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Chieng CY, Nazir H, Sayan A, Ilankovan V. Role of neck dissection in management of patients with clinically apparent parotid metastatic melanoma - systematic review. Br J Oral Maxillofac Surg 2024; 62:604-611. [PMID: 38945797 DOI: 10.1016/j.bjoms.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 05/11/2024] [Accepted: 05/13/2024] [Indexed: 07/02/2024]
Abstract
Patients with cutaneous melanoma with metastatic deposits in the parotid gland have poor prognosis due to the high risk of developing distant metastasis. In the era of effective immunotherapy, there is no consensus amongst head and neck surgeons about the extent of neck dissection required for patients presenting with clinically apparent parotid metastasis. This review aims to determine the incidence and pattern of occult neck disease for patients with parotid metastasis reported in the literature to help guide clinicians on the extent of neck dissection required. The systematic review search was conducted using PubMed, EMBASE and Medline, using PRISMA guidelines. The inclusion criteria include cases treated with parotidectomy and neck dissection for patients with parotid melanoma metastasis. A narrative synthesis was carried out due to heterogeneity of studies. A total of 14 studies was included. We found no study reporting on outcomes with surgery and adjuvant immunotherapy in this cohort of patients. The incidence of distant metastasis reported was variable but remains high for patients with parotid metastasis. Patients with parotid and neck involvement have poorer prognosis than patients with parotid only metastatic disease. The effect and extent of neck dissection in patients with clinically apparent parotid nodes remains unclear in the era of effective immunotherapy. There is a need for further well-designed studies evaluating the outcomes for such patients following surgery and adjuvant immunotherapy.
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Affiliation(s)
- C Y Chieng
- Barts and The London School of Medicine and Dentistry, United Kingdom
| | - H Nazir
- Manchester University NHS Foundation Trust, United Kingdom
| | - A Sayan
- Oral & Maxillofacial Surgery Department, Oxford University Hospital NHS Foundation Trust, United Kingdom
| | - V Ilankovan
- Oral & Maxillofacial Surgery Department, Poole Hospital NHS Foundation Trust, United Kingdom
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Berger DMS, Verver D, van der Noort V, Grünhagen DJ, Verhoef C, Al-Mamgani A, Zuur CL, van Akkooi ACJ, Balm AJM, Klop WMC. Therapeutic neck dissection in head and neck melanoma patients: Comparing extent of surgery and clinical outcome in two cohorts. Eur J Surg Oncol 2021; 47:2454-2459. [PMID: 33867173 DOI: 10.1016/j.ejso.2021.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/21/2021] [Accepted: 04/05/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The extent of surgical management of regional lymph nodes in the treatment of cutaneous head and neck melanoma on and anterior to O'Brien's watershed line is controversial. By comparing patients' cohorts of two separate melanoma expert centers we investigate the effectiveness of comprehensive versus (super-) selective neck dissection approach. METHODS Sixty patients with macroscopic (palpable) neck node metastases (N2b) from anterior scalp and face melanoma were retrospectively studied. Forty therapeutic modified radical neck dissections (MRND; levels I-V) combined with elective parotidectomy from The Netherlands Cancer Institute (NCI) were compared with 16 (super-) selective neck dissections [(S)SND; 3-4 levels] and 4 solely MRNDs from Erasmus Medical Center (EMC). Cohorts were analyzed for site of recurrence, overall survival (OS), melanoma-specific survival (MSS), and disease-free survival (DFS). RESULTS Clinical characteristics of patients were equal in both groups. In the NCI cohort 62.5% (n = 25) of patients recurred versus 65% (n = 13) in the EMC cohort. None of the NCI recurrences affected the parotid gland in contrast to 3 patients in the EMC group. Survival characteristics were not different between the two groups: OS (p = 0.56), MSS (p = 0.98), DFS (p = 0.92). CONCLUSION This study does not support to continue the practice of routine elective parotidectomy and MRND in melanoma patients undergoing a lymph node dissection for macroscopic (palpable) nodal disease and justifies (S)SND.
