25, 50 & 75 years ago

Microvascular free-tissue transfer is now the primary method of reconstruction in many centres. The aim of this study was to evaluate the applications, complications and limitations of free-ﬂ ap reconstruction in a series of patients with tumours of the head and neck. This study reviewed prospectively accessioned computerized records in a dedicated head and neck database. Patients treated between 1987 and 1995 with a minimum of a 1-year follow-up were reviewed. There were 242 patients with a mean age of 58 years (172 men and 70 women). The most common tumour sites were oral cavity (42%), oropharynx (32%) and hypo-pharynx (1 1%). Mucosal squamous carcinoma accounted for 87% of primary cancers. Among the 250 free ﬂ aps, the radial forearm ﬂ ap (205) and free jejunum (25) predominated. There were 21 episodes of vascular occlusion (8%), failure of 10 ﬂ aps (4%) and two patients died peri-operatively (0.8%). A second free ﬂ ap was used in ﬁ ve of 10 cases of ﬂ ap failure. The ﬁ stula rate was 4.4% among 203 patients at risk for this complication, which comprised four of 178 forearm ﬂ aps and ﬁ ve of 25 free jejunal grafts. Four of 16 jaw reconstructions failed. A 96% success rate was achieved using free tissue transfer for head and neck reconstruction. The overall complication rate was low but jaw reconstruction and free jejunal grafts posed the greatest problems because of failure of radial bone and ﬁ stulas, respectively. The radial forearm septocutaneous ﬂ ap was very reliable and remains our mainstay for oral reconstruction.

opportunity for the most effective management resulting in both adequate local control and functional limb salvage surgery is compromised.A high rate of wound complications following open incisional biopsy may also compromise local treatment.Inappropriate siting of the incision for both incisional and excisional biopsies may adversely affect subsequent surgery and radiotherapy.We therefore assessed the accuracy of core biopsy in the diagnosis of soft-tissue tumours, and planning of definitive surgery.All patients with primary soft-tissue tumours managed by two surgeons with a special interest in soft-tissue sarcomas since 1991 were reviewed.More than half (53%) were referred from other specialists.Of 45 cases, 37 (82%) were referred with the tumour intact, and of these 31 (84%) underwent core biopsy.The overall accuracy of core biopsy was 84%.The sensitivity was 94%, with 100% specificity.In most patients, this allowed planning of definitive one-stage surgery (P < 0.005).Of the remaining five non-diagnostic cores, four were benign and one was a non-specific malignancy.Core biopsy has a high degree of accuracy in the diagnosis of softtissue tumours, particularly malignant lesions, and is not misleading.Core biopsy avoids the complications of open biopsy and enables planning of one-stage surgery when used in combination with appropriate imaging.
A one-stage distant ilio-femoral flap (Fig. 1) repair of a compound lower leg injury is discussed introducing a 'free flap' transfer with vascular anastomosis (Fig. 2) as a method of primary closure (Fig. 3).It is suggested as an alternative method to a difficult cross-leg flap or a tedious tube pedicle repair.It proved a most satisfactory alternative to a difficult flap coverage on the lower extremity by these methods, and demonstrates a new application of microvascular techniques.It deserves further clinical evaluation.The vascular predictability of the ilio-femoral flap is currently being evaluated in fresh cadaver dissections, and the role of preoperative angiography calls for further investigation.O'Brien BMcC, Shanmugan N. Experimental transfer of composite free flaps with microvascular anastomoses.ANZ J. Surg. 1973;43:285-8.
The transfer of composite island flaps with microvascular anastomoses in rabbits from one iliac fossa to the other is described (Fig. 1).Twenty-seven out of 29 flaps had total survival, with mild necrosis in the remaining two.All five control flaps without microvascular anastomoses necrosed quickly.No measures such as perfusion, anticoagulants or antibiotics were used.Cadaver dissections are described, and it is suggested that suitable donor sites for clinical use include the groin flap, the deltopectoral flab and possibly the dorsum of the foot.Whilst there is mounting evidence of the availability of these donor sites, further work is being carried out to locate additional sites.The versatility of reconstructive procedures would be greatly augmented by the evolution of safe free flap transfers with microvascular anastomoses.T h e successful use of a clinical composite free flap has been achieved and has been reported elsewhere (O'Brien et al., 1973), and an analysis of a series of clinical free flaps is in preparation.
Results obtained in the treatment of 18 patients with facial paralysis and two with clonic facia1 spasm by means of the operation of hypoglossal-facial nerve anastomosis are described.Recovery of tone and voluntary power was satisfactory in 18 patients, unsatisfactory in one.One patient has not been reviewed.Recovery was very satisfactory in two cases in which there was a delay of nine and a half months between the date of onset of facial paralysis and that of the reparative operation, and also in one other in which the delay was 26 months.These observations would seem to demonstrate that degeneration of muscle fibres and end plates is not of such importance as is generally believed.

Fig. 3 .
Fig. 3.The leg following free-flap repair of the compound injury.