Biomedical subjects
R W Griffiths
Publications and source records attributed to R W Griffiths.
Skin malignancy and the reconstructive plastic surgeon.
Skin malignancy represents at least 25% of the plastic surgeon's workload. The commonest tumour, the basal cell carcinoma, usually arises in the skin of elderly patients who are frequently managed by surgery under local anaesthetic, often as outpatients. The recurrent basal cell carcinoma poses a difficult problem regardless of the primary therapy. Skin repair with direct closure or skin grafts is usually simple, but skin flaps will be needed when bone, cartilage or major neurovascular structures are exposed, or where tissue vascularity has been reduced by irradiation fibrosis. Squamous cell carcinomas of lip, ear and hand may recur as lymph node metastases despite clinical and histological clearance. Malignant melanoma continues to present as advanced disease (thick tumours) in this country, and this largely dictates prognosis, since tumour thickness is recognised as the single most important dominant prognostic variable. Incisional biopsy compromises histological microstaging and should be avoided. Indirect evidence from narrow margin excision of invasive head and neck cutaneous melanomas suggests no detriment, and narrow margin excision of melanomas is increasingly being practised.
Outpatient clinics.
Explore the source record for details and available documents.
The bolus tie-over "pressure" dressing in the management of full thickness skin grafts. Is it necessary?
It has been taught that the bolus tie-over "pressure" dressing is essential for the successful "take" of full thickness skin grafts. This was tested in a prospective randomised trial in which 40 full thickness grafts were either managed with the conventional bolus dressing, or alternatively with quilting sutures and no dressing. Whether under local or general anaesthesia there was only one total graft failure from haematoma (tie-over bolus group) and one partial graft failure from haematoma (quilted group). Sixty-five per cent. of all grafts were performed by junior surgical trainees. The bolus tie-over "pressure" dressing does not appear essential for full thickness skin graft survival in the areas of the head and neck studied.
Relative risk: mortality probability and plastic surgery.
Recent publications indicate an increasing interest in the description and assessment of risks related to medical and surgical treatment. The law may come to require fuller disclosure of therapeutic risks than was formerly the case. Against this background the mortality risks of plastic surgery procedures are considered in relation to other well documented mortality probabilities. The possible implications for clinical practice and "informed consent" are discussed.
Necrotising fasciitis caused by dental infection.
A case of necrotising fasciitis caused by dental infection is presented, which resulted in severe mutilation but the patient survived. The diagnosis and management of this condition is discussed.
Plastic surgery manpower, training, and prospects in Great Britain.
Compared with all other developed Western countries, Great Britain has a gross underprovision of trained and trainee plastic surgeons. As a result, it has become essential to define specific priority conditions admitted for treatment without unreasonable delay. This has resulted in large waiting lists for nonurgent surgery. In 1985 the average number of patients on each plastic surgeon's waiting list exceeded 400, of which over 60% had waited over 12 months for operative treatment. The implications of this situation for patient care and trainee experience are discussed.
Incidence of locally metastatic ('recurrent') cutaneous malignant melanoma following conventional wide margin excisional surgery for invasive clinical stage I tumours: importance of maximal primary tumour thickness.
In a minimum 5-year follow-up study of 638 primary clinical Stage I invasive cutaneous malignant melanomas (excluding lentigo maligna melanomas) excised with conventional wide normal tissue margins, the incidence of local tumour metastasis was 48/638 (8 per cent). The incidence of locally metastatic tumours rose from 2 per cent for tumours less than 0.99 mm thick, to 14 per cent for tumours between 5 and 6 mm in thickness. The rate of local metastasis was significantly greater for tumours greater than 2.0 mm compared with tumours less than 2.0 mm thick (P less than 0.01). Despite the anatomical restrictions to wide resection margins in the head and neck, these areas had the lowest regional incidence for local tumour metastasis (2 per cent). Over the prolonged postoperative follow-up period (median 11 years) 67 per cent (32/48) of patients with locally metastatic disease died of disseminated malignant melanoma, compared with a 31 per cent mortality (180/590) for those without local disease metastasis. The term 'local recurrence' is unhelpful in our attempts to understand the pathology of malignant melanoma, and the term 'local metastasis' could replace it with benefit.
Observations on dermal blood flow as reflected by technetium-99m pertechnetate clearance.
Skin blood flow as reflected by the clearance rate of intradermal injections of Technetium-99m (99mTc) was studied in the skin of human volunteers and in a variety of clinical situations. In volunteers comparisons between the effect on clearance following intradermal injections of either lignocaine or lignocaine/adrenaline showed that the latter resulted in a dramatic reduction in the clearance rate of the technetium isotope and that such clearance curves exhibited no fast component. Clinical studies in grossly ischaemic skin revealed a similar absence of the fast component of isotope clearance and this was also the case for healed split thickness skin grafts. The dermal isotope clearance was also used in pedicle skin flaps both before and after clamping the axial pedicle in order to derive clearance ratios which would reflect the degree of neovascularisation to the flap. These preliminary observations suggest that the technique is safe, and easy to use in many clinical circumstances. We consider that it offers a valuable method by which changes in dermal blood flow may be quantified, when simultaneous control areas of isotope clearance are also studied. Suggestions are made for further avenues of study.
Biopsy procedures, primary wide excisional surgery and long term prognosis in primary clinical stage I invasive cutaneous malignant melanoma.
