bluuebunny/crossref_metadata_2025 huggingface dataset:
NS05 PENETRATING HEAD INJURY FROM NAILGUNS: THE NEW ZEALAND EXPERIENCE. A CASE SERIES
Authors: Monteith S. J. , Winder M. J. , Lightfoot N. , Mee E.
Published: April 2007

Introduction  Penetrating head injury from nailguns has become increasingly recognised due to their frequent use in the construction industry and home. We report a New Zealand case series of 12 penetrating nailgun injuries, the largest of its type, detailing presentation, management, risk factors and outcomes.

Methods  The Auckland Neurosurgical Unit database was reviewed to identify cases of cranio‐cerebral nailgun trauma. In addition we surveyed the clinical directors of the remaining three Neurosurgical units in New Zealand for cases that had presented to their institution. From the identified cases we performed a chart review to identify demographics; past medical and psychiatric history; details surrounding the event; surgical management and clinical outcomes.

Results  All 12 cases were male, with a mean age of 38 years. All but one case involved one nail of 3–12 cm in length. The other case involved a staggering 24 nails of 5cm length and represents the largest number of intra‐cranial nails in a surviving patient. GCS at presentation ranged from 3 to 15. All four patients who had a GCS less than 11 at presentation died. Two thirds of cases demonstrated a psychiatric history and three quarters of cases were attempted suicide. Operative intervention ranged from non‐operative, to a small craniotomy or craniectomy depending on the case.

Conclusion  This case series would suggest a minimal surgical approach and individual case assessment regarding the need for antibiotic prophylaxis and anti‐epileptic drugs. A surprisingly good outcome can occur in many of these patients.
NS09 DETECTION AND FOLLOW‐UP OF ANEURYSMS BY CTA
Authors: Dorsch N. W. C. , Young N. , Kang A. , Ly S.
Published: April 2007

Purpose  To analyse usefulness of CTA in detecting aneurysms in subjects with a family history, and in follow‐up of patients with known aneurysms.

Methodology  From 1997 to 2004, 286 adults with a family history of cerebral aneurysms were investigated by a spiral CT angiogram of the Circle of Willis. Their age range was 20–76, and 192 were female. Over a similar period 119 patients with 138 known aneurysms, described as Group 1, and another 84 with a past history of SAH and aneurysm treatment (Group 2), were followed by serial CTAs for up to 97 months, median 36 months.

Results  Of those with a family history, 193 had one CTA and the other 93 averaged 2.8 studies. Aneurysms were found in 15.4%, with 56 detected in 44 patients. There were multiple aneurysms in 12 of the 44 (27%); 80% of the aneurysms were under 7mm in diameter and 93% less than 13mm; 39% were on the MCA – all findings similar to other literature.

In the 119 group 1 patients there were initially 120 aneurysms. During follow‐up 18 more developed, a rate of 5% per year. Of these 138, 99 remained stable, 29 enlarged (21%), and nine became smaller. One aneurysm ruptured, a rupture rate of 0.28% per year.

In group 2 patients, 75 aneurysms were found on the initial CTA in the 84 patients. Subsequent studies showed 19 new aneurysms for a total of 94 – annual development rate 7.5%. Four aneurysms ruptured in the study period, equivalent to 1.7% annually.

Conclusions  CTA is useful for relatives of aneurysm patients, for subjects with unruptured aneurysms, and for patients with past aneurysmal SAH. As others have shown, in this last group new aneurysms develop more often, they grow faster, they rupture more often, and they rupture at smaller size.
PS11 PANCREATITIS – INDICATIONS FOR SURGERY IN CHILDREN
Authors: Stringer M. D.
Published: April 2007

Purpose  With modern imaging techniques, multidisciplinary management, and advances in supportive care, what are the indications for surgery in children with pancreatitis and have outcomes improved?

Methods  During a 12 year period, 62 children [31 girls, median age 12.0 (2.3 –16.9) years] with pancreatitis were managed in a single centre. All were investigated using a combination of ultrasound, ERCP, MRCP, and CT. Management comprised supportive care and treatment of any primary pathology. Severe acute pancreatitis (pancreatic necrosis, pseudocyst/abscess, and/or organ failure) was managed with broad spectrum intravenous antibiotics, H2 antagonists, prophylactic antifungal agents, and early parenteral nutrition followed by naso‐jejunal feeding.

Results  51 children had acute pancreatitis, 14 (27%) of whom had severe disease. The leading causes were trauma (12), pancreaticobiliary malunion (6), gallstones (5), drug‐induced (4) and viral (4). In 10 patients no cause was found. Twenty four (47%) of these 51 children required surgery (20) and/or interventional procedures (4) to treat primary pathology (13) or pseudocysts (11) with resolution of pancreatitis in all. Eleven children had chronic pancreatitis: 6 required surgery (5) or an interventional procedure (1).

All 62 patients survived. Only two experienced surgical complications.

Conclusions  In this series, using modern investigative techniques, only 20% of children with acute pancreatitis had no identifiable etiology. Half of the total series of children with pancreatitis required surgery either to treat primary pathology or to treat complications of the disease. Selective surgical intervention in children with pancreatitis is both beneficial and safe.
PS12 SONIC HEDGEGHOG PATHWAY – A POSIBLE THERAPEUTIC TARGET FOR HEPATOBLASTOMA
Authors: Arsic D. , Sullivan M. J. , Beasley S. W.
Published: April 2007

Background and Objectives  It has been shown that the hedgehog (Hh) signalling pathway that is turned off once organogenesis is complete in the embryo is re‐activated in a number of different cancers. We analyzed re‐activation of the Hh pathway in hepatoblastoma to investigate whether this pathway can be used as a therapeutic target.

