Browsing by Department "Division of Plastic and Reconstructive Surgery"
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- ItemOpen AccessAllotransplantation of free vascularised skin flaps(1988) Lechtape-Grüter, Reinhard
- ItemOpen AccessArterial microanastomosis with size mismatch : a trial of two techniques(2010) Rickard, Rory Frederick; Hudson, DonaldUse of perforators as recipient vessels in microvascular reconstruction has led to arterial diameter discrepancy becoming an increasingly common finding. Experimental and clinical evidence confirms that patency rates decrease with increasing diameter mismatch, but no good evidence is available to direct the choice of end-to-end microanastomotic technique where a small-to-large discrepancy exists. A programme of research has been conducted comparing two techniques of endto-end arterial microanastomoses, where a small-to-large diameter discrepancy exists of between 1:1.5 and 1:2.5. These techniques are; 45º oblique section of the smaller vessel, and; invaginating the smaller vessel inside the larger.
- ItemOpen AccessAutologus fat grafting for mild to moderate velopharyngeal insufficiency: Our experience(2018) Xoagus, Elizabeth Alexia; Adams, Saleigh; Hudson, Donald AnthonyThe standard surgical treatment of velopharyngeal insufficiency (VPI) includes revision palatoplasty, posterior pharyngeal flap and sphincter pharyngoplasty. These procedures are not without complication and can also be challenging to the occasional cleft surgeon. The greatest complication is iatrogenic obstructive sleep apnoea particularly in high risk patients. With the introduction of posterior pharyngeal wall augmentation, a lesser and simpler surgical procedure, various materials have been used for this purpose with limited success and significant complication rates. Augmentation of the velo-pharynx with autologous fat has been practiced for decades. Autologous fat has multiple advantages compared to other biological and synthetic materials used for augmentation of the velopharynx. Autologous fat is readily available, has low donor site morbidity, does not migrate, injects easily and is non-allergenic. The outcome of fat grafting for VPI is good and stable long term, albeit unpredictable due to the resorption of fat. The procedure may therefore need to be repeated in order to achieve the desired results. The aim of this study is to evaluate and document the outcome of autologous fat grating for the treatment of mild to moderate VPI in children at the Red Cross War Memorial Children's Hospital (RCWMCH). A retrospective folder review was conducted on 9 consecutive patients who underwent velopharygeal fat grating for the treatment of mild to moderate VPI at the RCWMCH from 2010 to 2014. All the patients had had primary palatoplasty performed previously and subsequently developed VPI. Patients were assessed pre- and postoperatively by two cleft surgeons, and an experienced speech and language therapist with the aid of laterl view videofluoroscopy (VF). Pre-operative and post-operative perceptual speech assessments were performed by a dedicated speech and language therapist. Two senior cleft surgeons performed pre-and post-operative videofluoroscopy interpretations. Eleven fat grafting procedures were performed on 9 patients and an average of 5.64 ml (range 1 ml to 7 ml) of autologous fat was transferred to the velopharynx. The average age at the time of operation was 6.5 years (range 3 years to 14 years) with a follow-up period of 18 months (range 7 months to 34 months). Most of the patients (7 out of 9) showed improved speech following fat grafting. There were no complications related to the fat grafting procedure. This small study suggests that fat grafting is an effective, minimally invasive surgical alternative for the treatment of mild to moderate VPI and to our knowledge, is the first reported study from Africa.
- ItemOpen AccessThe biomechanics of negative-pressure wound therapy(2011) Kairinos, Nicolas; Hudson, DonaldDespite the success of negative-pressure wound therapy, its mechanism of action remains unclear. The common perception that it reduces tissue pressure and increases perfusion has recently been challenged following the observation that tissue necrosis can be caused as a result of its application. A programme of research has been conducted to clarify how tissue pressure changes during negative-pressure wound therapy and the resultant effect thereof on perfusion. The cause for conflicting evidence from other studies was also investigated.
- ItemOpen AccessEthnic-specific associations between abdominal and gluteal fat distribution and the metabolic complications of obesity : implications for the use of liposuction(2011) Hayes, Philip Michael; Goedecke, JuliaMore than three-quarters (77%) of the 40.5 million people living in South Africa are black African, of which more than 40% are urbanised. Black African women living in urban areas have a significantly higher prevalence (62%) of overweight than urban black males (28%) or white females (53%). It was previously thought that obesity in black South African women was not associated with deleterious metabolic sequelae and was termed "healthy" obesity...
