This study aimed to describe a one-stage technique for nasal skin defect reconstruction using an oxidised regenerated cellulose/collagen matrix (Promogran™) to enhance contour and graft survival.

Following excision of a skin lesion, Promogran™ is cut to size, placed in the wound bed to restore contour and provide bulk, saturated with blood and covered with a full-thickness skin graft.

The technique improves cosmesis and enables graft survival over avascular structures, including exposed bone and cartilage. Promogran™ exerts wound-healing effects such as matrix metalloprotease inhibition, regulation of growth factors and cytokines, free-radical scavenging and fibroblast proliferation.

This simple, one-stage approach offers an alternative to complex or multistage reconstruction for patients unsuitable for, or preferring to avoid, more invasive procedures.

The virtues of the scapular tip free flap for reconstruction of complex midface oncologic defects have been claimed by many. To obtain optimal functional and aesthetic results, precise positioning of the free flap used for reconstruction is paramount.

Four cases illustrate our approach to midface reconstruction with angular branch-based scapular tip flaps. A standard surgical navigation device was used both to plan bone cuts for the oncologic resection and to optimise the positioning of the flap.

Case 1 illustrates the usefulness of navigation for reconstruction of total palato-septectomy defects, using a horizontally positioned flap. Optimal neo-palate height, alignment of the anterior nasal spine and nasal projection were obtained. For cases 2–4, vertical inset of the flap yielded optimal midface projection and orbital floor position.

Surgical navigation systems are useful adjuncts for midface reconstruction.

Reconstruction of a pharyngoesophageal defect remains a challenging problem, especially with involvement of the neck skin. This study aimed to demonstrate the surgical technique of utilising a butterfly modification of the anterolateral thigh flap.

Reconstruction of the pharyngoesophageal defect was accomplished using the butterfly modification of the anterolateral thigh free flap. The flap was tubed on the leg while still being attached to the pedicle, to minimise the ischaemia time.

Butterfly anterolateral thigh free flap allows for multi-layer closure of the neopharynx and can be utilised for reconstruction of pharyngoesophageal and neck skin defects.

Effective nasal reconstruction requires skin and soft tissue cover, cartilage or bone structure, and mucosal lining. Ideal lining is thin, pliable and vascularised, making reconstruction challenging. This paper presents the first case series with long-term outcomes of pericranial flaps used as inner lining for nasal reconstruction.

Patients undergoing paramedial forehead flaps from 2007 to 2019 were identified using second-stage nasal reconstruction billing codes. Patients with pericranial flaps for lining, for whom there were data on resulting outcomes and complications, were identified.

Sixty-six patients underwent second-stage nasal reconstruction. Eighteen patients had paramedian forehead and pericranial flaps for inner lining reconstruction. The flap lining had no immediate post-operative complications. Three patients suffered partial to major reconstructive failure post radiotherapy. Other complications included nasal stenosis and orocutaneous fistula.

Combined with paramedian forehead flaps, the pericranial flap is reliable as inner lining for nasal reconstruction. It is easily accessible and useful in resections with limited mucosal options.

Pott's puffy tumour is a rare complication of sinusitis. This osteomyelitis can affect the outer and inner tables of the frontal sinus. The treatment of Pott's puffy tumour combines medical and surgical approaches. Surgical approaches have traditionally been open, but endoscopic techniques have been adopted recently in select cases. The bony defect from debridement can be left alone, or closed with autografts or allografts.

To describe a technique for the reconstruction of a large skull vault after the debridement of extensive osteomyelitis of the anterior cranial vault.

Modified distraction osteogenesis is used in the cranial vault, to induce new bone formation. This is customarily used to lengthen long bones. The advantages of this technique include avoiding autologous grafts or alloplastic cranioplasty in the infected surgical bed, and allowing primary closure.

Early post-operative imaging results have been encouraging, with no reported complications.

Modified distraction osteogenesis is a novel technique in the primary reconstruction of calvarial bone.

There has been little reported on the transoral reconstructive options following salvage transoral robotic surgery. This paper describes the facial artery musculomucosal flap as a method to introduce vascularised tissue to a previously irradiated resection bed.

A facial artery musculomucosal flap was used to reconstruct the lateral pharyngeal wall in 13 patients undergoing salvage transoral robotic surgery for oropharyngeal squamous cell carcinoma. Outcomes recorded include flap and donor site complications, length of stay, and swallowing and speech outcomes.