Methods  Surgically resected hepatoblastoma specimens and hepatoblastoma cell lines were analyzed by immunoblot and PCR, looking into different components of the pathway.

Results  We found that pharmacological pathway blockade leads to decreased cell proliferation in hepatoblastoma cells, demonstrating an ongoing requirement of Hh signalling in this tumour.

Conclusion  The Hh pathway may be a useful therapeutic target for hepatoblastoma and other tumours in which the Hh pathway (or a component of the pathway) are over‐expressed or re‐activated at an inappropriate time.
PS13 DEVELOPMENT OF THE URINARY BLADDER IN ETU‐EXPOSED FETAL RATS IS AFFECTED BY DOWNREGULATION OF SHH AND ITS TARGET GENESCAGES
Authors: Quan Q. B. , Sullivan M. J. , Beasley S. W. , Mandhan P.
Published: April 2007

Objective  The cloaca develops into the urinary bladder and distal part of the hindgut. Abnormalities of cloacal development result in a variety of anorectal and urogenital malformations. This study evaluated the formation of the urinary bladder in ETU exposed fetal rats in relation to shh and its target genes.

Methodology  Embryos of pregnant SD females administered 1% ETU (125 mg/kg) on the tenth day of gestation (gD10) were collected from gD12‐16 and gD21. Cloacal development was viewed with serial histology followed by qualitative and quantitative gene expression studies of shh and target genes to elucidate the expression pattern of these genes during each time point.

Results  ETU exposed fetuses have incomplete separation of the cloaca leading to a variety of anorectal and urinary abnormalities eg rectourethral fistula. Shh and downstream genes are expressed during urinary bladder development in fetal rats. Relative quantification showed that expression of shh, BMP4 and Hox genes are reduced in ETU‐exposed fetal rats during the process of cloacal separation and development of the urinary bladder.

Conclusion  This study demonstrates that ETU‐exposure in fetal rats produces abnormal cloacal development, including urinary fistulae. Shh cascade is active during the process of cloacal separation and urinary bladder development and down regulation of shh, BMP4 and Hox genes during this process may contribute to the abnormal development of urinary bladder and anorectum.
PS02 ATRESIA OF THE JEJUNUM AND ILEUM: THE DISTINCTION
Authors: Tongsin A. T.
Published: April 2007

Purpose  Atresia of the jejunum and ileum is one of the major causes of neonatal intestinal obstruction. Most affected newborn infants present with bilious emesis and abdominal distention. Traditionally, jejunal and ileal atresia have been grouped together as jejunoileal atresia. From our observation and experience, we found many differences regarding clinical features and outcome between these two groups. The purpose of this study is to elucidate the difference between jejunal and ileal atresia.

Methodology  A retrospective analysis of patients diagnosed with jejunal or ileal atresia during 1991–2005 was carried out.

Results  There were 68 patients with jejunal atresia and 56 with ileal atresia. The mean birth weight and gestational age of patients with jejunal atresia were significantly lower than those with ileal atresia. Antenatal perforation occurred more frequently in ileal atresia. Postoperative course was more prolonged and mortality was higher in jejunal atresia. Prolonged ileus and anastomotic dysfunction requiring long‐term parenteral nutrition were the major causes of complications leading to death.

Conclusion  There were many differences between patients with jejunal atresia and those with ileal atresia. The more compliant jejunal wall allows massive dilatation upon obstruction with subsequent loss of peristaltic activity, thus poorer outcome in comparison with ileal obstruction. We suggest that atresia of the jejunum and ileum be considered distinctly.
PS03 IS THE PREDICTED OUTCOME OF DIAPHRAGMATIC HERNIA DIAGNOSED IN UTERO, DETERMINED BY POSTNATAL CARE?
Authors: Russell G. A. B. , Anderson N. , Kang A.
Published: April 2007

Outcome of isolated left congenital diaphragmatic hernia (CDH) has been predicted by the position of the fetal liver and lung:head ratio (LHR) on ultrasound scans between 22–28 weeks gestation (1). Variations in postnatal management will determine if the findings of such studies can be generalised.

This retrospective study aimed to (1) determine if outcome, predicted by antenatal findings, was achieved in a small regional centre and (2) identify what postnatal factors could adversely alter a predicted favourable outcome.

Method  All fetal cases of isolated CDH diagnosed between 1998 and 2006 were included if liver position and LHR could be measured and babies were born alive. Survival to discharge was compared to the predicted chance of survival (1). Significant physiologic disturbances, possibly due to care practices including lung overdistension, were identified.

Results  Ten cases were identified. The median (range) gestation at earliest estimate of liver position and LHR was 27 (16–35) weeks. The median (range) of LHR was 1.28 (0.63–3.35) and part of the liver was in the thoracic cavity in 2/10. The overall survival was 7/10 (70%). Eight babies had a predicted survival of 70%. Three cases predicted to have a favourable outcome had significant and unexpected perioperative deterioration related to lung overdistension, and 2 died.