- ItemOpen AccessEvaluation of the clinical outcome of curvilinear transport distraction osteogenesis and revascularised fibula free flaps in the reconstruction of large post-maxillectomy defects(2017) Hendricks, Mogamat Rushdi; Vicatos, George; Hudson, DonaldBackground: Maxillary defects caused by trauma or tumour resection in the head and neck region can be devastating to the patient from a cosmetic and functional perspective. Patients who undergo maxillectomy procedures experience a substantial deterioration in their primary oral functions such as breathing, mastication, salivation, deglutition and phonation, which has a collective adverse influence on their quality of life (QOL). The revascularised free fibula flap (RFFF) has been demonstrated to be most reliable for the reconstruction of maxillary defects, and has been regarded as the 'gold standard.' A novel method of regenerating bone and soft tissue through the process of curvilinear transport distraction oseteogenesis (CTDO) has been developed and compared with the RFFF technique. Method: A prospective cohort study of 6 post-maxillectomy patients was compared regarding the clinical outcome of function and aesthetics with a group of 6 patients who had undergone RFFF reconstruction. The new bone (regenerate) was compared with the parent bone from which it had been generated. Objective measuring tools were employed to assess pre and post quality of life (QOL) aspects. The RFFF patients were not subjected to any invasive procedures save to undergo a clinical evaluation and undergo a CT scan of their maxillae. A cohort of 6 participants was treated prospectively using CTDO and the results were analysed within that cohort. These results were compared with a retrospective group of 6 participants of similar age and gender distribution who had undergone RFFF reconstruction as an external control. The patented Hendricks-Vicatos (H-V) maxillary transport distractor was applied to all selected participants by the primary investigator under general anaesthesia at Groote Schuur Hospital or a private clinic. The H-V maxillary transport distractor (5 prototypes) was pre-shaped and pre-fitted onto a 3-D model of the participant's maxilla, in a laboratory. This method reduced clinical installation time. If teeth were present in the area to be distracted, then at least 2 teeth were removed from the maxilla, preferably three months before the date of distraction. In the first few cases, this was the protocol for developing bone stock. This protocol was revised in the last 2 patients of the study, where no teeth were extracted at all. A linear fracture (bi-cortical) was created in the maxilla in a vertical direction (segmentally) to develop a mobile, well-vascularised transport disc. This carrier disc was attached to the metal plate of the 'crawler' via small titanium screws. The crawler was then moved on the reconstruction plate (BiometTM Zimmer Biomet,
- ItemOpen AccessExperience with the Meek micrografting technique in major burns(2016) Potgieter, Dawid Jacobus; Rode, Heinz; Adams, SaleighBackground. Early excision of burn eschar and urgent skin cover is mandatory for survival in all major burns. The tremendous cost and time delay in cultured skin and the shortage of donor allograft can make early skin cover a life threatening problem for paediatric patients in this country. The Meek micrografting technique was introduced in 2003 as a rescue method to achieve epithelialisation in major burns. Objective. To evaluate its role in the management of major burns with reference to its efficacy, technical detail and role in major burn surgery.
- ItemOpen AccessMicrovascular free tissue transfer for the head and neck reconstructive in a resource-limited setting(2016) Dos Passos, Gary; Hudson, DonaldBackground: Free tissue transfer has become the standard of care for the reconstruction of head and neck oncological defects. The Groote Schuur Hospital provides a microsurgical reconstructive service in a resource-limited setting, without access to venous couplers, invasive monitoring devices, modern microscopes or sophisticated pre-operative imaging. The reconstructive surgeons perform all anastomoses under x4.5 loupe magnification. Methods: A retrospective chart review was undertaken of cases performed by the service over a 3-year period. Demographic factors, indications for flap cover, operative details (flap used, duration and lowest recorded temperature), intensive care and hospital length of stay, and other outcomes were recorded and evaluated (including flap and systemic complications, donor site morbidity, haematomas as well as returns to theatre). Results: Over a 36-month period, 109 flaps for head and neck reconstruction were performed. The main indication for surgery was squamous cell carcinoma of the oral cavity. The mean operating time for resection and reconstruction was 6.02 h (range of 4 to 12 h). Virtually, all reconstructions were performed using one of either radial forearm, free fibula or anterolateral thigh flaps. We report a complete flap loss rate of 6 %. All four successful salvages were undertaken in the early (less than 24 h) post-operative period. Hypothermia intra-operatively appears to correlate very closely with pejorative outcomes. Conclusions: By restricting reconstructive options to three main 'workhorse' flaps and by utilising a simultaneous two-team approach for tumour ablation and flap elevation, success rates comparable to international standards have been achieved. Limited resources should not be regarded as an impassable barrier to providing a successful microvascular head and neck reconstructive service.
