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Inspection of the baseline occlusion is critical during the initial assessment of an oral malignancy. If the mandible is involved and requires reconstruction, restoring class I or premorbid Buccal Mucosa the buccal mucosa is the membranous internal lining of the cheek extending from the inner oral commissure anteriorly to the pterygomandibular raphe found just lateral to the retromolar trigone. Medially, the buccal mucosa attaches to the upper and lower alveolar ridges to create the gingivobuccal sulci. Low resilience of these tissues to infiltrating buccal lesions can allow lateral tumor extension, which may cause facial nerve paresis, orocutaneous fistulae, or skin changes. Additional routes of spread may occur in all directions to reach the alveolar ridge, retromolar trigone, ascending mandibular ramus, lateral tongue, and floor of mouth. The degree of mouth opening and presence of trismus is assessed by measuring the inter-incisor distance. Tumor infiltration of the pterygoid space or pain in opening of mouth may cause severe trismus which can make airway management difficult as well as make surgery necessary. Furthermore, the large primary tumors that create multisite defects often require postoperative adjuvant radiation therapy. Vascularized free tissue can resist the effects of radiation that lead to late complications. Lips the lips form the anterior entrance into the oral cavity and have several crucial functions including articulation of speech, facial expression and aesthetics, oral competence during eating, and sensation. The orbicularis oris muscle courses circumferentially to create the upper and lower lips which join laterally at the oral commissure. Motor innervation to the lips is by the facial nerve, and sensation by the second and third divisions of the trigeminal nerve. Oral competence should create a watertight seal when the mouth is closed to prevent drooling or air escape during speech. The lips can be palpated and distracted away from the jaw in order gauge mobility. For primary lip cancers, determination of the percentage of the total lip length involved is important when choosing reconstructive options microstomia is to be avoided. The role of angiography is mainly for assessing the vascularity of potential free flap harvest sites, such as the lower leg in patients with peripheral artery disease or the forearm in patients with history of prior trauma. The learning curve for efficient use of the technology is another potential challenge. Defects involving multiple subsites may demand attention to all or many of these challenges. The reconstructive ladder represents a conceptual framework useful in the assessment of any defect. It includes every surgical option starting with the simplest and least invasive and moving toward the most complicated techniques. The smallest and most superficial defects can be addressed either by healing by secondary intention or primary closure, which make up the first two rungs of the ladder.
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Gestational Diabetes Screening: the International Association of the Diabetes and Pregnancy Study Groups Compared With Carpenter-Coustan Screening. Jelly beans as an alternative to a fifty-gram glucose beverage for gestational diabetes screening. Physical activity interventions in pregnancy and risk of gestational diabetes mellitus: a systematic review and meta-analysis. No safe level of exposure has been demonstrated, although sporadic use of less than 1 oz of alcohol per day has not been associated with the syndrome. Alcohol use among pregnant and nonpregnant women of childbearing age - United States, 1991-2005. Possible Complications: Higher rate of spontaneous miscarriage in heavy users of alcohol. Expected Outcome: Infants affected by fetal alcohol syndrome vary from mildly to profoundly mentally retarded. Systematic review of effects of lowmoderate prenatal alcohol exposure on pregnancy outcome. Alcohol abuse and other substance use disorders: ethical issues in obstetric and gynecologic practice. Because of the large size of some molar pregnancies and a tendency toward uterine atony, concomitant oxytocin administration is advisable and blood for transfusion must be immediately available, should it be needed. Oxytocin or methylergonovine maleate (Methergine) is used to help contract the uterus during surgical evacuation. Primary or recurrent malignant trophoblastic disease is generally treated with chemotherapy (methotrexate, actinomycin D, chlorambucil, or cyclophosphamide [Cytoxan], singly or in combination). Possible Complications: Gestational trophoblastic neoplasia is notable for the possibility of malignant transformation, although fewer than 10% of patients develop malignant changes. In general, the larger or more advanced the molar pregnancy, the greater the risk of pulmonary complications, bleeding, trophoblastic emboli, or fluid overload during evacuation. Expected Outcome: Approximately 80% of molar pregnancies follow a benign course after an initial therapy. The prognosis for patients with primary or recurrent malignant trophoblastic disease is generally good (>90% cure rate). The theca lutein cysts often found in molar pregnancies may take several months to regress after evacuation of the uterine contents. Fewer than 5% of patients will require hysterectomy to achieve a cure for choriocarcinoma. Methotrexate with citrovorum factor rescue for nonmetastatic gestational trophoblastic neoplasms.
