Saleigh Adams

Intralesional bleomycin injection in management of low flow vascular malformations in children

Abstract Low flow vascular malformations are challenging to manage, particularly with their propensity to grow, and can lead to severe disfigurement and dysfunction. Traditional surgical excision is fraught with tedious dissection and complications, particularly in the head and neck region. Trends toward less invasive techniques, such as intralesional sclerotherapy, are proving to be successful independent treatments or adjuncts in management in low flow vascular malformations. This study was a retrospective case note review, over an 8-year period, reporting the outcomes of 32 children (mean = 5.8 years, range = 5 months–11.5 years) with radiologically confirmed low flow vascular malformations, treated with serial intralesional bleomycin injection (IBI) therapy. Patient demographics, lesion characteristics, imaging findings, treatment course, radiological and clinical response to treatment were recorded. An overall 91% (n = 29) response rate was achieved, with 28% obtaining complete resolution for low flow vascular malformations. Lesions were sub-categorized into venous malformation, including mixed venous-capillary (n = 27) or lymphatic malformation (LM) (n = 5). Twenty-seven of 32 children experienced no complications. Local complications included superficial skin infection (n = 2), skin necrosis (n = 1), hyperpigmentation, and minor contour deformity. There was no recurrence and no systemic side-effects to bleomycin. Mean follow-up was 38 months (range = 6–95 months). In conclusion, serial intralesional bleomycin injections can be effective and also safe in a paediatric population for the successful management of symptomatic or disfiguring low flow vascular malformations.

Autologous Dermal Graft in Breast Reconstruction

Introduction:The role of allogenic dermis is well established in reconstructive breast surgery, where it acts as a hammock between the detached inferior border of pectoralis major and the inframammary fold. Method:The study reports on the outcome of 19 women (21 breasts as 2 were bilateral) in which autologous dermis was used rather than allogenic material. The autologous dermis was harvested from the abdomen, as a miniabdominoplasty in 15 patients, and from the contralateral breast in 4 patients having simultaneous breast reduction/mastopexy. In all, 15 women underwent immediate reconstruction (7 with tissue expanders, 8 with immediate prosthesis), whereas 4 patients underwent delayed reconstruction (with expanders). Results:Two patients developed infection requiring explantation. There were no abdominal complications after the miniabdominoplasty. The coverage of the prosthesis or tissue expander by the dermal graft was achieved on average in three-quarters of cases (range, just under two-thirds to 100%). The mean follow-up was 17 months (range, 6–36 months). Conclusions:Autologous dermis is a useful alternative to allogenic dermis. It is cheap and readily available. In patients having a contralateral breast reduction, there is no donor site. The risk of complications is not dissimilar to allogenic dermis.

The Introduction of a Protocol for the Use of Biobrane for Facial Burns in Children

Biobrane has become an indispensible dressing with three established indications in acute burns care at our institution: (1) as the definitive dressing of superficial partial thickness facial burns, (2) after tangential excision of deep burns when autograft or cadaver skin is unavailable, and (3) for graft reduction. This paper details our initial experience of Biobrane for the management of superficial partial thickness facial burns in children and the protocol that was compiled for its optimal use. A retrospective analysis of theatre records, case notes and photographs was performed to evaluate our experience with Biobrane over a one-year period. Endpoints included length of stay, analgesic requirements, time to application of Biobrane, healing times, and aesthetic results. Historical controls were used to compare the results with our previous standard of care. 87 patients with superficial partial thickness burns of the face had Biobrane applied during this period. By adhering to the protocol we were able to demonstrate significant reductions in hospital stay, healing time, analgesic requirements, nursing care, with excellent cosmetic results. The protocol is widely accepted by all involved in the optimal management of these patients, including parents, anaesthetists, and nursing staff.

Use of Resorbable Fixation System in Pediatric Facial Fractures

INTRODUCTION Resorbable fixation system (RFS) is an alternative to titanium in open reduction and internal fixation of pediatric facial fractures. METHODS This study retrospectively reviewed all medical records in a major metropolitan pediatric hospital in Cape Town, South Africa from September 2010 through May 2014. Inclusion criteria were children under the age of 13 with facial fractures who have undergone open reduction and internal fixation using RFS. Intraoperative and postoperative complications were reviewed. RESULTS A total of 21 patients were included in this study. Twelve were males and 9 were females. Good dental occlusion was achieved in all patients and there were no complications intraoperatively. Three patients developed postoperative implanted-related complications: all 3 patients developed malocclusions and 1 developed an additional sterile abscess over the right zygomatic bone. For the latter, incision and drainage was performed and the problem resolved without additional operations. DISCUSSION Resorbable fixation system is an alternative to titanium products in the setting of pediatric facial fractures without complications involving delayed union or malunion. The combination of intermaxillary fixation and RFS is not needed postoperatively for adequate fixation of mandible fractures. Resorbable fixation system is able to provide adequate internal fixation when both low-stress and high-stress craniofacial fractures occur simultaneously.Introduction: Resorbable fixation system (RFS) is an alternative to titanium in open reduction and internal fixation of pediatric facial fractures. Methods: This study retrospectively reviewed all medical records in a major metropolitan pediatric hospital in Cape Town, South Africa from September 2010 through May 2014. Inclusion criteria were children under the age of 13 with facial fractures who have undergone open reduction and internal fixation using RFS. Intraoperative and postoperative complications were reviewed. Results: A total of 21 patients were included in this study. Twelve were males and 9 were females. Good dental occlusion was achieved in all patients and there were no complications intraoperatively. Three patients developed postoperative implanted-related complications: all 3 patients developed malocclusions and 1 developed an additional sterile abscess over the right zygomatic bone. For the latter, incision and drainage was performed and the problem resolved without additional operations. Discussion: Resorbable fixation system is an alternative to titanium products in the setting of pediatric facial fractures without complications involving delayed union or malunion. The combination of intermaxillary fixation and RFS is not needed postoperatively for adequate fixation of mandible fractures. Resorbable fixation system is able to provide adequate internal fixation when both low-stress and high-stress craniofacial fractures occur simultaneously.