Conclusion  Failure to achieve expected outcome in individual cases may be determined by avoidable postnatal factors.
PS05 LONG‐TERM OUTCOMES IN NEONATAL SURGERY
Authors: Stringer M. D.
Published: April 2007

Historically, for good reason, the main measures used to assess outcome after neonatal surgery have been mortality and early postoperative morbidity. These remain crucial yardsticks of surgical care. However, as results have steadily improved more refined indicators of outcome are needed. Long‐term results and quality of life outcomes are being demanded increasingly by clinicians, parents, and health economists.

For paediatric surgeons, knowledge of long‐term outcomes not only enable us to inform parents and patients better about future health expectations but also help us to anticipate potentially avoidable late complications. Outcomes inform us when to operate and when not to operate. Some neonatal surgical conditions and their treatment have almost no long‐term sequelae but most have definite consequences of variable severity.

Common themes run through the analysis of long‐term outcomes. These centre around the future impact on growth, risk of malignancy, psychological issues, implications for fertility, sexuality and inheritance, and quality of life. There are many reasons why long‐term data are lacking. These include the difficulties of maintaining long‐term surveillance within healthcare systems overstretched by lack of manpower and funding. Problems of continuity are exacerbated by geographic mobility in society. Robust long‐term studies require careful data collection over many years, the co‐operation of ex‐patients, and familiarity with tools such as independent quality of life measures not readily accessible to paediatric surgeons.

Only by addressing long‐term outcomes will the true impact of neonatal surgical conditions be fully understood.
PS06 LONG‐TERM OUTCOME OF BILIARY ATRESIA IN NEW ZEALAND
Authors: Yu T. , Morreau P. , Beasley S. , Brown S. , Samarakkody U. , Mandhan P.
Published: April 2007

Objective  This is a multicenter study to assess the long‐term outcomes of children with biliary atresia (BA) who have undergone Kasai operation in New Zealand.

Material and Methods  This retrospective analysis includes 97 patients who underwent a Kasai operation in the tertiary paediatric surgical centres between 1989 and 2006 in New Zealand. The demographic data, age at diagnosis and surgery, success of surgical procedure, need for liver transplantation and long‐term outcomes were studied.

Results  BA was diagnosed in 58 Mäori and Pacific People, 31 Caucasian and 8 Asian children. The average age and time at presentation and surgery was 50.37(±37.3) and 61.6 (±25.7) days respectively. Eighty‐six (89%) children had recoloration of the stool and 71 (68%) became jaundice free (bilirubin <20 µmol/L) 1 year after the surgery. Ascending cholangitis was the commonest complication and occurred in 41% of children. Five and 10‐year survival rates with native liver were 47% and 23% respectively. Liver transplantation was performed in 50 patients and 38 (76%) survived. The overall actuarial 5 and 10‐year survival rates for BA patients were 45.4% and 27.8% respectively.

Conclusion  BA was more common in Mäori and Pacific People children. There was a trend of less favourable results in children who had surgery late (>90 d). Long‐term prognosis was not directly related to age at diagnosis and surgery. The survival of patients with and without liver transplantation was similar to that of other series.
PS08 BILIARY ATRESIA: POLITICS AND PROGRESS – A UK PERSPECTIVE
Authors: Stringer M. D.
Published: April 2007

Biliary atresia (BA) is a congenital obliterative cholangiopathy of unknown aetiology. It is a rare condition with an incidence of ∼1 in 17,000 live births in the UK. BA must be diagnosed promptly in any infant with conjugated hyperbilirubinaemia since prognosis is improved by early detection and timely surgery (Kasai portoenterostomy).

In the UK, a survey of all infants with BA conducted between 1993 and 1995 demonstrated that outcome was related to centre experience. Consequently, in 1999 the management of BA in England and Wales was centralised to three supra‐regional paediatric liver units. The results of this national change in practice were carefully audited. This showed that approximately 60% of all infants undergoing Kasai portoenterostomy for BA in these centres now achieve clearance of jaundice (plasma bilirubin <20 umol/l). Infants with BA that require a liver transplant remain under the care of the same team and can be listed for transplant at the optimum time.

An additional benefit of centralised management has been to facilitate clinical research as a result of concentrating a relatively rare disease into specialist centres with multidisciplinary teams. Recent advances include improved diagnostic accuracy of BA using ultrasound scanning and a better understanding of the role of adjunctive postoperative corticosteroids in improving outcome.

Despite these advances, BA remains the commonest indication for liver transplantation in children. Five‐year survival after liver transplantation for BA is currently 80–90%. Current medical and surgical management has transformed a disease that was almost invariably fatal in the 1960s into one with an overall 5‐year survival of about 90%.
PS09 CONTEMPORARY SURGICAL MANAGEMENT OF SILALORRHEA
Authors: Hornibrook J.
Published: April 2007

Peristsent sialorrhea (drooling) is often a problem in cerebral palsy, mental retardation and neurological conditions. Management modalities have included behavioural and postural modifications, pharmacotherapy, radiotherapy and surgery. Early surgical treatments were removal of glands, duct ligations and neurectomies. The newest and most conservative operation is relocation of submandibular ducts to the tongue base and removal of sublingual glands. In a personal series of 16 cases 11 were children.

Purpose  To review the indications and results of submandibular duct relocations (with sublingual gland removal) in 11 children with uncontrolled sialorrhea.

Methodology  Review of hospital and outpatient records, and illustration of the operative technique on a video. Anatomical variations can be encountered.

Results  The median hospital stay was 2 days. There were no significant complications. Caregivers judged the efficacy with a median score of “75%”.

