the use of paper tape application in skin tissue expansion and abnormal scar modulation

272 Pages·2017·12.48 MB·English

THE USE OF PAPER TAPE APPLICATION IN
SKIN TISSUE EXPANSION AND ABNORMAL
SCAR MODULATION
By
MAHENDRA DAYA

Submitted in fulfillment of the academic requirements
for the degree of PhD
in the Department of Plastic and Reconstructive Surgery
School of Clinical Medicine
College of Health Sciences
University of KwaZulu-Natal
Durban
2016 (year)
As the candidate’s supervisor I have/have not approved this thesis for submission.

Signed: _____________ Name: ____________ Date: ____

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Prologue

I am a tailor by heritage, an engineer at heart and a plastic and reconstructive
surgeon by trade.

My forefathers arrived in South Africa as traders in early 1900’s. Back in India, the
father to son passage of the tailoring trade spanned centuries. My grandfathers on
both paternal and maternal sides set up tailoring shops on landing in SA. As
expected their sons were shown the art of tailoring and entrained into the business
at the time. This was not peculiar to the male counterparts only. My mother and
some of her sisters also took to the trade of tailoring in traditional ladies garments.
This art was passed on to them by their mothers.

The facets of the trade included knowledge of the fabric, designing of the garments,
cutting the fabric to design. A multistaged production of the garment with trial body
fitting, specifically for intricate work was not uncommon. This eventually culminated
in the sewing of the garment by machine and by hand. Perfection was the goal in
the hope of appeasing the patron and cultivating personal pride.

In their newly adopted country of South Africa, families maintained developing and
propagating their society of tailors. The association was further strengthened by the
parents arranging marriages of their sons and daughters from unrelated or distantly
related families. This was generally from another town. Here in lies my beginning as
my father and mother were matched. The rest is history.

I grew up in this society. My exposure to tailoring was constant. At home where my
mother worked churning out her products and at the workshop were my uncles and
father continued their tailoring trade. It was customary for all the boys in the families
to go to their family shop to work after school on a Friday and on weekends. I started
at the age of eight.
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As factory made garments made their way onto the shelves and counters of the
tailoring shops, and customised tailoring was beginning to slow down, the need for
performing neat alterations was increasing. I learnt in my teens to perform some of
these alterations using both machine and hands. I continued to work on weekends
and in holidays in this way until I finished medical school.

Medical school was never my idea. I had my heart set on mechanical engineering
in the latter years of my high schooling. I liked fixing things and took on every
opportunity at home indulging in painting, carpentry, electrical repairs etc. My
fascination with cars also started at an early age and my elder 1st cousin brother
allowed me to drive his car from an age of 13. The mechanical side of the car was
a constant wonder in my mind. I would have been become a mechanic if it had not
been for my good grades in school. Mechanical engineering was the dream and fast
sports cars the product. The independent variable that I was not able to manipulate
was the man in-charge, my father of course.

I applied in my matriculation year for registration in medicine and mechanical
engineering. Hopeful that I would not get accepted to medical school at the
University of KwaZulu-Natal (UKZN). But I was.

My two most valued outcomes of my medical studies are my qualification and my
wife. We were class mates. Whilst she was serving the community in her own
practice she provided me with support in every respect. She was and remains the
pillar of strength and to her I owe my success. She took on most family
responsibilities whilst remaining dedicated to her practice.

A day before the commencement of a rotation in cardiothoracic surgery, my first
choice of an elective rotations associated with my specialising in surgery, I was
contacted by Prof Bhugwan Singh (general surgeon in charge of the rotation), to go
to Plastic and Reconstructive Surgery for one week because the assigned registrar
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had taken ill. I complained but accepted the interim measure. I did not have the
foggiest idea what plastic and reconstructive surgery was about. A few days at work
and it felt like I was a duck taking to water. I was fascinated by the hands on nature
of the discipline. I negotiated to stay on for the full three months and decided that
this was going to be my career. I felt at home with this trade.

Skin was the material. Design, cut and sew was the execution. The results were
there to be seen. Little alterations immediately or later could easily be done to
achieve perfection and make patrons happy. It was tailoring after all.

My career continued to evolve. The unique aspect of plastic and reconstructive
surgery was that one can express ones personality in ones work. Books and
colleagues are a guide. An artist with an empty canvass, paint brush in the hand
and all the colours to express your passion to the benefit of the patient was the
game.

It was not uncommon for my clinics to be frequented by patients with scar related
functional problems, hypertrophic scars and keloids. In the management of
abnormal scars, as a plastic and reconstructive surgeon I felt powerless. High failure
rates in control, symptomatic relief and treatment was a commonplace. I found it
almost impossible to provide any good assistance to patients with large keloids
and/or multiple keloids in our resource constrained setting. Cosmesis other than
facial keloids were not an important factor for these patients. The pain and itch was
intolerable to many. There was no magic potion for this especially if the intralesional
injection of steroids was not an option. Silicone sheeting was expensive and not
available. Pressure garments and lanolin cream was the default treatment.