There were no immediate or late flap complications, or cases of delayed wound healing in this series. There were two facial artery musculomucosal related complications requiring surgical management: one bleed from the facial artery musculomucosal donor site and one minor surgical revision. Healing of the flap onto the resection bed was successful in all cases.

The facial artery musculomucosal flap provides a suitable transoral local flap option for selected patients undergoing salvage transoral robotic surgery for oropharyngeal malignancies.

The sternocleidomastoid can be used as a pedicled flap in head and neck reconstruction. It has previously been associated with high complication rates, likely due in part to the variable nature of its blood supply.

To provide clinicians with an up-to-date review of clinical outcomes of sternocleidomastoid flap surgery in head and neck reconstruction, integrated with a review of vascular anatomical studies of the sternocleidomastoid.

A literature search of the Medline and Web of Science databases was conducted. Complications were analysed for each study. The trend in success rates was analysed by date of the study.

Reported complication rates have improved over time. The preservation of two vascular pedicles rather than one may have contributed to improved outcomes.

The sternocleidomastoid flap is a versatile option for patients where prolonged free flap surgery is inappropriate. Modern vascular imaging techniques could optimise pre-operative planning.

Tracheocutaneous fistula represents one of the most troublesome complications of prolonged tracheostomy. Simple closure of a fistula can be ineffective, particularly in the context of prior surgery and adjuvant radiation. As such, modes of repair have expanded to include locoregional flaps and even free tissue transfers.

This paper describes a case of persistent tracheocutaneous fistula in an irradiated patient who had undergone previous unsuccessful attempts at repair.

The use of regional fasciocutaneous supraclavicular flap with prefabricated conchal bowl cartilage resulted in successful closure of the tracheocutaneous fistula.

This represents a novel technique for closure of such fistulas in patients for whom previous attempts have failed. This mode of repair should be added to the surgeon's repertoire of reparative techniques.

The ablation of advanced head and neck cancer often results in large three-dimensional defects that require free tissue transfer to optimally address functional and cosmetic issues. The subscapular system is a highly versatile donor site for flaps used for head and neck reconstruction. Traditional methods of harvesting subscapular flaps require repositioning and re-preparing, which significantly increases the operative time and prevents simultaneous harvesting of the flap.

This paper presents our experience of a single-stage ‘sit and tilt’ technique, which provides a convenient method for harvesting subscapular system free flaps without significant repositioning.

This technique was used for a variety of head and neck defects, and body habitus did not seem to affect free tissue harvesting. It is hoped that utilisation of this preparation and harvesting technique will make head and neck surgeons more willing to take advantage of the subscapular system.

Giant basal cell carcinoma, in which the tumour measures 5 cm or greater in diameter, is a very rare skin malignancy that accounts for less than 1 per cent of all basal cell tumours. Very few studies have reported on the incidence, resection and reconstruction of this lesion worldwide.

In total, 17 patients with giant basal cell carcinoma of the head and neck region underwent surgical excision and reconstruction at our hospital. Medical charts were retrospectively reviewed and analysed.

The lesion was usually in the forehead, eyelid, lips or nasal-cheek region. The greatest diameter ranged from 5 to 11 cm, with 5–6 cm being the most common size at the time of presentation. All patients had their tumour resected and reconstructed in a single-stage procedure, mostly with a local advancement flap, and with no post-operative flap failure.

Giant basal cell carcinoma of the head and neck can be successfully treated with a local flap in a single-stage approach.

Reconstruction with a vascularised flap provides the most reliable outcome, with post-operative cerebrospinal fluid leak rates of less than 5 per cent. This article aims to review and summarise the critical technical aspects of the vascularised flaps most commonly used for skull base reconstruction.

Vascularised flaps are classified as intranasal or extranasal. The intranasal group includes the Hadad–Bassagaisteguy nasoseptal flap, the Caicedo reverse nasoseptal flap, the nasoseptal rescue flap, the posteriorly or anteriorly based lateral wall flaps, and the middle turbinate flap. Extranasal flaps include the transfrontal pericranial and transpterygoid temporoparietal flaps.

The Hadad–Bassagaisteguy nasoseptal flap is overwhelmingly favoured for reconstructing extensive defects of anterior, middle and posterior cranial base. Its pertinent technical features are described. However, it is essential to master the skills required for the various extranasal or regional vascularised flaps because each can offer a reconstructive alternative for specific patients, especially when open approaches are needed and/or intranasal vascularised flaps are not feasible.