Conclusion  Duct relocation with sublingual gland removal is a safe and reliable technique for sialorrhea, with very good control in most cases. In contrast to botulinum toxin treatment its effects are permanent.
PM01 SPINAL CORD STIMULATION FOR CHRONIC REFRACTORY ANGINA
Authors: Acland R. H.
Published: April 2007

Spinal cord stimulation (SCS) involves the use of an epidurally placed, multiple electrode lead. Electrical stimulation between electrodes produces stimulation of the posterior spinal cord and can provide excellent pain relief and increased blood flow in a number of chronic limb pain conditions. Its efficacy has more recently been demonstrated in angina.

Chronic stable angina pectoris is a major cause of disability and suffering. The aims of treatment are to prevent MI and death (increase the quantity of life) and reduce the symptoms (improve the quality of life). In the non‐acute condition, practitioners often struggle to manage angina because of a lack of understanding of modern concepts of pain. There is a widely held misconception that only revascularisation improves prognosis in chronic refractory angina‐ the term used to describe patients with stable angina that is treatment refractory. Over the last decade two pain services in New Zealand have been approached by cardiologists to provide spinal cord stimulation for such patients. This has been an intriguing experience! We have demonstrated that the placement of such leads in the lower cervical cord region provides excellent relief of angina. The technology is expensive (akin to the overall cost of CAVG surgery). We have demonstrated cost recoupment, by decreased hospitalisation, at approximately16 months post procedure. Sadly, this therapy has not been embraced. Possible reasons for this will be discussed. The concept of electrically modifying the neuronal signals versus re‐plumbing the blockage appears to be an anathema to cardiologists.
PM03 TERMINAL CARE – PAIN RELIEF IN ADVANCED CANCER
Authors: Macleod A. D.
Published: April 2007

Pain is the Fifth Vital Sign. Relief of pain should be achievable in up to 90% of cancer patients. Many patients however continue to suffer unnecessarily as a result of inadequate pain management. 75% of those with advanced malignancies experience severe pain caused directly by the disease and/or the treatment. Nocioceptive pain is most responsive to intervention, the control of visceral and neuropathic pains is more difficult.

The mainstay of pain management in the terminally ill is opioid medication. Morphine remains the drug of first choice. Oxycodone, fentanyl and methadone are now available and alternative options. Though the oral route of administration is preferred, parenteral (particularly sub‐cutaneous administration) opioid may be necessary during the final days of life. The phenomenon of ‘wind‐up’ (the fading efficacy of an opioid) will be discussed as will the role of the anaesthetic agent ketamine in managing this complication of opioid therapy. The risk of iatrogenic addiction to medicinally prescribed opioid is miniscule. Analgesic adjuvant medications for neuropathic pain have a role as may spinal and intrathecal delivery systems of opioid medication.

In cases of intractable pain in the terminally ill deep sedation is a medically, legally and ethically acceptable management option.
PM05 STEREOTACTIC RADIOSURGERY FOR TRIGEMINAL NEURALGIA
Authors: McDowell D. I.
Published: April 2007

Stereotactic radiosurgery (SR) is effective in managing trigeminal neuralgia (TN). Over the past 15 years, over 20,000 patients (world wide) have undergone SR for TN. SR is an outpatient procedure with no associated mortality and minor morbidity (generally new facial paraesthesia: 6–16.7%). Initial success rates range from 77 to 95% (generally within 2 days of SR). The benefit then declines to 55.8%–70% (at 3 years). SR can be repeated for recurrent TN (68‐85% benefit at 13.5–43 mths: 5 published reports; N = 111). Dunedin Public hospital holds the national contract for SR in New Zealand. Since 7.5.04, 6 patients with TN have been treated with SR in Dunedin (90 gray, 0.75 cm collimator, 7 table angles and 7 arcs). Details of this experience will be presented and discussed. A summary of the SR/TN literature will be given.
PM06 MODERNISING OUR APPROACH TO POST‐OPERATIVE PAIN
Authors: Jones D.
Published: April 2007

Pain is not a single entity, but many complex biological processes combined with psychosocial responses. Therapies therefore have to be multimodal. Single analgesics suit only a few. Although promoting positive thoughts and interactions with team members is important, this presentation will bias towards biological factors.

Reducing unnecessary postoperative pain suffering starts long beforehand in elective cases. Mounting evidence, of long‐lasting (‘chronic’) pain following procedures needs accurately portraying to patients for informed consent. Denial of these facts causes later problems. Appropriate preparation reduces beliefs that ongoing pain means an error.

Once embarking on a procedure, measures prior to nociceptive surgical stimulus contribute to reduced postoperative pain, although robust evidence for pre‐emptive analgesia in many situations remains elusive. But lack of evidence does not mean evidence against. A perfect single solution does not exist. Illustrating with pathophysiology of pain and of nerve disturbance, pharmacology and genetic information, this presentation discusses rationalizing and combining common measures, why generous morphine doses don’t always work, and why some results are less than expected.
PR10 DUAL PLANE BREAST AUGMENTATION FOR TUBEROUS BREAST DEFORMITY
Authors: Connell A. F. , Luo D. Y. W. , Luo J. Y. B.
Published: April 2007

The tuberous breast deformity is an uncommon congenital breast anomaly which affects young women unilaterally or bilaterally. It is associated with usually a constriction in the lower pole of the breast as a result of the constricting fibrous ring with hypoplasia of the breast gland and pseudo‐herniation of breast tissue into an enlarged areola.