Explore the source record for details and available documents.
Management of multiple casualties with burns.
Explore the source record for details and available documents.
Malignant melanoma, evaluation of clinical follow up by questionnaire survey.
A retrospective questionnaire study, by post, revealed that 69% of patients, still living following first tumour recurrence, had detected the recurrence themselves prior to routine clinic appointments. Nearly 90% developed their first recurrence in the first 5 years following primary surgical treatment. Not only could the length of routine clinic follow-up after primary melanoma treatment be shortened, but with further education of the patient and involvement of the general practitioner it seems likely that patients can be trusted to detect their own recurrences and seek appropriate advice.
Biopsy procedures, primary wide excisional surgery and long term prognosis in primary clinical stage I invasive cutaneous malignant melanoma.
281 patients managed for primary clinical Stage I invasive cutaneous malignant melanoma at one Plastic Surgery Unit were followed up to a minimum of 10 years after primary surgical treatment. Sixty-three (23%) had received an initial biopsy procedure prior to definitive wide margin excisional surgery. One third of all lesions initially treated by so called incisional biopsy were rendered histologically unassessable on current histopathological criteria. Incisional biopsy significantly interfered with the accurate histopathological staging of the tumours. Of the assessable incisional biopsy specimens the majority were greater than 4.0 mm thick. When the incidences of local tumour recurrence and mortality were related specifically to maximal tumour thickness of the primary lesion, prognosis at minimum follow up of 10 years was not significantly different between patients treated initially by either incisional biopsy, minimal margin excisional biopsy or primary wide excisional surgery. Whether or not incisional biopsy adversely affects prognosis in cutaneous malignant melanoma, the technique should be avoided since it compromises accurate histopathological microstaging which represents one of our most valuable prognostic guides. Clinical doubt over the diagnosis of cutaneous malignant melanoma should be resolved by a total excisional biopsy of the lesion in question.
The surgical management of intractable venous ulceration in the lower limbs: excision, decompression of the limb and split-skin grafting.
Fourteen patients with severe chronic venous ulceration and constricted lower limbs underwent an operation to release the constriction and to ligate the perforating veins in the calf. At 4-year follow-up 6 patients remained healed. Two further patients were healed when last seen 3 years and 19 months after surgery. The operation is suggested as a salvage procedure for selected patients, when all other methods of treatment have failed.
A study of the thickness of uninvolved dermis beneath cutaneous malignant melanoma: the ratio of uninvolved dermis to tumour thickness (DT:TT) as a prognostic index.
The histological material from 147 patients treated for clinical stage I primary cutaneous malignant melanoma between 1968 and 1972 was reviewed. All patients had a minimum follow up of 10 years. Measurements were made of the thickness of uninvolved dermis (DT) deep to the tumour and the tumour thickness (TT) itself. The ratio of dermal thickness: tumour thickness (DT:TT) was correlated with clinical progress at follow-up and compared as a prognostic index with tumour thickness alone. The ratio DT:TT was found to be a useful prognostic guide, a value of greater than 2.0 proving to be a very favourable sign. It is suggested that this simple ratio should be routinely reported in all cases of primary cutaneous malignant melanoma to provide an additional index with a view to assessing its value as a prognostic guide.
Experience of thin cutaneous melanomas (less than 0.76 mm and less than 0.85 mm thick) in a large plastic surgery unit: a 5 to 17 year follow-up.
The detailed histological findings of 728 melanoma patients treated at Frenchay Hospital during the period 1967 to 1978 have been fully reviewed and analysed. Of these, 75 patients with lesions less than 0.76 mm thick and 15 with lesions greater than 0.75 mm and less than 0.85 mm thick have been identified using a computerised data base. The general practitioners of all the patients in the series have been approached and the clinical histories found in nearly every case (69/75 and 15/15) thus providing a follow-up period of 5 to 17 years. A number of fatal melanomata have been found in these two groups. The histopathological features have been related to the known prognosis in an attempt to characterise the lethal lesions. No statistically significant relationship could be found between prognosis and any histological feature, including specifically the amount of regression within the lesion. However, it was found that assessment of the ratio of the uninvolved dermis beneath the tumour to tumour thickness itself might prove helpful in future case evaluation.
Long term follow-up in cutaneous malignant melanoma: the relationship of maximal tumour thickness to disease free survival, disease recurrence and death.
284 patients with invasive cutaneous malignant melanoma and known maximal tumour thickness (MTT) were followed up for 10 to 16 years (or to earlier death) following conventional wide margin excision of the primary tumour. Of these 26 (9%) presented with clinical Stage II disease (enlarged regional lymph nodes). The 10 year disease free survival was 45% for clinical Stage I disease, with 5/26 patients with Stage II disease alive 10 years after tumour excision combined with lymph node dissection. Ninety per cent of first tumour recurrences (lymph node or local skin recurrence) occurred within 5 years of primary surgical treatment for clinical Stage I disease, whilst only 63% of deaths from melanoma occurred within this 5 year period. Although maximal tumour thickness is a valuable prognostic guide, cutaneous malignant melanoma remains an unpredictable disease.
A Melanoma Registry based on a computer-run word and data processing system.
A Melanoma Register, previously organised on a filing card system, has been largely transferred to a computer which utilises both word and data processing programs. This transfer has revolutionised not only the analytical potential of the material, but the follow up of all patients, both old and new. The system is applicable to many other tumours and diseases.