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Affiliation(s)
- Danique M S Berger
- Department of Head and Neck Surgery and Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands.
| | - Danielle Verver
- Department of Surgical Oncology, Erasmus MC-Cancer Institute, Rotterdam, the Netherlands
| | - Vincent van der Noort
- Department of Epidemiology and Biostatistics, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Dirk J Grünhagen
- Department of Surgical Oncology, Erasmus MC-Cancer Institute, Rotterdam, the Netherlands
| | - Cees Verhoef
- Department of Surgical Oncology, Erasmus MC-Cancer Institute, Rotterdam, the Netherlands
| | - Abrahim Al-Mamgani
- Department of Radiotherapy, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Charlotte L Zuur
- Department of Head and Neck Surgery and Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands; Department of Maxillofacial Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Alexander C J van Akkooi
- Department of Surgical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Alfons J M Balm
- Department of Head and Neck Surgery and Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands; Department of Maxillofacial Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - W Martin C Klop
- Department of Head and Neck Surgery and Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands; Department of Maxillofacial Surgery, Academic Medical Center, Amsterdam, the Netherlands.
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Berger DMS, van Veen MM, Madu MF, van Akkooi ACJ, Vogel WV, Balm AJM, Klop WMC. Parotidectomy in patients with head and neck cutaneous melanoma with cervical lymph node involvement. Head Neck 2019; 41:2264-2270. [PMID: 30762921 DOI: 10.1002/hed.25670] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 11/21/2018] [Accepted: 01/15/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Parotidectomy in melanoma of the coronal scalp and face with clinically involved cervical lymph node metastasis is based on predicted cervical lymphatic drainage described by O'Brien. METHODS In total, 40 parotidectomies with en bloc therapeutic neck dissection were retrospectively analyzed. RESULTS Lymphatic spread of melanoma to the parotid lymph nodes was observed in 10 of 40 specimens (25%). Eight of the 10 parotid-positive patients developed a recurrence vs 17 of the 30 parotid-negative patients (P = 0.28). There were no differences in overall survival, melanoma-specific survival, and disease-free survival between the parotid-positive and parotid-negative patients. CONCLUSION Although in this series no survival differences were found, parotidectomy still merits a sustained role in therapeutic neck dissection procedures to improve regional control and to prevent facial nerve damage after surgery for a second relapse from occult metastases in the parotid.
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Affiliation(s)
- Danique M S Berger
- Department of Head and Neck Surgery and Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Martinus M van Veen
- Department of Head and Neck Surgery and Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Max F Madu
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Alexander C J van Akkooi
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Wouter V Vogel
- Department of Nuclear Medicine, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Radiotherapy, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Alfons J M Balm
- Department of Head and Neck Surgery and Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Maxillofacial Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Willem M C Klop
- Department of Head and Neck Surgery and Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Maxillofacial Surgery, Academic Medical Center, Amsterdam, The Netherlands
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Suton P, Lukšić I, Müller D, Virag M. Lymphatic drainage patterns of head and neck cutaneous melanoma: does primary melanoma site correlate with anatomic distribution of pathologically involved lymph nodes? Int J Oral Maxillofac Surg 2012; 41:413-20. [DOI: 10.1016/j.ijom.2011.12.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 10/19/2011] [Accepted: 12/19/2011] [Indexed: 10/14/2022]
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Abstract
AIM OF THE STUDY Secondary malignant tumors of the parotid gland are uncommon. They arise from primary tumors located in the head and neck or from distant primary tumors. The formers are dominated by squamous cell carcinomas and melanomas, the latters by renal and lung cancers. Distinction between malignant primary tumors and metastasis of other primary tumors to the parotid gland is very important to appreciate, because the result of this will change therapeutic procedure and the evaluation of prognosis. METHODS A series of 23 patients with tumors metastatic to the parotid gland are reported. All clinical and pathological data were reviewed. The management of secondary tumors of the parotid gland and the results were analyzed in order to try to identify common features and implications for management. RESULTS The most frequent histologic types were squamous cell carcinoma and melanoma. Most primary tumors occurred in the head and neck. Metastasis to the parotid gland presented with a median time of 18 months after diagnosis of the primary tumor. All the patients had a parotid mass. No patient had facial nerve weakness. Parotid metastases were treated by superficial parotidectomy with preservation of the facial nerve in all cases, associated in 14 cases with a homolateral selective neck dissection and in 6 cases with a homolateral radical neck dissection. Twenty-one patients were submitted to radiation therapy. Seven patients died after the treatment: in 3 cases, death was due to a local recurrence with cervical relapse; 4 patients presented cervical and metastatic lesions. CONCLUSION This retrospective review confirmed that patients with involvement of cervical nodes and metastatic parotid tumors have a worse prognosis than those without involvement of cervical nodes. The addition of postoperative radiotherapy provides no additional benefit.