Several methods have been suggested to correct this deformity. A retrospective analysis has been undertaken of six consecutive patients with tuberous breast deformity using a dual plane breast augmentation via an inferior peri‐areolar approach creating a dual plane pocket and using Marionette sutures to control the lower pectoralis major edge. Surgical release of the constricting lower pole glandular tissue was undertaken with excellent aesthetic results. Either immediate or delayed areolar reduction was carried out if required.

Results show excellent expansion of the lower pole with good soft tissue coverage of the implant by the pectoralis major in the supero‐medial aspect of the breast. The dual plane pocket combined with lower pole release assists lower pole expansion in a one stage procedure without requiring two stage tissue expansion.

The results have been uniformly acceptable and compare favourably with those presented in the literature where other methods were used. The dual plane breast augmentation technique is a simple and reliable way to treat tuberous breast deformity.
PR13 THE USE OF PEDICLED LATISSIMUS DORSI FLAPS IN LARGE CHEST WALL RECONSTRUCTION
Authors: Luo D. Y. W. , Hanikeri M. , Savundra J. , Newman M. , Carey‐Smith R. , Wood D.
Published: April 2007

Purpose  to report a challenging case of reconstructing a massive chest wall defect. To demonstrate the usefulness of the pedicled latissimus dorsi flap to reconstruct massive sternal wounds.

Methodology  Case Report – A 35 year old man presented 2 weeks after a chest wall resection for a primary amyloidoma and reconstruction using a combination of a titanium mesh and Gore‐tex soft tissue patch with primary skin closure. He was clinically septic, with the primary focus being the chest wound. The infected Gore‐tex and titanium mesh were removed, and the cavity debrided, resulting in a chest wall defect measuring 30 cm (subcutaneous width) × 20 cm (height) and a bony defect measuring 15 cm (width) × 18 cm (height). An initial attempt of reconstructing this with a free latissimus dorsi flap was abandoned prior to raising of the flap because of difficulty in finding a recipient vessel. The defect was finally reconstructed using a pedicled latissimus dorsi flap.

Result  We describe a single stage technique for reconstructing a massive sternal defect. The use of a pedicled latissimus dorsi flap provided a reliable reconstruction in what can be a traditionally difficult reconstructive site.

Conclusion  A pedicled latissimus dorsi flap is useful even in the reconstruction of large chest wall defects.
PR14 LATISSIMUS DORSI MYOCUTANEOUS FLAP WITH ANATOMICAL EXPANDER‐IMPLANTS FOR SINGLE STAGE BREAST RECONSTRUCTION – AN ACHIEVABLE GOAL?
Authors: Dunkin C. S. J. , Jeeves A. , Wiener M. , Mackie I. , Caddy C. M.
Published: April 2007

Introduction  Implant‐based breast reconstruction has evolved from two‐stage methods using round smooth expanders to single‐stage using definitive textured biodimensional anatomical expander‐prostheses. The aim of this study was to assess if single‐stage reconstruction is achievable using McGhan 150 expander‐implants with latissimus dorsi (LD) myocutaneous flaps and if so, at what cost.

Methods  Data was collected retrospectively on all women who underwent this type of breast reconstruction, between 1997–2005, with a minimum of 6 months follow‐up.

Results  147 patients had 164 reconstructions (17 bilateral cases). Mean age 48 ± 9 years. The indications for reconstruction were mastectomy, breast asymmetry and Poland’s syndrome. 144 patients had pedicled flaps and 3 patients had contralateral free flaps. The majority were delayed reconstructions.

Single‐stage reconstruction was achieved in 81/147 patients. The number of procedures per completed reconstruction was 2.2 or 1.9 if nipple‐areola reconstruction and contralateral surgery were excluded. The overall complication rate was 38%. Implants were removal for infection in 12% and exchanged for capsular contracture in 15%. LD/expander‐implant reconstruction failed in 3 patients.

Conclusions  Single‐stage reconstruction is an achievable goal but patients should be counselled that further surgery might be required to complete the reconstruction.
PR20 PAEDIATRIC NASAL FRACTURES: PATIENT SATISFACTION FOLLOWING CLOSED REDUCTION
Authors: Love R. L.
Published: April 2007

Introduction  Nasal trauma in childhood is a frequent occurrence. Management of resultant fractures in the paediatric age group presents a unique diagnostic and therapeutic challenge. The immature patient is less likely to be cooperative with examination, and clinical evaluation is difficult owing to facial oedema and lack of rigidity of the nasal bones. Subsequent nasal growth and development must be considered in determining the most appropriate treatment. Closed reduction of nasal fractures is usually undertaken at the Wellington Regional Plastic, Maxillofacial & Burns Unit at Hutt Hospital. Little exists in the form of follow‐up studies assessing patient satisfaction following this technique.

Methods  A retrospective chart reviewed yielded 39 patients aged under seventeen years who underwent closed reduction of their nasal fracture during the two year period ending in July 2006 at Hutt Hospital. Follow‐up was between three and twenty‐seven months. A structured telephone interview was carried out to assess the degree of satisfaction with both functional and aesthetic outcome present in this group. Patients and their parents were invited to respond.

Results  Most patients and their families are satisfied with nasal function and appearance following closed reduction. Few had subsequently sought or would consider a secondary open procedure in the form of septorhinoplasty.