- ItemOpen AccessPaediatric burn wound patients: blood transfusion and requirements in the peri-operative period(1993) Grobbelaar, Adriaan Ockert; Brown, R. A.The concept suggesting primary excision and immediate grafting as the definitive treatment for a thermal burn is not new (1 ). To avoid the sequelae of local and systemic sepsis, early excision of burn eschar to remove all devitalized tissue has been a widely accepted method of treatment of deep burns since 1929, when Wells performed total excision and grafting of electric burns (2). While the technique has many advantages, it is not without significant complications. Haemorrhage accompanying burn wound excision can be deceptively large, as can the metabolic stress associated with large surgical procedures performed in the post-burn period (3).
- ItemOpen AccessPatient reported outcome measures (PROMs) in breast cancer patients after immediate breast reconstruction using the Breast-Q(2020) Möller, Ernst Lodewicus; Cairncross, Lydia; Panieri, Eugenio; Hudson, DonaldBackground Mastectomy is the mainstay of surgical treatment for women with breast cancer in South Africa. The increase in breast reconstruction after a mastectomy has prompted the need to evaluate patient reported outcome measures (PROMs) for this set of operative intervention. This study aimed to assess clinical and patient reported outcome measures in immediate breast reconstruction patients using the BREAST-Q and compare these with international cohorts. Methods A cross-sectional study was performed on all patients who underwent immediate breast reconstruction between January 2011 and December 2016. This consisted of a retrospective clinical record review of perioperative outcomes, and a quality of life analysis using the BREAST-Q Post-Reconstruction questionnaire. Outcome predictors were identified using Chi-square, Fisher exact, One-way ANOVA, Student t-tests and Kruskal Wallis analysis of variance. A random-effect single arm meta-analysis was performed to compare the BREASTQ scores with international cohorts. Results A total of 52 patients were included with a mean age of 43.2 (+/-9.5) years. Eighteen patients (34.6%) developed early complications; of these 8 (44.4%) were major. Thirty-one patients (59.6%) developed late complications; of these 18 (58.1%) were major. Fifteen patients (28.8%) had failed reconstruction. There was a significantly higher risk of failure following a total mastectomy (TM) (p=0.02), tissue expander reconstruction (TE) (p< 0.01) and stage 2 breast cancer (p=0.01). Patients who underwent nipple reconstruction and immediate-delayed reconstruction before 12 months, reported higher well-being and satisfaction scores. Compared to international cohorts our BREAST-Q scores were lower but fall within the 95% confidence interval for Sexual Well-Being and Satisfaction with Nipples and Care. Conclusion Immediate breast reconstruction poses a high risk of complications and reconstructive failure especially, with TM and TE. Our BREAST-Q scores are comparable to international studies and may be useful in guiding patient consent.
- ItemOpen AccessPercutaneous Puncture of Flexor Sheath Ganglions: An Assessment of Recurrence(2020) Najjaar, Azzaam; Hudson, Donald; Solomons, Michael; McGuire, DuncanBackground Flexor tendon sheath ganglions (FTSG) comprise up to 15% of hand ganglions. The management is split between two schools of practice: percutaneous puncture or surgical excision. The literature is equivocal as to which holds true superiority in terms of recurrence rates. The cost of surgical excision is higher and the recovery is longer. In addition, surgery also brings with it the potential for surgical complications, both immediate and long term. Percutaneous puncture can be performed at the time of the initial consult and an immediate return to normal activity with no down-time for the patient. The aim of this study is to assess the recurrence rate after percutaneous puncture. We also describe our employed technique. Method The technique for percutaneous puncture involved the use of a 25-gauge needle for ganglion puncture, no sclerosant or corticosteroid was injected, and an immediate post-procedure mobilisation protocol was employed. Patients were identified from clinical records and were followed up at a minimum of six months to check for recurrence. Results Eighteen patients were included in the study, 12 females and 6 males. The majority of FTSG were found to occur in the middle finger. Two patients experienced a recurrence. Both were successfully treated with a repeat puncture. No patients experienced a complication. Conclusion In our study, we show a low recurrence rate obtained with percutaneous puncture of FTSG using a simple technique. No complications were noted in our cohort on follow-up. We, therefore, recommend employing it as a first line treatment in the management of FTSG.
