clinicians from University Hospital Southampton and the Royal Surrey County Hospital. We retrospectively analysed the data and case notes of 143 patients who had SLNB to establish its safety, efficacy, and prognostic value. The detection rate of at least one sentinel lymph node was 100%. Nodes positive for metastatic melanoma were found in 20% of patients. Of them, 76% went on to have completion lymphadenectomy. Multivariate Cox regression analysis suggested that positive SLNB was a strong predictor of reduced overall survival for all Breslow-thickness melanomas (HR=3.9, p=0.019) and intermediate melanomas (HR=6.3, p=0.007). It predicted reduced recurrence-free survival for all melanomas (HR=7.4, p

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Orthognathic surgery improves quality of life in terms of oral function and facial aesthetics. Our aim was to establish and compare operative time and length of inpatient stay for orthognathic procedures, and to assess the reoperation rate. Departmental electronic data base was used to identify all patients undergoing orthognathic surgery in a single unit between the 01/01/2016 and the 01/08/2018. 251 patients were identified who underwent 409 orthognathic surgery procedures. The mean operating time for a bimaxillary osteotomy (n=107) was 139.3 min. For single jaw procedures, the mean operating time for a Le Fort I osteotomy (n= 42) was 82.2 min and for a bilateral sagittal split osteotomy (BSSO) (n= 102) was 80.3min. Bimaxillary osteotomy combined with genioplasty (n=17) this increased the operating time on average by 31 min. and of a BSSO combined with a genioplasty (n=14) by 27 mins. The mean postoperative hospital stay was 1.2 ± 0.2 days. 96.4% patients spent only one postoperative night in hospital. 6/251 (2.4%) patients required re-operation. In regression analysis, age was the only significant factor in increasing length of stay (p

Skin grafts are commonly used for reconstruction of defects following excision of facial skin cancers. Tie-over bolster dressings are routinely placed to secure these grafts, but are they necessary for healing or graft success? A total of 96 patients was treated from 2013-2019 who underwent full thickness skin graft (FTSG) reconstruction following facial skin cancer excision were retrospectively analysed. All patients were treated by one consultant with non-fenestrated FTSG's placed on defects varying from 10 to 55mm in maximum diameter. Grafts were sutured circumferentially with a continuous resorbable suture. Tie-over bolster dressings were not used, and the recipient site was dressed with Mepitel (TM) and Steristrips (TM). Primary defect sites where we used this technique included the pinna, the nose and face, and less commonly, the scalp. Graft harvest sites included the neck, pre-auricular, and submental regions. Complete graft take was noted in 94/96 patients. Partial graft failure was observed in two patients, one who healed and had successful late scar revision surgery and one who was managed conservatively and healed well. Two further patients with complete graft healing later underwent minimal revisional contour surgery with satisfactory results. This retrospective study has shown FTSG success in cutaneous defects of the head and neck to be excellent without the use of tie-over bolsters. This has significant benefits of saving operative time, reducing cost, and sparing the patient both unnecessary intraoperative steps, and the inconvenience of a bolster with its often-painful removal. We recommend that the use of tie-over bolsters in the management of most FTSG reconstructed head and neck cutaneous defects be considered an unnecessary step. We believe there are no adverse effects of our described simple technique, and that there are significant benefits to the patient. (c) 2022 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

We retrospectively reviewed the management at our centre of 25 patients with Merkel cell carcinoma (MCC) of the head and neck. We obtained details of the operation, including wide local excision, sentinel lymph node biopsy (SNB), neck dissection, postoperative radiotherapy, and clinical outcomes, from patients' records. All patients were white, 11 were men and 14 women, mean age at presentation 81 years (range 67-90). At the time of diagnosis, 18 patients had stage I disease, and 7 stage II disease. Twenty had wide local excision and radiotherapy, and 5 had wide local excision alone. Wide local excision and radiotherapy are successful treatments. In patients with no sign of metastases, SNB at the time of excision is a well-researched option and should be considered the gold standard of care.

This is the second of 2 articles giving an overview of the current evidence for management of the neck and parotid in cutaneous cancers of the head and neck. We discuss cutaneous malignant melanoma and review the latest evidence for management of the regional nodes.

The use of iodinated contrast material in radiography is contraindicated in patients with known iodine sensitivity and such patients may present a management dilemma. The successful use of gadolinium in contrast sialography is described.

Desmoplastic fibromas are rare, benign bone tumours, which often behave in a locally aggressive manner. In the head and neck region they are most commonly seen in the mandible and have been treated in various ways. We present an unusual presentation of the lesion, which was subsequently treated by the less commonly used technique of enucleation, with good results.