Conclusion  Closed reduction remains a satisfactory treatment in this age group. On the basis of patient satisfaction, it is successful in maintaining the function and appearance of the nose in most.
PR02 THE SPLIT THICKNESS SKIN GRAFT DONOR SITE; HAVE WE FOUND THE PERFECT DRESSING?
Authors: Terrill P.
Published: April 2007

Calcium Alginate dressings have been used for many years as the standard dressing for donor sites. They require a secondary absorbent dressing which is not waterproof, will frequently leak blood and are difficult to remove and heal. Polyurethrane film dressings have also been used routinely with excellent healing rates, are waterproof, but highly prone to leakage.

We present the results of a prospective randomized controlled trial using a new dressing, Tegaderm Absorbent, which provides all the regular benefits of a Polyurethrane film dressing but with absorptive capacity. Tegaderm Absorbent (TA) consists of a conformable acrylic pad enclosed between 2 layers of transparent film. The film in contact with the wound surface is perforated to allow uptake of the wound fluid by the absorptive acrylic pad.

Forty patients were randomized to receive either Tegaderm Absorbent (3M) or Kaltostat Alginate dressing (Convatec)/gauze/combine/Mefix dressing.

Twenty females and 16 men, with a mean age of 72 years (11–94 years), 19 with TA and 17 with Kaltostat, completed the trial. TA dressings were significantly easier to apply (89% vs. 31% very easy to apply), less painful on the first two days postoperatively (mean pain score 0.3 vs. 1.9 at Day 1 and 0.2 vs 2.7 Day 2), were easier and less painful to remove (mean pain score 0.5 vs. 2.9), healed quicker (99.7% vs. 58.9% healed at 10–16 days) and were more convenient for the patients to manage. Eight dressings leaked in the Kaltostat group and 5 in the TA group. To avoid this a dressing change may be required.
PR23 ALTERATIONS IN THE LYMPH STRUCTURE OF THE UPPER LIMB FOLLOWING AXILLARY DISSECTION – RADIOGRAPHIC STUDY IN A HUMAN CADAVER
Authors: Suami H. , Pan W‐R. , Taylor G. I.
Published: April 2007

Purpose  There have been very few anatomical reports on the changing lymph structure of the upper limb after axillary dissection despite its clinical significance for predicting skin cancer recurrence in the limb and secondary lymphoedema. We used both upper limbs harvested from a fresh human cadaver who had undergone unilateral right radical mastectomy and radical axillary dissection for breast cancer.

Methodology  Hydrogen peroxide was used to identify and inflate the lymphatic vessels. Individual channels were injected with a radio‐opaque lead oxide mixture and recorded on X‐ray film.

Results  Results from the left normal upper limb were similar to results from our previous studies. However, the right limb from the mastectomy side showed remarkable differences as well as revealing that the lymph node clearance in the axilla had been incomplete on that side. The major difference was the almost complete absence of the superficial lymph collecting vessels in the right arm, proximal to the elbow, due to fibrosis and blockage of the lymphatic channels. A circuitous pathway was identified that by passed the blocked lymphatics in the arm to reach the deep system. This was often facilitated by backflow through precollectors and avalvular lymph capillaries in the dermis of the forearm, to eventually reach the few remaining lymph nodes in the axilla.

Conclusions  Previously undetected lymph channels connecting the superficial and the deep lymphatic system had opened up due to the blockage of superficial lymphatic vessels caused by axillary dissection. It is presumed that these channels prevented lymphoedema in this case.
PR26 FACIAL RE‐ANIMATION
Authors: Poole M. D.
Published: April 2007

The author will cover the various methods he has had experience with in facial re‐animation over the years including free vascularised muscle transfers, cross face nerve grafting and temporalis and masseter transfers. The long term results of some of these techniques and the pitfalls associated with them and the lessons learned by the author over the years will be discussed.

In summary, free vascularised transfers have now been abandoned in favour of temporalis and masseter muscle transfers using a modified technique to avoid facial scars.
PR28 TRACING THE FLUID MANAGEMENT OF BURNS PATIENTS IN THE FIRST TWENTY‐FOUR HOURS FOLLOWING THEIR ADMISSION
Authors: Burge J. A. , McKenzie K. , Yang A. , Sinclair S.
Published: April 2007

Patients with major burns are prescribed fluids at the time of their admission in accordance with the Parkland formula. It was the intention of this audit to compare the fluid prescribed versus the actual fluid received by these patients in the first 24 hours post burn. Overloaded patients run the risk of extending their burn amongst other complications of fluid overload. Under‐hydrated patients will likewise be receiving suboptimal treatment. This study serves as an informative audit of fluid management of burns patients admitted to Christchurch Public Hospital that were subsequently admitted to Intensive Care. Patients with major burns that required admission to the Intensive Care Unit over five years from 2000 to 2005 were audited. The results of this audit are to be presented.
PR30 ASSESSMENT OF MELAN‐A STAINING IN SENTINEL NODES OF PATIENTS WITHOUT A DIAGNOSIS OF MELANOMA
Authors: Burge J. A. , Nye B.
Published: April 2007

Sentinel lymph node biopsy is now an accepted standard of care for specific patients with malignant melanoma. With this comes an increase in sensitivity of diagnosis of melanoma metastases but also possible false positive results. Proceeding to a formal lmyphadenectomy in sentinel node positive patients is accompanied by a large amount of morbidity and should not be undertaken lightly. Melan‐A is one of the stains used to identify melanoma metastases in sentinel node biopsies. The dilemma arises when there is a small number of Melan‐A positive cells or even a single Melan‐A positive cell in the entire examined sentinel node. Do we proceed to formal lymphadenectomy or “watch & wait”. The purpose of this projected study is to examine the sentinel nodes of patients without a diagnosis of melanoma. We aim to perform a Melan‐A stain on these nodes and identify the incidence of Melan‐A positive staining nodes in presumed melanoma free patients. These nodes will be taken from sentinel nodes of breast cancer patients.
PR03 AN ALTERNATE MODEL FOR LEARNING MICROSURGICAL SKILLS
Authors: Varkey A. , Cigna E. , Tan N. C.
Published: April 2007

Purpose  To highlight a suitable option in training and optimizing microsurgical skills in situations without access to an animal laboratory. The rat model has been the standard model but stringent laws on experimental animals and rising cost of this model necessitate alternative models.

