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Introduction Humans have several different types of hair, classified into eight different groups, of which types VII and VIII predominate in South Africa. The scalp with its abundance of hair is often used as a preferential donor site for small burns. Major reasons cited are that the donor site is hidden from view (covered by hair), rapidly epithelializes with minimal scarring and provides a relatively large surface area. The author postulates that the type of hair will have an influence on the healing of scalp donor sites, complications and aesthetic outcome. Contrary to international consensus, the Red Cross War Memorial Children’s Hospital (RCWMCH) experience indicated that the use of the scalp as donor area is not ideal due to the frequent complications seen amongst paediatric patients e.g. visible scars, recurrent folliculitis, patchy alopecia, hypertrophic scarring and areas of de- and hyperpigmentation. Objective This study reviewed the complications encountered with the use of the scalp as primary donor area in children of mostly black African origin (type VI-VIII hair). Methodology A retrospective folder review of patients admitted to RCWMCH between 2003 and 2015 with major burns (>30% total body surface area) was conducted. A total of 179 patient folders were reviewed. Only children (n=25) with unburned scalp donor areas were included in this study. Both short- long-term complications were identified. The patient age range was six months - 12 years, while the mean patient follow-up period was 580 days and mean burn TBSA was 44.92% (range 4 – 85%). Results Patient demographics: black African 60% descent (hair types VI-VIII), 32% mixed race (hair types III-V) and 4% Caucasian (hair types II-III). In the group of black African children 60% had short-term and 46.7% long-term complications, whereas in the mixed race children 37.5% had short-term and 25% long-term complications. No complications were encountered in the Caucasian group. Eleven (48%) of patients in total had short-term complications (88.9% folliculitis, 22.2% delayed healing) and seven (28%) had long-term complications (57,1% non-healing wounds, 42.8% recurrent folliculitis, 57.1% alopecia, 42.9% depigmented scars, 28.6% visible scars, 28.6% hypertrophic scars). The first procurement in 11 children resulted in a 91% complication rate (54.5% short-term and 36.4% long-term). Ten children had two procurements resulting in an 80% complication rate (40% short-term and 40% long-term complications). In four children with three scalp procurements an acute 25% complication rate, with no subsequent long-term complications, was encountered. Discussion Hair type has an influence on outcome and donor sites should be carefully selected. Hair types VI-VIII has a higher propensity for complications and these usually follow the first procurement procedure. Complications did not increase with multiple procurements. Significant complications with long-term sequelae are not uncommon when the scalp is used as donor site and these complications are difficult to treat. Although the sample size is small, it does reflect a significant complication rate. Conclusion Contrary to international consensus, the use of the scalp as donor site in South African children with hair types VI-VIII with large burns should not be the preferential site and should only be used as a last resort.

Background 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.

Background 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.

Introduction 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.

Background: 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.

Background The anthropomometry of the “ideal” breast is well described, but changes that occur with enlarged breasts are not. The aim of this study was to assess the prevalence of nipple asymmetry in the horizontal plane and changes in the inframammary fold (IMF) in patients presenting with macromastia (defined as excessive development of the mammary gland by Merriam-Webster dictionary). Methods One hundred patients (200 breasts) presenting to the Plastic Surgery Clinic for bilateral breast reduction were enrolled in this study. Patient's characteristics captured for this study included age, body mass index (BMI), and breast anthropometric measurements, such as suprasternal notch to nipple, nipple to IMF, IMF projected to cubital fossa, midhumeral point, and nipple measurement from meridian. Basic univariate statistical analysis were performed to evaluate the impact of nipple asymmetry. Results The average age was 37 years (SD 12 years), and the median BMI was 33 (IQR 28-37). More patients presented with nipple asymmetry, of whom 45% were classified as lateral to meridian, 19% were classified as medial to the meridian, and 36% were classified as central to the meridian. Patients with lateral asymmetry and medial asymmetry has a significantly higher BMI (median BMI 35) compared with patients with central positioning (median 30). Increasing breast size was positively associated with nipple asymmetry, whereas BMI (R = - 0.30, P =0.003) and macromastia correlated negatively with IMF position (R= - 0.38), P= 0.0001). Conclusion In macromastia, nipple displacement from breast meridian, especially lateral displacement, is common and is aggravated by an increase in BMI. The IMF also descends, and this is also common in patients with a raised BMI. These changes have clinical implications.

Includes bibliographical references. / Use 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.

Includes references. / Despite 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.

Background: 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,