- ItemOpen AccessPractical aspects in first aid cooling of burns(1993) Venter, Tertius Hendrik Johannes; Rode, HThe beneficial effects of first aid cooling of fresh burn wounds have been recognised for many years, particularly with regard to the relief of pain, but there still exists controversy as to the effects of cooling in limiting the damage and the influence on subsequent healing in the burn wound. This might be influenced by the temperature of the coolant, the time delay from the injury to commencement of cooling, how effectively the coolant is applied and the time period of cooling. Four identical burn wounds were created on the back of an anaesthetized pig. One wound was not cooled and the other three wounds cooled,· two with a time delay of half an hour and one immediately, each of the three for different periods of time. Eleven pigs were used and each pig served as an independent experimental model. The animals were farther divided in two groups,· Group I using ice water to cool the wounds and Group II using tap water,· Group Ila using slightly warmer water than group Ilb. It was found that the temperature of the coolant was crucial if applied effectively. An effective method of cooling of fresh burn wounds is demonstrated. When ice water of 1-8 degrees celsius (Group I) was used it caused more damage than in the wounds that were not cooled. When tap water was used at 12-18 degrees celsius (Group II) to cool the wounds it could be demonstrated clinically and histologically that the cooled wounds had less damage than the uncooled wounds and healed faster. In group II it was shown that the beneficial effects of cooling was still present in the wounds where commencement of cooling was delayed for half an hour.
- ItemOpen AccessThe role of propranolol in the treatment of infantile haemangioma(2013) Moodley, Sean Thirumalay; Hudson, DonaldThere has been a change in the management of infantile haemangioma with the introduction of propranolol. The aim of this study is to retrospectively evaluate a simple treatment for infantile haemangioma at the Red Cross War Memorial Children’s Hospital (RCWMCH) and document the results. While it is known that all haemangiomas undergo involution at some stage, some haemangiomas pose certain problems. These relate mainly to visual axis obstruction and aesthetics. Subjects are children in the first two years of life presenting with haemangiomas. All patients were treated with oral propranolol in conjunction with haemangioma size documentation, using a simple radiological modality, i.e. ultrasound imaging. Patients are followed up and clinical and radiological evaluations are undertaken to observe changes in size and appearance. Propranolol is non-selective β-adrenergic antagonist that is used extensively for the treatment of a multitude of disorders, mainly cardiovascular indications. The main adverse effects include bradycardia, hypotension and bronchospasms. For the purposes of this study, all subjects were routinely examined, especially with regard to the cardiopulmonary systems. Any perceived anomaly was referred to the cardiorespiratory physicians at RCWMCH for further evaluation, which includes all the necessary investigations such as electrocardiograms(ECG) and echocardiograms. Therefore, only fit healthy patients were selected for this study. Patients are educated and fully informed regarding the adverse effect profile of propranolol, and advised of the appropriate route of management.
- ItemOpen AccessSoft tissue Reconstruction of Gustilo-Anderson Grade IIIB Open Extra-Articular Tibial Fractures at a Tertiary Hospital in Cape Town, South Africa: A Retrospective Case Series(2020) Barouni, Elyas; Laubscher, MaritzIntroduction: Management of Gustilo-Anderson grade 3b tibia fractures are challenging due to the high rate of complications which includes infection, nonunion and possible amputation. Due to limited soft tissue coverage of the tibia antero-medially, open fractures remain a treatment challenge. Despite many advances, the ideal time delay to definitive soft tissue cover remains controversial. Aim: We aimed to investigate the management strategy and the outcome of soft tissue reconstruction of Gustilo-Anderson grade 3b tibia fractures at a tertiary hospital in Cape Town, South Africa. Methods: A retrospective study was conducted on 22 patients who underwent soft tissue reconstruction for grade 3b tibia fractures from January 2014 to July 2017. Patient demographics, comorbidities, injury characteristics and management practices such as time to debridement, relook time, Negative Pressure Wound Therapy (NPWT), soft tissue coverage and complications were recorded. Results: Most patients were males (n=18; 81.8%) with an average age of 39.3 years. Pedestrian vehicle accidents accounted for 45.4%(n=10), motor-vehicle accidents (n=6; 27.3%) and gunshot wounds (n=2; 9.1%). The commonest site of injury was the middle third of the tibia (n=13; 59.1%), distal third (n=7; 31.8%) and proximal third (n=2; 9.1%). Most patients (n=18; 81.8%) were debrided within 24 hours. The mean times for NPWT prior to cover was 12.5 days and for soft tissue cover 13.7 days (range 2-35), respectively. Fasciocutaneous flaps (n=11; 50%) were predominantly used as cover, then pedicled muscle flaps (n=8; 36.4%), free flaps (n=2) and skin graft(n=1). Most patients (n=13; 59.1%) received satisfactory outcomes. Seven (31.8%) required soft tissue revisions. Three patients (13.6%) suffered complications namely, complete flap loss resulting in amputation, partial skin graft loss and soft tissue infection, respectively. Patients who underwent debridement after 24 hours reported the least complications and there appeared to be better outcomes in the relooks beyond 48 hours. Conclusion: Despite achieving outcomes which concur with other published studies, the BOAST 4 guidelines were not fully reflected in our management strategy. We will require larger numbers in future studies to formulate a standardized management protocol going forward.