Methods  Tissues obtained from the operating room which would otherwise be discarded We practiced microsurgical anastomosis of vessels and nerves using the operating microscope. Over a one year period, 86anastomosis were done on various vessels of different caliber. The patency was evaluated using colored colloidal solution to flow through from a height creating a pressure gradient. Transecting the vessel beyond the anastomosis was subsequently done to examine the anastomosis in greater detail.

Results  86 anastomosis performed were evaluated. The anastomosis performed are summarized:Upper limb‐Radial artery10; Cephalic vein‐10. Lower limb‐Peroneal artery‐6. Dorsalis pedis‐3; Vena commitantes‐5; Digital vessels on toes 3 arteries 3 veins; Umbilical cord‐artery‐12; Umbilical vein‐12; Lymphedematous tissue‐vein‐4; Derma‐lipectomy specimen‐Unnamed veins‐5, arteries‐5; Intestine‐Mesenteric vessels veins‐4; arteries‐4.

Conclusion  The use of tissue which would otherwise be discarded proved to be a suitable alternative in training basic microsurgical skills with specific advantages of allowing for practice of all steps including adventectomy which is not possible on synthetic models. It offered the novice a first hand experience with vessels of various characteristic attributes and enables the trainee to get the life like experience of the feel of the vessel and its specific characters as one would encounter.
PR31 A LITTLE GIRL WITH A GIANT NAEVUS. A CASE REPORT
Authors: Mackenzie K. A. , Langley S. J.
Published: April 2007

Purpose  The treatment of congenital giant hairy naevi remains controversial and it can present a challenge for the reconstructive surgeon. Recent publications promote the use of curettage and laser treatment, however they show incomplete clearance. In this atmosphere we present a case of surgical resection involving serial excision, skin grafts and tissue expansion with early good cosmetic results.

Methodology  Now aged 2 year old girl was born with extensive congenital melanocytic naevi of her face, involving lower forehead, glabella, medial eyelids, nasal bridge and medial cheeks bilaterally. Lower back and right calf were also involved. No associated anomalies were recorded. At one week of age she had curettage of the facial naevus, when the surface naevus containing most of pigment and naevus cells was removed in London. She was left with the left eye ectropion due to a small scar. She moved to NZ and underwent further treatment. There was no role for laser treatment so surgical excision at the age of 12 months was performed, followed by insertion of tissue expanders, bilateral cheek and forehead advancement and full thickness graft to defects post serial excisions. A literature review was performed and our findings compared with historical results from other centres.

Results  Multiple treatment techniques have been used over the last few decades. Surgical approach provides stable long term results in terms of cosmesis and function and early good results are shown in our case. We will continue further reconstructions in the future to achieve the best appearance and function.
PR36 WHAT I’VE LEARNT IN CRANIOFACIAL SURGERY
Authors: Poole M. D.
Published: April 2007

In a long career in the area of craniofacial surgery the author has learned many lessons, often the hard way. These will be discussed and some strategies presented to avoid problems which can be disastrous in craniofacial surgery such as massive haemorrhage, infection and airway obstructions. Protocols for safe practice will be discussed.
PR37 EVOLUTION OF SURGERY FOR CRANIOSYNOSTOSIS IN CHRISTCHURCH – A REVIEW OF 67 CHILDREN
Authors: Mackenzie K. A. , Langley S. , Davis C. , MacFarlane M. R.
Published: April 2007

Purpose  The treatment of craniosynostosis has continued to evolve over the last few decades. Techniques from linear strip craniectomies through osteotomies, orbital bandeau fashioning, craniotomies and immediate calvarial remodelling to the latest spring‐mediated dynamic reshaping have been used to achieve ongoing improvements in facial and skull shape. This paper discusses the timing, long‐term results and recent advances of surgical techniques based on our experience. We also aim to identify factors which could affect the outcome.

Methodology  We performed a retrospective analysis of 67 patients surgically treated for craniosynostosis over a 24 year period in Christchurch Hospital. The craniofacial team consisted of a Plastic Surgeon and a Neurosurgeon. We analyzed results based on type of sutural involvement, cosmetic outcome, complications, blood transfusions and surgical technique.

Results  There were 20 females and 47 males. 62 had a non‐syndromic craniosynostosis and 5 had a syndromic craniosynostosis. The non‐syndromic cases comprised: sagittal (n = 30), metopic (n = 17), unilateral coronal (n = 9), bicoronal (n = 2) and multiple (N = 4). The 5 syndromic cases comprised: Crouzon’s/bilat coronal (n = 2), Apert’s (n = 2, 1 bilateral coronal, 1 unilateral coronal)) and Klippel‐Feil/unilateral lambdoid (n = 1). The median age at first operation was 8 months. Complications and outcomes will be presented and our conclusions will highlight the evolving surgical techniques and that a multidisciplinary approach (including neurosurgeon, plastic surgeons and paediatric team) provides the best outcome for children with craniosynostosis.
PR42P RISK FACTORS AND SAFETY OF IMMEDIATE BREAST RECONSTRUCTION
Authors: Mackenzie K. A. , Nye B. J.
Published: April 2007

Purpose  Indications for immediate breast reconstruction (IBR) vary depending on many factors, including clinical stage of carcinoma, age, diabetes, hypertension, obesity and smoking. This paper seeks to assess the risk factors and complications in patients undergoing immediate breast reconstruction and define selection criteria for IBR based on the local population.