Pediatric facial fractures

Introduction:There are few published articles describing the epidemiology of facial fractures in South Africa, and there is only one published study in pediatric patients. Material and Methods:This study retrospectively reviewed all medical records in a major metropolitan pediatric hospital in Cape Town, South Africa from September 2006 through May 2014. Inclusion criteria were children aged under the age of 13 with facial fractures. Fractures were assessed through head computed tomography (CT) scans. Patients age, sex, cause of injury, general condition, existence of concomitant injuries, location of fractures, type of interventions, and length of stay were recorded and analyzed. Results:A total of 53 men and 34 women were included in the study. Motor vehicle collisions (MVC) were the most common cause of facial fractures (56.3%). One hundred thirty facial fractures were presented on CT scans. The most common fractures in this study were mandible (43.1%). Comparing unrestrained motor vehicle collisions (UMVC) patients with those of other etiologies (OE), there was an increase in the average number of fractures (OE: 1.1, UMVC: 1.9; P < 0.0001), the average length of stay (OE: 4 days, UMVC: 9 days; P < 0.003), and the probabilities of sustaining concomitant injuries (OE: 31.0%, UMVC: 68.8%; P < 0.05) and requiring an operation (OE: 42.3%, UMVC: 81.3%; P < 0.01). Discussion:This study establishes MVC as the most common etiology of facial fractures in South Africa. It demonstrates an increase in the complexity of facial injuries in unrestrained MVCs, suggesting the need for public awareness campaigns to install restraint devices in automobiles in South Africa.

Tissue Expansion: Further Attempts to Improve Results in Breast Reconstruction

Tissue expansion, is a simple method of breast reconstruction. Method. A prospective study of 27 patients treated over a 43 month period is described. At the first stage the expander is inserted in the dual plane, and the medial pectoral nerve is divided. The tissue expander is over-expanded. Second stage: a de-epithelialized vertical triangle is used to aid anterior projection, an inframammary fold is created and a silicone gel prosthesis inserted. Z-plasties are added to the transverse scar. The contralateral breast can be treated or left alone. Complications were recorded and the results were assessed by 4 plastic surgeons using a visual analogue scale. Results. 19 patients had expanders inserted at mastectomy (2 bilateral) and 8 underwent delayed reconstruction, with a mean age of 47 years (range 30–65 years). A single prosthesis was inserted in 15 patients (mean size 320 mL) and two prosthesis were stacked in 12 patients (mean volume of 400 mL). The mean delay from full expansion to the second stage was 10 weeks (range 3 weeks–11 months). A contralateral augmentation was performed in 5 patients, pexy in 10, a reduction in 2 and in 8 patients no procedure was performed. One patient required explantation. The mean visual analogue assessment was 7. Conclusion. This technique should be considered enhance the cosmetic results in tissue expansion.

Scalp as a donor site in children: Is it really the best option?

BACKGROUND Since 2003 we have used the scalp as a donor site for split skin grafts (SSGs) in major burns when there was a shortage of conventional donor areas. However, we seen a high incidence of complications, contrary to international experience. OBJECTIVE The aim of this study was to analyze the results and complications related to the scalp as a donor site and to determine whether there is an association between our specific patient population and the complications encountered. METHODS A retrospective review of our scalp donor site outcomes over a 12-year period was conducted. The cohort included 25 patients, 15 of black African descent, nine of mixed race and one Caucasian. The various hair types were identified based on ethnicity and classified into eight types. Most of our patients had hair types VI-VIII. None of these patients had scalp burns and all received standard burn treatment. The SSGs were taken with an electric dermatome with a standard micrometric setting of 0.2mm. Complications were categorized into short- or long-term, with a mean follow-up time of 1.59years. RESULTS The mean age of the 25 children was 5.7years. Nineteen sustained flame burns and 6 sustained hot water burns, with a mean total body surface area of 44.9%. A total of 43 scalp procurements were performed in the 25 patients studied. The group of 15 black African patients (hair types VI-VIII) had a total of 22 procurements, the nine patients of mixed race (hair types III-V) had 18 procurements and the single Caucasian patient (hair types II-III) had two procurements. The median healing time was 15days, 11.8days and 8.5days, respectively, per group. Significant complications were encountered, including folliculitis 44%, non-healing wounds 52%, alopecia 16% and visible, hypopigmented scars 3%. One patient had a hypertrophic scar and no hair transfers to the recipient areas were observed. The various hair types correlated with the complications encountered. Five children, with an average burn size of 65.2% (range: 40-85%) died of sepsis. Due to the small sample size, the only statistically significant findings were related to the total body surface area of the burn and the number of times skin was harvested from the scalp, with a p-value of 0.005. The p-values for the healing times related to the first, second and third croppings, were p=0.022, p=0.00032 and p<0.001 respectively. CONCLUSION Our study suggests that in pediatric patients of black African descent (hair types VI-VIII) the scalp is not an ideal donor area, due to the unacceptably high incidence of complications. Hence, every precaution should be taken when it becomes necessary to harvest donor skin from the scalp.