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Affiliation(s)
- D Dequanter
- Service de chirurgie, Institut Bordet, 1 rue Héger-Bordet 1000 Bruxelles.
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Ballo MT, Garden AS, Myers JN, Lee JE, Diaz EM, Sturgis EM, Morrison WH, Gershenwald JE, Ross MI, Weber RS, Ang KK. Melanoma metastatic to cervical lymph nodes: Can radiotherapy replace formal dissection after local excision of nodal disease? Head Neck 2005; 27:718-21. [PMID: 15952196 DOI: 10.1002/hed.20233] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Completion cervical lymphadenectomy is usually performed after excisional biopsy of nodal metastases from melanoma. Radiation (XRT) might be effective for some patients in lieu of formal lymph node dissection. METHODS Thirty-six patients with parotid or cervical node metastases from melanoma were treated with excision of nodal disease and postoperative XRT without formal lymph node dissection. Radiation was delivered to the primary site (if known), the site of nodal excision, and the undissected ipsilateral neck. RESULTS With a median follow-up of 5.3 years, the disease recurred within the regional basin in two patients and at distant sites in 14 patients. The actuarial 5-year regional control and distant metastasis-free survival rates were 93% and 59%, respectively. Two patients had a clinically significant side effect develop. CONCLUSIONS The results of this study suggest that selected patients may receive regional XRT after local excision of nodal disease from melanoma in lieu of formal lymph node dissection.
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Affiliation(s)
- Matthew T Ballo
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
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Mack LA, McKinnon JG. Controversies in the management of metastatic melanoma to regional lymphatic basins. J Surg Oncol 2004; 86:189-99. [PMID: 15221926 DOI: 10.1002/jso.20080] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The primary management of lymph nodes involved with metastatic melanoma is regional lymphadenectomy. Many controversies of regional lymph node dissection exist including extent and nature of the lymphadenectomy, treatment of lymphatic metastases in unusual locations and the role of adjuvant radiotherapy. Although radical neck dissection has been the gold standard for cervical disease, modified dissections do not seem to compromise regional control in appropriately selected patients. In the axilla, a Level I, II, and III dissection is most commonly performed. Combined superficial and deep groin dissection is justified for clinically palpable disease although management of patients with histologically positive yet clinically non-palpable disease is more controversial. Burden of disease, imaging, patient co-morbidity, and Cloquet nodal status must be considered. Many technical variations exist in an attempt to improve morbidity rates secondary to lymphadenectomy. Unfortunately, complication rates are difficult to compare secondary to variable study designs, definitions, and patient populations. Adjuvant radiation therapy appears warranted in patients with high risk of regional recurrence including bulky disease, extracapsular extension or cervical location.