Scar revisional surgery was more rewarding to deal with. Simple ones being
managed by options of simple excision, serial excision, skin grafts, little flaps and Z
plasties. Replacing like with like tissue, made local tissue the first choice. The
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concept of using tissue expanders for skin creation was a brilliant one using nature’s
biological and physiological processes in fast forward.

One of my earlier experiences in my residency with tissue expansion in 1997 was a
patient that was struck by lightning in an open field. He arrived for treatment in our
clinic as a delayed presentation with exposed necrotic bone on the vertex of the
skull. The debridement included the full thickness removal of the bone to an already
granulating dura. A skin graft to this was performed at the second operation. My
final plan was to reconstruct the traumatic alopecia of the scalp by tissue expansion.
Six months later I placed a tissue expander under the normal scalp adjacent to the
defect. The expansion resulted in extrusion at one of the corners. I continued to
expand rapidly on a daily basis for maximum tissue gain before surgery. I was forced
to remove the expander without any preplanning. With carefully considered design
I was able to remove the perforated portion of the skin at the site of extrusion,
transpose a flap and recreate the defect and get tension free closure. This case
became a turning point for me.

My use of tissue expansion as reconstructive technique rapidly increased, with
attention to detail in preplanning, and to effective and efficient expanded flap use in
the reconstruction. I was however discouraged from using tissue expansion in limbs
because of their failure rate.

The largest drawback of tissue expansion devices were that of its invasive nature,
non-uniform distribution of the tension and pain. The most important contribution
was its use in open existing wounds. This was not the domain of the traditional tissue
expander. The common characteristic of these devices was tension application to
generate skin. This was the birth place for my first attempt in 2003 for tape
dermatogenesis in a lower limb pretibial scar.

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Changes seen in scars of patients during the tape dermatogenesis gave support to
my idea that the taping technique would improve abnormal scars.

At the inception of my new work using tape to create skin, the concept of PhD thesis
did not come to my mind. My first original paper titled “Traction-Assisted
Dermatogenesis by Serial Intermittent Skin Tape Application” was submitted to the
Plastic and Reconstruction Surgery in Dec 2007. It was the encouragement and the
positive comments from the reviewer for the journal, Prof Dennis Orgill that
prompted my correspondence to the Chairman of the postgraduate committee to
have the paper reviewed for a PhD.

Eventually with the support Prof Bhugwan Singh, the PhD looked like it would
materialise. Prof Singh was the very one that was responsible for my unplanned
exposure to Plastic and Reconstructive Surgery as a resident in 1993.

Prof Dennis Orgill on my approach, immediately agreed to be my co-supervisor.
With Prof Colleen Aldous as my supervisor by my side, I started writing my thesis in
April of 2016 and within the next few days of writing this prologue, it will be complete.

It was a journey, and my heartfelt gratitude need to be extended to Colleen and
Dennis for their support.

It is hoped that you the examiner will enjoy reading the thesis. I will like to thank you
in advance for taking time off from your busy schedules and families to do this.

11th January 2016

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Dedication

I dedicate this PhD and my career as a plastic and reconstruction surgeon
to my beautiful wife Dr Kavitha Bisnath. Without her understanding and support
this work may not have been achievable.

A great big thank you
to my parents for their guidance in my childhood, for being given no choice other
than a career in medicine and for the tailoring heritage.

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Declaration

I...Mahendra Daya.............................................................................declare that

(i) The research reported in this dissertation, except where otherwise indicated, is my
original work.
(ii) This dissertation has not been submitted for any degree or examination at any other
university.
(iii) This dissertation does not contain other persons’ data, pictures, graphs or other
information, unless specifically acknowledged as being sourced from other persons.
(iv) This dissertation does not contain other persons’ writing, unless specifically
acknowledged as being sourced from other researchers. Where other written sources
have been quoted, then:
a) their words have been re-written but the general information attributed to them has
been referenced;
b) where their exact words have been used, their writing has been placed inside quotation
marks, and referenced.
(v) Where I have reproduced a publication of which I am an author, co-author or editor, I
have indicated in detail which part of the publication was actually written by myself alone
and have fully referenced such publications.
(vi) This dissertation does not contain text, graphics or tables copied and pasted from the
Internet, unless specifically acknowledged, and the source being detailed in the
dissertation and in the References sections.

Signed: Date: 16/01/2017

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Acknowledgements

I acknowledge the contribution of the following people who have rendered assistance to
make this work possible:-
 Prof Colleen Aldous (Supervisor)
 Prof Dennis Orgill (Co-supervisor)
 Prof Miriam Adhikari
 Dr Veena Singaram

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