Tissue engineering using biocompatible scaffolds, with or without cells, can permit surgeons to restore structure and function following tissue resection or in cases of congenital abnormality. Tracheal regeneration has emerged as a spearhead application of these technologies, whilst regenerative therapies are now being developed to treat most other diseases within otolaryngology.

A systematic review of the literature was performed using Ovid Medline and Ovid Embase, from database inception to 15 November 2014. A total of 561 papers matched the search criteria, with 76 fulfilling inclusion criteria. Articles were predominantly pre-clinical animal studies, reflecting the current status of research in this field. Several key human research articles were identified and discussed.

The main issues facing research in regenerative surgery are translation of animal model work into human models, increasing stem cell availability so it can be used to further research, and development of better facilities to enable implementation of these advances.

Adult patients with obstructive sleep apnoea can be a therapeutic surgical challenge if other treatments fail or are rejected. We report the outcomes of a series of 17 patients for whom standard device-based treatments failed or could not be used. These patients were considered unsuitable for a lesser operation and therefore underwent multilevel upper airway reconstruction.

Data from 17 consecutive patients were collected prospectively. This included pre- and post-surgery findings for clinical assessments, body mass index, sleep questionnaires, and laboratory polysomnograms. Patients underwent a combination of modified uvulopalatopharyngoplasty, transpalatal advancement and various tongue reduction procedures.

Analyses revealed statistically and clinically significant reductions in: mean apnoea-hypopnoea index scores (from 36.3 pre-operatively to 14.5 post-operatively, p < 0.001), mean Epworth sleepiness scale scores (from 11.3 to 5.3, p < 0.001) and mean snoring severity scores (from 6.9 to 1.3, p < 0.001). Body mass index remained unchanged.

Multilevel upper airway reconstructive surgery was associated with large reductions in both objective and patient-centred subjective measures of obstructive sleep apnoea severity.

Obstructive sleep apnoea is a common condition that is unfortunately associated with a high rate of patient non-compliance regarding device use. Newer surgical interventions have focused on procedures at the palate level, using variants of palatoplasty and transpalatal advancement. However, the extent of tongue reduction surgery required remains controversial. The authors propose an in-between variant that combines midline glossectomy resection (with minimal mucosal sacrifice) and lateral coblation tongue channelling.

Four patients underwent a coblation-assisted Lewis and MacKay operation, which is a new technique for tongue reduction. This involved a midline glossectomy combined with lateral coblation channelling of the tongue, alone or as part of major airway reconstruction. Demographic, polysomnographic and quality of life questionnaire data were collected prospectively and analysed.

No significant complications were noted in the four patients. (Results of the post-surgical outcomes are presented in another paper.) The coblation-assisted Lewis and MacKay operation reduced the potential complications of aggressive tongue surgery. The contours of the tongue were maintained, but significant reduction was still achieved.

Large defects of the anterior wall of the frontal sinus require closure using either autologous or foreign material. In cases of osteomyelitis, the reconstruction must be resistant to bacterial infection. Split-rib osteoplasty can be used in different sites.

Two patients with malignant sinonasal tumours underwent repeated treatment, and subsequently developed osteomyelitis of the frontal bone. After adequate therapy, a large defect of the anterior wall persisted. Reconstruction was performed using the split-rib method. The literature on this topic was reviewed.

Both patients' treatment were successful. No complications occurred. A PubMed search on the topic of rib reconstruction of the frontal sinus and skull was performed; 18 publications matched the inclusion criteria. From these sources, we noted that 182 reconstructions yielded good results with few complications.

Large defects of the anterior wall of the frontal sinus can be closed successfully using autologous split-rib grafting. Aesthetic outcome is good and donor site morbidity is minimal.

We evaluated the efficacy of laryngotracheal reconstruction with costal cartilage grafting for the treatment of idiopathic laryngotracheal stenosis.

From January 2001 to December 2005, 129 patients with laryngotracheal stenosis were treated at our hospital. Of these patients, five (4 per cent) female patients whose ages ranged from 14 to 34 years were identified as having idiopathic laryngotracheal stenosis. These patients were treated with a modified laryngotracheal reconstruction with anterior costal cartilage grafting. A Montgomery T-tube remained in place for 12 to 22 months.

Three patients presented with grade three and two with grade two stenosis. Three patients were decannulated after one procedure, with normal respiratory function and good exercise tolerance; one patient was decannulated after two procedures. One patient failed decannulation. The mean time to decannulation was 13 months.

