Plastic and Reconstructive Surgery

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Anaesthesia for microsurgery
(Health and Medical Publishing Group -- HMPG, 1985-04) Jakubowski, M.; Lamont, A.; Murray, W. B.; De Wit, S. L.
The data from a retrospective study of 32 anaesthetics administered for free-flap tissue operations are analysed. We suggest balanced analgesic-dominated general anaesthesia, supported wherever possible by continuous regional block. Special attention is paid to full control over the cardiovascular system and the haemodynamics, including the microcirculation and optimal rheological properties of the blood, as well as metabolic ability. Our results suggest that factors such as adequate infusion therapy guided by central venous pressure and urinary output and strict body temperature control, supplementary use of regional blocks and peri-operative use of dextran 40 (Rheomacrodex) can contribute significantly towards the overall success of free-flap surgery.
Breast reconstruction during the COVID-19 pandemic in resource-limited settings
(GMS, 2021) Al-Benna, Sammy; Gohritz, Andreas
The coronavirus disease 2019 (COVID-19) is a novel, rapidly changing pandemic. It has affected specialized medical services in unprecedented ways. Surgical decision making, always the most important aspect of care has taken on an added layer of complexity in the face of the COVID-19 pandemic. Therefore, recommendations for breast reconstruction during COVID-19 remain challenging and unclear. This article reviews the impact of the COVID-19 pandemic and suggests potential approaches that could be considered in the absence of validated strategies in breast reconstruction.
Considerations for breast reconstructive surgery in South Africa during the COVID-19 pandemic
(Medpharm, 2020-09) Al-Benna, S.; Gohritz, A.
ENGLISH ABSTRACT: The coronavirus disease 2019 (COVID-19) pandemic has added a layer of complexity to surgical decision making particularly for complex reconstructive oncological surgery. In the absence of data on which to base validated strategies for breast reconstruction in the South African context, this article discusses the current trends in management and potential approaches which could be employed
Free flap transfer with microvascular anastomosis
(HMPG, 1976-11) Visse, J. H.; Adendorff, D. J.; Malherbe, W. D. F.
The development of the flap transfer technique in plastic and reconstructive surgery has evolved to the stage where free transplantation of a full thickness skin flap, by means of microvascular anastomosis, has become possible. For the first time in South Africa, a case is documented where such a free graft was used successfully to reconstruct a severe burn contracture of the neck. Experience with this and subsequent cases has taught valuable lessons about the procedure.
Generalized surgical emphysema as an early complication of facial fracture : a case report
(HMPG, 1977-05) Adendorff, D.; Malherbe, W. D. F.; Grotepass, F.
A case of multiple facial fractures complicated by subcutaneous emphysema, pneumomediastinum and pneumoretroperitoneum, in the absence of intra-abdominal, neck or chest injuries, is described.
Impact of COVID-19 on surgical registrars' education and training
(Medpharm Publications, 2020) Al-Benna, S.
The coronavirus disease 2019 (COVID-19) pandemic has affected all aspects of medical practice in unprecedented ways. It has already produced significant changes within most hospitals, including, cancellation of elective procedures, decreased volume of acute care surgery, and cancellation of lectures and educational conferences to adhere to social distancing recommendations. This article focuses on the effects of the COVID-19 pandemic on surgical registrars, their education and training and proposes ideas on how to get through this major disruption.
Improving the longevity and results of mastopexy and breast reduction procedures : reconstructing an internal breast support system with biocompatible mesh to replace the supporting function of the ligamentous suspension
(Springer Open, 2011-10) Van Deventer, Petrus V.; Graewe, Frank R.; Wuringer, Elisabeth
The reasons for recurrent ptosis in mastopexy and breast reduction procedures are twofold. First, available surgical techniques do not reconstruct the normal breast anatomy responsible for maintaining breast shape. Second, in many instances the techniques rely on atrophied tissue to provide long-term support. The discovery in 1997 of the ligamentous suspension (the supporting system of the breast) gave rise to the concept that reconstruction of this anatomical structure was needed to ensure a sustained postoperative result. Applying the latest knowledge regarding the structural and vascular anatomy of the breast in the surgical technique and utilizing material other than atrophied breast tissue enabled us to prevent the recurrence of breast ptosis. Methods A surgical technique was developed to replace the supportive function of a failed ligamentous suspension in 112 patients with ptotic breasts. This was done by reconstructing an internal breast-supporting system (IBSS) with biocompatible mesh. Results Satisfactory breast shape, nipple projection, and upper breast fullness was obtained with this technique in mastopexy patients with moderate-sized ptotic breasts. In patients with larger breasts good results were obtained with a simultaneous breast reduction. The longest follow-up is 6 years 3 months. Conclusions With this technique recurrent breast ptosis can be prevented in mastopexy and breast reduction procedures. The results are such that it eliminates the need for silicone prostheses to obtain satisfactory upper-breast fullness. The surgical technique is especially indicated in patients with skin of poor quality or patients with high expectations.
The incidence of cleft lip and palate in the Western Cape
(Health and Medical Publishing Group (HMPG), 1985-10) Morrison, G.; Cronje, A. S.; Van Vuuren, I.; Op't Hof, J.
The incidence of cleft lip and palate in the Western Cape was studied using data from two cleft palate centres and from all plastic surgeons in practice in the area. A high incidence was found among coloureds, while the incidences among whites and blacks were similar to figures reported from other countries.
Injuries to the skin of the male external genitalia in Southern Africa
(Health and Medical Publishing Group (HMPG), 1975) Malherbe, W. D. F.
The more common injuries to the skin of the male external genital organs are described; some of these mutilations are unique to the African continent. The extent of trauma ranges from small penile skin defects after circumcision to complete avulsion of the skin of the penis and scrotum. The techniques of reconstruction are described.
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.
Mycotic aneurysm of the radial artery of the hand : a case report
(Health and Medical Publishing Group -- HMPG, 1983-03) De Greef, A.
Aneurysms of the hand (including the wrist region) are reviewed; a case is reported, and the relevant surgical anatomy is discussed.
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.
Repair of a cosmetic defect of the lower leg with a myocutaneous free flap
(Health & Medical Publishing Group, 1982) Lamont, A.; Malherbe, W. D. F.; Middelhoven, J.
The use of free-tissue transfers by modern techniques of microvascular surgery is not new, and the many possibilities in reconstructive surgery are well documented. A case in which a disfiguring cosmetic defect of the lower leg was repaired in one stage with a latissimus dorsi myocutaneous free flap is described.
Tissue expansion in reconstructive surgery : a case report
(Health & Medical Publishing Group, 1986-05) De Greef, A.
A case is reported in which serial expansion was used to create scalp and forehead flaps of superior quality skin and subcutaneous tissue to cover a central forehead defect. The background and principles governing this surgery are discussed.
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.

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