Masters Degrees (Plastic and Reconstructive Surgery)

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    Modified total cranial vault remodeling technique for scaphocephaly repair
    (Stellenbosch : Stellenbosch University, 2015-12) Altaib, Mohamed Giuma; Graewe, F. R.; Zuhlke, Alexander; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Surgical Sciences: Plastic and Reconstructive Surgery.
    ENGLSIH ABSTRACT: Introduction: Sagittal synostosis or scaphocephaly is the most common isolated single-suture synostosis that accounts for 40% to 60% of all craniosynostosis cases which affects 1 out of 2000 live births. The craniofacial unit at Tygerberg Academic Hospital modified the technique of total vault remodeling by lag screw fixation of onlay bone segments in the temperoparietal region to: a) improve the stability of the reconstruction; b) to increase the biparietal distance; c) to reduce operation time; and lastly d) to avoid secondary procedures for the removal of titanium plates. The aim of this study was to evaluate the surgical outcomes of the modified total cranial vault remodeling procedure for the management of sagittal synostosis. Method: A retrospective study was employed to investigate the surgical outcomes of the modified total cranial vault remodeling technique for non-syndromic scaphocephaly repair by use of medical records of eight pediatric patients operated over thirty-two months from October 2011 to May 2014. The sample comprised three boys and five girls with an age range of 4 months to 5 years and 7 months. The head circumference was measured pre- and post-operatively and the parents’ satisfaction recorded. The surgical duration of the modified procedure and the patients’ blood transfusion volume was compared to the unit’s traditional approach. Results: The head circumference of all patients increased on the percentiles of the head circumference-for-age growth chart. Pre-operatively a mean of 47 cm and post-operatively a mean of 50.94 cm were measured. Parents were generally satisfied with the aesthetic outcomes of the surgery. The average volume for intraoperative blood transfusion was 230 ml compared to 763 ml for the conventional method. The average surgical time decreased from 5.5 hours with the conventional method to 3.4 hours with the modified technique. Conclusion: The modification of the cranial vault remodeling increased the head circumference, yielded good parental satisfaction, decreased the surgery time and intraoperative blood transfusion volume with complications comparable to the traditional method.
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    Reconstruction of the lower eye lid with a rotation-advancement tarso-conjunctival cheek flap
    (Stellenbosch : University of Stellenbosch, 2010-12) Wessels, William Louis Fick; Graewe, F. R.; Van Deventer, P. V.; University of Stellenbosch. Faculty of Health Sciences. Dept. of Surgical Sciences. Plastic and Reconstructive Surgery.
    The repair of full-thickness defects of the lower eyelids poses a challenge because a graft in combination with a flap is typically used to replace either the posterior or anterior lamella. This often results in aesthetically and functional unsatisfactory outcomes. A rotation-advancement tarso-conjunctival cheek flap, which reconstructs both posterior and anterior lamella with vascularized tissue similar to the native eyelid, is described. Nine patients underwent reconstruction with a rotation-advancement tarso-conjunctival cheek flap. The indications, complications and outcomes were evaluated. The follow-up time ranged from 6 to 60 months with an average of twenty three months. The main indication for use of this flap is full-thickness defects of the lower eyelid between 25 – 75 %, typically after tumour ablation. All the patients had a functional and aesthetically satisfactory outcome. One patient underwent a revision canthoplasty. The rotation-advancement tarso-conjunctival cheek flap adheres to basic plastic surgery principles resulting in a satisfactory outcome; (a) Vascularized tissue is used to reconstruct the defect. (b)The flap composition is similar to the native eyelid i.e. replace like with like. (c) The flap makes use of tissue that is excess and therefore limits donor morbidity.
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    The vascular anatomy of the forehead related to forehead flaps and its application in plastic and reconstructive surgery
    (Stellenbosch : University of Stellenbosch, 2007-12) Kleintjes, Wayne George; Du Toit, D. F.; Zeeman, B. J. van R.; University of Stellenbosch. Faculty of Health Sciences. Dept. of Surgical Sciences.