- ItemOpen AccessThe use of Acellular Dermal Matrices in the Management of Complex Traumatic Wounds in a Paediatric Population(2020) Pillay, Kamlen; Adams, Saleigh; Hudson, Donald AnthonyIntroduction Complex soft tissue injuries are common in children. Paediatric wounds associated with large soft tissue defects pose a surgical challenge. This often necessitates extensive reconstructive surgery and frequently requires the use of microvascular free flaps. Local, regional and free flap surgery in children poses several challenges related to donor site morbidity, flap failure and the long-term sequelae of repeated surgeries for flap modification in a growing child. The introduction of acellular dermal matrices (ADM's) in recent decades has dramatically influenced the management of complex soft tissue wounds. The dermis in skin represents the functional aspect of skin. ADM's represent dermal structures artificially, hence their incorporation into the wound should restore skin characteristics specifically pliability. Some authors believe that ADM's have improved prognosis and reduced morbidity in the treatment of open wounds. Combining the use of ADM's together with split-thickness skin grafting (SSG) is rapidly becoming an important method used to manage such complex wounds. In this study, we explore whether the use of this technique has been a beneficial addition to the traditional management armamentarium for complex injuries in the extremities and report the rate of complications experienced by our patients at our paediatric hospital in Cape Town. Objective This study reviewed the number of complications experienced with the use of ADM's in treating complex wounds on the extremities of children. It includes 54 children treated between the years 2011 and 2016 at a national paediatric hospital. Methodology A retrospective folder review of children treated at our hospital between the years 2011 and 2016 with extremity injuries was conducted. A total of 189 patient folders were reviewed. Children (n= 54) with complex wounds in their extremities who had received an ADM were included in this study. Both short and long-term complications were identified. The patient age range was six months - 12 years, while the mean patient follow-up period was 390 days. Results All patients treated with ADMs for traumatic extremity injuries during this period were included in the study, irrespective of age or co-morbidities. In 45 patients the ADM and SSG healed without any complication that is, not requiring revision surgery at 1 year follow up. Seven patients who did not receive postoperative splinting and occupational / physiotherapy displayed wound contractures, requiring further reconstructive surgery, 4 of which were also in the group who experienced complete ADM or graft loss below. Six patients experienced complete loss of the ADM due to infection, which led to graft failure, requiring revision surgery. Of the six patients that experienced complete loss of the ADM, five were not treated with NPWT dressings. Noteworthy, is that all 45 patients who healed without any complication were treated with NPWT dressings. Biopsies that were performed on 18 patients at 2 weeks post application of the ADM, showed only granulation tissue. No evidence of residual ADM or accessory dermal structures was found in any of the samples, which were obtained from multiple loci of the ADM in situ. The mean time to closure with this method was 3 weeks and the mean hospital stay was 26 days. Two patients were lost to follow-up and were excluded from the morbidity analysis arm of the study. Discussion We found that post-operative physiotherapy, occupational therapy and splinting are extremely important in preventing morbidity in particular scar contracture when associated with wounds treated with ADMs. There was no histological evidence to suggest that the ADM remains intact after 2 weeks post application. Our data reveals that vacuum assisted closure is a vital adjunct to this method, ensuring adequate ADM and graft take. Conclusion Complex wounds in the extremities of children pose a reconstructive dilemma to the plastic surgeon. In anatomically sensitive areas where traditional plastic surgery options are unavailable or undesirable, the use of ADMs and SSGs represent a realistic alternative for the reconstruction of large wounds associated with complex soft tissue injuries in the extremities of children.
- ItemOpen AccessVentilator associated pneumonia in major paediatric burns(2013) Rogers, Alan David; Rode, Heinz; Hudson, DonaldIncludes abstract. Includes bibliographical references.