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Affiliation(s)
- Lloyd A Mack
- Tom Baker Cancer Centre and the University of Calgary, Calgary, Alberta, Canada
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Jol JAD, van Velthuysen MLF, Hilgers FJM, Keus RB, Neering H, Balm AJM. Treatment results of regional metastasis from cutaneous head and neck squamous cell carcinoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2003; 29:81-6. [PMID: 12559082 DOI: 10.1053/ejso.2002.1330] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIMS To investigate the results of our treatment policy, we present our institutional experience in the management of regional neck node metastases of cutaneous head and neck squamous cell carcinoma (CHNSCC). METHODS Between 1977 and 1997, 343 patients presented with CHNSCC, of whom 41 were treated for regional metastases, with parotidectomy and/or (selective) neck dissection. Histological analysis was performed on all operation specimens. Patients with multiple nodes and/or extra capsular rupture, at risk for recurrence, received adjuvant radiotherapy. RESULTS Seventy-six percent of the regional metastases occurred within the first 2 years, but a delay of more than 5 years was also observed. Parotid gland (56%), neck levels II (39%) and V (22%) were most frequently involved. Twenty-four percent of patients treated with curative intent failed at the regional site. Five years overall survival was 46%, with a median survival of 49 months. No survival differences emerged between patients treated by surgery alone and patients receiving adjuvant radiotherapy (P=0.14). Five patients died of disease, of whom three with distant metastases. CONCLUSION Regionally metastasized CHNSCC is a serious disease with a high risk of regional recurrence, calling for combined surgery and adjuvant radiotherapy. A small subset of patients with a long interval between completion of primary treatment and presence of regional nodes justifies a long follow-up.
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Affiliation(s)
- J A D Jol
- Department of Otolaryngology/Head and Neck Oncology, Antoni van Leeuwenhoek Hospital/Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
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Ollila DW, Foshag LJ, Essner R, Stern SL, Morton DL. Parotid region lymphatic mapping and sentinel lymphadenectomy for cutaneous melanoma. Ann Surg Oncol 1999; 6:150-4. [PMID: 10082039 DOI: 10.1007/s10434-999-0150-0] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Routine elective superficial parotidectomy for patients with primary cutaneous melanomas of the scalp, auricle, or face has been questioned. We evaluated an alternative, i.e., lymphatic mapping and sentinel lymphadenectomy, for patients with primary cutaneous melanomas draining to the region of the parotid gland. PATIENTS Retrospective review of our large (>8000 patients) melanoma database identified 39 patients with primary melanomas (American Joint Committee on Cancer stage I or II) of the scalp (n = 19), auricle (n = 11), or face (n = 9) who underwent intraoperative lymphatic mapping to identify a sentinel node (SN) in the region of the parotid gland, between June 1985 and July 1997. RESULTS A SN was identified in the parotid region of 37 patients (94.9%), four of whom had SN metastases. The mean number of SN obtained was 2.3/patient (range, 1-4/patient). The two patients (5.1%) for whom a parotid-region SN could not be identified underwent superficial parotidectomy during the same operation. Among the 33 patients with tumor-free SN, with a median follow-up period of 33.2 months (range, 1-121 months), there was one (3.1%) intraparotid recurrence; thus, the false-negative rate was 3.1%. The procedure-related surgical morbidity rate was only 2.6% (one case of temporary facial nerve paresis). CONCLUSIONS For patients with primary melanomas of the scalp, auricle, or face, sentinel lymphadenectomy can be performed accurately in the parotid region and offers a low-morbidity alternative to routine elective superficial parotidectomy.
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Affiliation(s)
- D W Ollila
- Roy E. Coats Research Laboratories of the John Wayne Cancer Institute, St. John's Health Center, Santa Monica, California 90404, USA
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Malata CM, Camilleri IG, McLean NR, Piggott TA, Soames JV. Metastatic tumours of the parotid gland. Br J Oral Maxillofac Surg 1998; 36:190-5. [PMID: 9678884 DOI: 10.1016/s0266-4356(98)90496-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Twenty patients (12 men and 8 women, median age 69 years) with metastatic tumours in the parotid gland who presented over a 12-year period were evaluated retrospectively. Preoperative investigations included fine needle aspiration cytology (n = 11) and computed tomography or magnetic resonance imaging (MRI) (n = 14). Most tumours originated from the head and neck region, the two main types being squamous cell carcinoma (n = 10) and malignant melanoma (n = 7). All 20 presented with a parotid mass and 11/20 (55%) had associated lymphadenopathy. Eleven patients (55%) underwent superficial, five total, and four radical, parotidectomy. Neck dissection was required in 16 patients (80%), and all 11 patients with clinically palpable lymph nodes had evidence of tumour in the neck dissection specimens. Half of all patients (n = 10) received adjuvant postoperative radiotherapy. Three-quarters of the patients (n = 15) were alive after a mean follow-up of 31 months and only one developed a marginal recurrence. The cumulative 5-year survival rate was 51%, and there was no significant difference (P = 0.48) in the 3-year survival rates of patients who had radical compared with those who had modified neck dissections. Patients who had superficial parotidectomy had a longer overall survival compared with those who had total or radical parotidectomy (P = 0.04) perhaps reflecting the advanced nature of tumours that required total or radical excision of the gland. We conclude that superficial parotidectomy is usually an adequate treatment for secondary parotid tumours (when disease is clinically limited to the superficial lobe), and we suggest that patients in whom metastatic disease of the parotid gland is suspected do not require neck dissection if they have no palpable lymph nodes and MRI shows no evidence of spread. There seems to be no survival advantage in radical over modified neck dissection.