    Aims: The goal of this study was to identify arterial variations by cadaveric dissection, in the forehead, in order to validate the practicality and implementation of planned forehead flaps and to increase the safety of forehead flaps in plastic and reconstructive surgery. Hypothesis tested: Unique frontal forehead flaps can be safely based on anatomical dissection and on the presence of the central vein and the anastomosing branches of the frontal ramifications of the angular artery (AA). Materials & methods: The study had two strategic components: an anatomical cadaveric study and a clinical study, based on the newly described forehead vasculature. The anatomical study consisted of a) dissection of 30 latex infused cadavers and 20 non-latexed cadavers; b) histological assessment of forehead vasculature of 20 cadavers. The clinical applicability study consisted of a cohort of 12 plastic and reconstructive surgery cases, undergoing nasal rhinoplasty, based on the cadaveric study and anatomical vasculature. The research was conducted within an ethical protocol and all patients gave informed consent. The follow-up period is 2 years. Results: In the cadaveric dissection, the following vessels, relevant to forehead flaps and nasal reconstruction, were consistently identified: DNA, FBSTA, STrA, TFA, AA, CA, CV, PCA, SOA and OV. Side branch analysis of STrA (N = 43) showed: MCB (60%), LCB (23%), SPA (26%), OB (19%), single VB (47%), medial and lateral VB (53%). Side branches of the supra-orbital artery (SOA) were: LRB (91%), OB (91%), VB (100%), MB (44%), BB (5%) and SVB (9%). Side branch profile of the angular artery (AA) was: DNA (96%), CB (67%) and PCA (47%). In 71% of cases the origin of the PCA was from the angular artery (AA). Individual artery side branches of the forehead were as follows: STrA (9), SOA (6), FBSTA (4), DNA (4), AA (3/4), CA (2) and PCA (2). Average diameter of the small arteries at point of entry ranged from 1 – 2mm (CA < 1mm, PCA < 1mm). The central vein was a constant finding in all dissections and an important landmark. Other constant veins detected included the nasofrontal, ophthalmic, angular, supra-trochlear and facial veins. Twelve prospective randomized patients met inclusion criteria for nasal flap reconstruction, based on the cadaveric vascular study. Race profile was white (6), mixed (4) and black (2). There were 8 males and 4 females. Disease demographics included cancer (6; melanoma 2, basal cell cancer 5), trauma (3), infections (1) and congenital (1). Post-operative grading was as follows: defects corrected (12/12), subjective improvement (12/12), objective improvement (12/12), partial flap necrosis (1/12) and secondary interventions (debulking or revision 2/12). Doppler assessment for pedicle vasculature showed identification of the following arteries: TFA (85%), STrA (65%), PCA (20%) and AA (25%). Doppler studies further indicated the following small side branches: TFA (49%), STrA (30%), PCA (9%), AA (12%). The central vein was identified in 9/12 (75%) by macroscopic examination. In one female with a basal cell carcinoma (BCC), modest dermal stock loss was demonstrated by the application of high frequency dermal ultrasound (Dermascan®). The results of the cadaveric anatomy study show the existence of various important subtle arterial variations in the forehead that are not described in the literature. Many arterial side branches not clearly named and others not described before, were highlighted in this anatomical study. Other observations regarding the anatomical relationships of the forehead nerves were of practical surgical value, the most important being to reduce sensory neuropraxia. The histological study endorsed the cadaver dissection observations and showed the importance of the flap vasculature at the proximal level of the pedicle. The clinical study with follow-up period of 24 months, illustrates an evolving refinement in surgical technique based on the findings of the anatomic vasculature study. A new method of planning a “2500-year-old operation” was confidently developed based on the anatomical vasculature observations detected during the cadaver study. The Doppler study suggests that crude arterial variations of the central forehead, in the region of the intended flap pedicle, can not be diagnosed and highlighted accurately pre-operatively. The macroscopic anatomy of the central vein (clinical landmark) is an accurate predictor of underlying arterial variations and may be more valuable clinically than the hand-held Doppler examination. Conclusion: Comprehensive vascular anatomical detail of the forehead was not described accurately or completely by clinical anatomists in the past and does not appear in classic text books of anatomy and morphology. This has led to one-dimensional (arterial) application of the midline forehead flap planning and eventually the introduction of the para-median forehead flap, which has become the modern “work horse” of forehead flaps for nasal reconstruction. Now that in a definitive cadaveric study of the forehead blood supply has been demonstrated, the results show that surgeons will once again be able to embrace the midline forehead flap, only this time there will be possibly no inconsistent descriptions of unnamed blood vessels or ill-defined landmarks for flap planning. New flaps and reconstructive options in or around the forehead will be hopefully planned and executed more effectively and safer based on a more comprehensive understanding of the forehead anatomy and vasculature. The subjective and objective end-point analysis of the clinical study show favourable measured outcomes in the interim follow-up period (24 months) and benefit to the patients, in the presence of a low percentage of flap loss (1/12; 8.3%). The use of pre-operative Doppler assessment helped with flap planning. In one patient, the application of high frequency ultrasound facilitated long term follow-up regarding recurrent tumour formation and enhancement of dermal consistency with anti-aging creams, vitamin A derivations and sunscreens. Recommendations: The classic anatomy text books and clinical plastic surgery works with their inconsistent descriptions of the central forehead blood supply (arterial and venous) need to be updated. The evolution of the midline forehead flap method is far from complete. The refinement of the one-stage midline forehead flap method without an island is in progress and can clinically be implemented, based on a sound anatomical dissection study.