Laryngotracheal reconstruction with anterior costal cartilage grafting is a safe and effective method, and provides an alternative treatment for idiopathic laryngotracheal stenosis.

To analyse correlations between quality of life measures, aspiration and extent of surgical resection in patients who have undergone free-flap tongue reconstruction.

Nine consecutive patients (seven men and two women; average age 51 years) who had been diagnosed with T4a carcinoma of the mobile tongue and/or tongue base and treated by glossectomy, free-flap reconstruction, and either radiation therapy or chemoradiation responded to the European Organization for Research and Treatment of Cancer Head and Neck-35 questionnaire, the performance status scale questionnaire and the hospital anxiety–depression scale questionnaire, an average of 43 months after treatment (range 18–83 months). Aspiration was evaluated by fibre-optic laryngoscopy. Correlations between quality of life domain scores, extent of surgery and the presence of aspiration were evaluated using non-parametric statistical analysis.

Scores for the swallowing and aspiration domains of the European Organization for Research and Treatment of Cancer Head and Neck-35 questionnaire were significantly correlated with the extent of tongue base resection (Spearman's correlation, p = 0.037 and 0.042, respectively). Despite a strong correlation between the European Organization for Research and Treatment of Cancer Head and Neck-35 questionnaire results and the performance status scale global scores (correlation coefficient = 0.89, p = 0.048), the performance status scale domain scores were not correlated with the extent of tongue resection. Clinically apparent aspiration was not correlated with the extent of tongue resection, nor were the anxiety or depression scores. However, clinically apparent aspiration was significantly related to the swallowing and aspiration domain scores of the European Organization for Research and Treatment of Cancer Head and Neck-35 questionnaire (p = 0.017 in both cases).

Our results imply that the volume of tongue base resection is a major factor in swallowing- and aspiration-related quality of life following tongue resection and free-flap reconstruction. Free-flap reconstruction does not seem to palliate the effect of the loss of functional tongue base volume, as regards swallowing-related quality of life.

Laryngeal injuries are uncommon but result in high mortality and morbidity rates when they do occur. We report a case of laryngeal fracture due to penetrating shrapnel injury, repaired with miniplates.

A 26-year-old soldier was involved in an explosion and sustained a shrapnel wound to his right neck. After immediate airway management at the field hospital he was transferred to the UK, where he underwent a neck exploration, laryngofissure and repair of the thyroid cartilage using miniplates. An endolaryngeal stent was placed, which was removed at a second operation seven days later. Post-operatively, the patient recovered well and his voice improved rapidly. Six months post-operatively, he returned to work.

The cause and nature of laryngeal injury differs between wartime and peacetime. The methods of diagnosis and management strategies are reviewed. The early recognition of injury and protection of the airway are of paramount importance when dealing with laryngeal injury. Delayed laryngeal reconstruction using miniplates can give a good functional result.

Ear lobule deformities can occur as a result of trauma. Surgical reconstruction can be challenging. There does not appear to be a consensus on the best form of repair. We report the case of a 27-year-old woman who suffered traumatic loss of the ear lobule during childhood. A novel technique is described using a posterior based bi-lobar flap to completely reconstruct the ear lobule in two stages.

This form of repair has the advantage of a well-hidden scar, with the donor site providing skin of similar thickness and pigmentation.

The management of laryngotracheal stenosis is still a serious surgical challenge. The fact that there are currently numerous reconstruction procedures indicates that there is at present no standard treatment.

Titanium mesh was used instead of traditional homografts in reconstruction of the anterior laryngotracheal wall in 12 tracheostomised patients with benign chronic laryngotracheal stenosis. The anterior laryngotracheal wall was split, followed by excision of scar tissue and fixation of the titanium plate at the split end. A Silastic® stent was inserted above the tracheostomy tube and fixed in place by running sutures fixed to the skin by buttons. The stent was removed endoscopically six weeks later and a trial of decannulation was undertaken.

Endoscopically, good epithelisation was seen on the inner surface of the mesh in 10 cases and decannulation was possible. Four of these patients required endoscopic debulking of granulation tissue. Decannulation was impossible in two cases, one due to excessive granulation tissue and the other due to prolapse of the titanium mesh into the tracheal lumen (the mesh was removed endoscopically and a Montgomery T-tube inserted).

Titanium mesh was found to be a good alternative for augmentation of the anterior laryngotracheal wall. It offered rigid support, with fewer of the complications reported with other grafts.