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Affiliation(s)
- C M Malata
- West of Scotland Plastic and Oral Surgery Unit, Canniesburn Hospital, Glasgow, UK
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Malata CM, Camilleri IG, McLean NR, Piggot TA, Kelly CG, Chippindale AJ, Soames JV. Malignant tumours of the parotid gland: a 12-year review. BRITISH JOURNAL OF PLASTIC SURGERY 1997; 50:600-8. [PMID: 9613402 DOI: 10.1016/s0007-1226(97)90505-1] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Malignant parotid tumours are uncommon and present a significant management challenge. Fifty-one such patients (25 male, 26 female, median age 64 years) operated on in the Newcastle Plastic Surgery Unit between 1983 and 1994 were retrospectively evaluated. Preoperative investigations included FNA cytology (n = 20), and for staging CT and/or MRI scans (n = 21). Of the 35 primary tumours 32 were epithelial and three lymphomatous. Metastatic tumours were squamous cell carcinoma (7), melanoma (6), renal cell carcinoma (2) and sebaceous carcinoma (1). FNA cytology correctly diagnosed malignancy with an 88% sensitivity (false negatives = 2). A total or radical parotidectomy was required in 60% of patients, the rest undergoing superficial parotidectomy. In continuity neck dissection was undertaken in 23 (45%) cases. Postparotidectomy reconstruction included 10 free, 3 myocutaneous, and 4 local transposition/rotation flaps. Thirty-seven patients (73%) received postoperative radiotherapy. Seventy-two per cent of patients are alive after a mean follow-up of 42 months. The crude 5- and 10-year survival rates were 68% and 49% respectively while the loco-regional control rate (Kaplan-Meier method) at 10 years was 79%. Fifteen patients (30%) have permanent facial palsy. It is concluded that radical surgery with appropriate reconstruction followed by planned postoperative adjuvant radiotherapy gives effective control of malignant parotid tumours.
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Affiliation(s)
- C M Malata
- Department of Plastic and Reconstructive Surgery, Royal Victoria Infirmary & Associated Hospitals NHS Trust, Newcastle-upon-Tyne, UK
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Stone CA, Goodacre TE. Surgical management of regional lymph nodes in primary cutaneous malignant melanoma. Br J Surg 1995; 82:1015-22. [PMID: 7648140 DOI: 10.1002/bjs.1800820806] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The management of regional lymph nodes in the patient with primary cutaneous malignant melanoma remains a contentious issue. Early removal of nodes, which may harbour occult microscopic disease before the development of clinically detectable malignant lymphadenopathy, is thought by some to confer a survival advantage and/or improve locoregional tumour control. While tumour burden at lymphadenectomy has been shown to correlate with prognosis, there are conflicting reports regarding the efficacy of elective lymph node dissection (ELND) compared with a regimen of delayed therapeutic dissection for clinically detectable nodal involvement. Evaluation of arguments for and against ELND, together with consideration of surgical morbidity and the predictability of lymphatic drainage patterns, has allowed a clinical algorithm to emerge which may identify patients who may benefit from prophylactic surgery. A chronological summary of the relevant studies is presented and the overall division of opinion regarding the efficacy of ELND is discussed.
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Affiliation(s)
- C A Stone
- Department of Plastic and Reconstructive Surgery, Radcliffe Infirmary, Oxford, UK
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