COVID-19 has resulted in an expansion of webinar-based teaching globally. Socially distanced e-learning is the new normal. The delivery of regional OMFS teaching programmes in the UK and the Republic of Ireland, for Specialty Trainees (ST's) under the Joint Committee on Surgical Training (JCST) and Intercollegiate Surgical Curriculum Programme (ISCP) umbrellas is variable. We recognised the need to provide additional teaching to supplement this teaching, at a time of crisis in our countries and healthcare systems, which had jointly led to a significant impact on the progression of training. The membership category of Specialty Trainees within the national specialty association-the British Association of Oral and Maxillofacial Surgeons (BAOMS) is Fellows in Training abbreviated to FiT. We designed an OMFS FiT (Fellows in Training) webinar series based on the current Oral and Maxillofacial Surgery (OMFS) curriculum. Senior trainers delivered weekly national web-based teaching using learning theories of education. Thirteen webinars were conducted between the 14th of May and the 4th of August 2020. Webinars were attended by 40-75 ST's with 98 percent of trainees rating the webinars as 'excellent' or 'very good', and 99% found the content 'extremely useful' or 'very useful'. We discuss the learning theories used for this teaching which include - Bloom's taxonomy, Bruner's spiral model, Vygotsky's zone of proximal development, the flipped classroom model, and Knowles' andragogy model. This pilot national teaching programme has been extremely well received by OMFS trainees and is here to stayl (C) 2021 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

A 33-year-old female patient developed an ipsilateral sixth nerve palsy and partial third nerve palsy following a Le Fort 1 osteotomy. Complete resolution occurred at 10 weeks. The likely mechanism of injury secondary to pterygo-maxillary dysjunction is highlighted, with description of the relevant anatomy. Previous cases of ocular motility complications following Le Fort 1 osteotomy are discussed. We recommend that significant care be taken in osteotome placement in the pterygo-maxillary fissure, particularly in those prone to unpredicted fractures such as older patients, or where the anatomy is congenitally abnormal or altered by previous surgery.

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. This paper provides consensus recommendations on the management of cutaneous basal cell carcinoma and squamous cell carcinoma in the head and neck region on the basis of current evidence.

Non-melanoma skin cancer is the most common type of malignancy in the Caucasian population and is four times more common than any other cancer in the UK. One in four men and one in six women will develop a non-melanoma skin cancer in their lifetime. Mortality from nonmelanoma skin cancer is rare, but tends to be from local or regional disease. Distant metastasis is rare with the exception of Merkel cell carcinoma. The majority of non-melanoma skin cancers can be cured by adequate initial surgical management. High-risk and complex non-melanoma skin cancer may be challenging to manage, and must be carried out through a skin cancer multidisciplinary team (MDT). The majority of non-melanoma skin cancers occur in the skin of the head and neck. However, their clinical behaviours do not mirror that of head and neck mucosal malignancies. In order to optimise management and outcomes, all nonmelanoma skin cancers (with the exception of specifically defined low-risk basal cell carcinoma (BCC)) should be managed by core members of a skin cancer MDT. This chapter will describe the recommendations for the investigation and management of non-melanoma skin cancer, drawing on guidelines produced by the British Association of Dermatologists. These are recommended reading, as they are accepted as the national guidelines for the management of non-melanoma skin cancer and are mandated by the National Institute for Health and Care Excellence (NICE).

Background Pleomorphic Dermal Sarcoma (PDS) is increasing in incidence and evidence-based guidelines as to optimal management are lacking. It is unclear from guidance which cancer MDTs should be involved in the care of patients with PDS and there is anecdotally widespread variation in patient pathways and management. Objective To determine current pathways and opinions regarding management of PDS amongst members of relevant UK MDTs. Methods A survey was devised, piloted, and circulated to MDT members, via national organisations. Responses were analysed using online SurveyMonkey tools. Results 105 consultant members of a relevant MDT responded, including 19 skin and 2 sarcoma MDT Chairs. There was widespread variation in referral pathways, with 25.7% of participants reporting no sarcoma MDT involvement in a hypothetical case of a patient with a 2.1 ​cm primary PDS of the scalp, with no clinically apparent regional or distant metastases (N0M0). Opinions on the correct peripheral and deep surgical excision margins (PM/DM) varied, with the majority choosing a 10 ​mm PM (53.3%). Taking periosteum as the deep margin was preferred by 50.5%. Histological clearance margins of at least 5 ​mm at the PM and at least 1 ​mm at the DM were preferred by 33.3% of participants and deemed to be acceptable as definitive treatment. Imaging at diagnosis and for surveillance showed wide variation, with 24.8% not offering any imaging at diagnosis, in the above case. Conclusions PDS pathways and clinical management have been shown to vary widely amongst UK MDT members. A modified Delphi study is proposed to develop consensus-based guidance.

A year after publication of the Breaking the Silence report, the authors share the progress made and discuss what still needs to be done by us all.

Facial and head and neck skin lesions are usually obvious to patients and others, and advice is often sought as to their nature, with cosmetic removal of benign lesions regularly requested. Premalignant and malignant skin lesions are increasing in incidence, and this is related to sunshine exposure, an ageing Caucasian population, along with increasing numbers of patients who are immunosuppressed. Important surgical anatomical considerations in skin surgery relate to appropriate curative resection margins, specifically where the deep margin may involve or be close to important underlying structures. Suspected melanoma should undergo narrow excision biopsy where direct closure is possible. Closure can be by purse string, and any ellipse should be short, to preserve proximal lymphatic channels. Consider closure of the primary defect without the darts of an ellipse in thick skin. Closure of skin should be in layers with deep resorbable sutures to close any dead space and oppose the deep dermis.

AN INDEPENDENT REPORT ON SEXUAL MISCONDUCTBY COLLEAGUES IN THE SURGICAL WORKFORCE