Methodology  A retrospective review of 94 immediate breast reconstructions over a 5‐year period was carried out. Patients were divided into subgroups based on the type of reconstruction: TRAM (n = 36), latissimus dorsi myocutaneous flap with implant (n = 28), autologus latissimus dorsi myocutaneous flap (n = 3), subpectoral saline implant (n = 8) and tissue expander (n = 19). Review of risk factors and complications in all groups was performed and our findings compared with results from other centres.

Results  Results including complications and outcomes will be presented and the conclusions used to provide recommendations for patient selection for immediate breast reconstruction. Statistical analysis will be performed to compare the rate of complications with respect to the surgical procedure and risk factors.
PR45P AN IMPROVED ALTERNATIVE TO VACUUM‐ASSISTED CLOSURE (VAC) AS A NEGATIVE PRESSURE DRESSING IN LOWER LIMB SPLIT SKIN GRAFTING: A CLINICAL TRIAL
Authors: Rozen W. M. , Shahbaz S. , Morsi A.
Published: April 2007

Background  The use of negative pressure in the dressing of split skin grafts has been shown to promote healing by a variety of mechanisms, including a decrease in interstitial oedema, an increase in perfusion and a decrease in bacterial colonisation. Vacuum‐assisted closure (VAC) dressings have, until now, been used as the archetype for negative pressure dressings and have been reflected as such in the literature. However, patient mobility and cost are still an issue with these dressings, and alternatives have been keenly sought. We describe an alternative method of negative pressure dressing, which we have found to be a safe and successful alternative, in the setting of lower limb split skin grafts.

Method and Materials  A prospective cohort investigation was performed at a Melbourne major metropolitan teaching hospital on 9 consecutive patients undergoing split‐skin grafting for a lower limb soft tissue defect. The dressing comprised a single cut foam sheet, a conventional disposable closed‐system suction drain and an adhesive dressing.

Results  In all 9 patients, there was a 100% take of the graft, with no partial or complete loss. There were no complications encountered. Cost analysis demonstrated a minimum treatment cost of $577 over 5 days compared to $3180 for commercial VAC dressed wounds: a net saving of $2603 per patient.

Conclusions  The use of a simple suction drain is a cheap and safe alternative to commercial VAC dressings for the treatment of lower limb split skin grafts. Length of hospital stay and cost are superior to VAC, with no diminished clinical outcome.
PR46P A CASE REVIEW OF PATIENTS PRESENTING TO ROYAL NORTH SHORE HOSPITAL, WITH HAIR REMOVAL WAX BURNS BETWEEN JANUARY AND NOVEMBER 2006
Authors: Zoumaras J. , Kwei J. , Vandervord J.
Published: April 2007

To date there has been no published literature on the dangers of hair removal wax burns. This case review illustrates the steady influx of patients presenting to Royal North Shore Hospital (RNSH) with hair removal wax burns. Between January and December 2006 ten patients out of 395 with burns (2.5%) presented to our dressing clinic with hair removal wax burns. All sustained burns under 5% Total Body Surface Area (TBSA) and two required debriding and split skin grafting (SSG). The mechanism of the burns was re‐heating the hair removal wax in the microwave for too long.
PR08 LYMPHATIC MALFORMATIONS AND THE MOLECULAR BASIS OF LYMPHANGIOGENESIS
Authors: Ch’ng S. , Tan S. T.
Published: April 2007

This paper reviews the clinical features of lymphatic malformations and the molecular basis of embryonic lymphangiogenesis.

Lymphatic malformations are classified as microcystic, macrocystic, or combined. Most commonly found in the axilla/chest and cervicofacial region, they can be localised or diffuse. The commonest complications are intralesional bleeding and infection. Other significant complications are due mainly to their mass effect on nearby anatomic structures including the airway and eyeball, and soft tissue and skeletal overgrowth including macrocheilia, macroglossia, macrotia, macromala and mandibular prognathism, resulting in functional problems in feeding, speech, occlusion, oral hygiene, and disfigurement. The characteristic radiological finding of a LM on gadolinium‐enhanced T1‐weighted MRI is a low‐density lesion with septation or rim enhancement. Histologically, LMs are cystic lesions that contain eosinophilic proteinaceous fluid whose walls are composed of smooth and skeletal muscle fibres, collagen and lymphocytes. Management options range from observation, comfort cares, empirical antibiotic treatment for LM cellulitis to sclerotherapy, surgical excision and Nd:YAG laser for selected cases.

Lymphangiogenesis is believed to occur in four sequential but overlapping stages: lymphatic endothelial cell competence, bias and specification, and finally lymphatic vessel terminal differentiation and maturation. Multiple genes are involved in this process including Lyve1, Nrp2, podoplanin, Prox1, VEGFR3, VEGFC and Ang2. Developmental defects during embryonic lymphangiogenesis result in lymphatic malformations.