| 1. |
- Mobargha, Nathalie, et al.
(författare)
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Scapular osseous free flap in head and neck reconstruction : An assessment of the postoperative function of the donor site
- 2022
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Ingår i: Journal of Plastic, Reconstructive and Aesthetic Surgery. - : Elsevier BV. - 1748-6815. ; 75:2, s. 753-760
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Tidskriftsartikel (refereegranskat)abstract
- Background: The scapular osseous free flap (SOFF) has become an important reconstructive option for complex head and neck defects. Postoperative donor site function is, however, an important consideration. The objective of this study was to prospectively investigate SOFF donor site morbidity and to relate the findings to hand dominance and neck dissection. Methods: Objective assessment included bilateral measurement of shoulder, elbow, and hand range of motion (ROM), hand strength, and distal nerve function in consecutive patients with head and neck cancer SOFF reconstruction at a tertiary referral center in Sweden between 2016 and 2019. The subjective function was assessed by the Disability of the Arm, Shoulder and Hand (DASH) questionnaire. Results: Sixteen of 20 consecutive patients were evaluated (median follow-up 10 months [range 3–17]). Significant side differences in shoulder range of motion (ROM) (flexion, abduction, external and internal rotation) were observed for patients where the SOFF had been harvested from the same side as their dominant hand (n = 9; Ps ≤ 0.04). For patients where the SOFF was harvested from the non-dominant hand side, no significant shoulder ROM side differences were observed (n = 7; Ps ≥ 0.08). There were significant side differences in shoulder ROM for patients who underwent neck dissections (n = 12; Ps ≤ 0.03), not for the other four patients. Patients reported low but varying DASH scores (median 2.5, range 0–57). Conclusion: Postoperative donor site morbidity seems to be quite acceptable after SOFF surgery. The results indicate possible benefits of choosing the non-dominant hand side for the SOFF and that a neck dissection affects postoperative shoulder outcome. Further studies are however needed.
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| 2. |
- Mobargha, Nathalie
(författare)
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The proprioception and neuromuscular stability of the basal thumb joint
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- OBJECTIVES: The basal thumb joint, or the first carpometacarpal joint (CMC1) is an enigmatic construction. The concavo-convex shape of the CMC1 and wide range of movement, allows for both precision and power grips and is particularly susceptible to the development of osteoarthritis. Previous theories regarding the development of CMC1 osteoarthritis have focused on the role of gender, excessive joint load and ligament laxity as causative factors. An emerging theory is the role of proprioception and sensorimotor functions that act to maintain adequate joint equilibrium. This concept constitutes the basis of this thesis with the intent on examining both healthy and osteoarthritic joints. Using microscopic, biomechanical and neurophysiological methods, we address the hypothesis that CMC1 holds proprioceptive and neuromuscular properties that are integral for proper thumb function. METHODS: Patients with CMC1 osteoarthritis that were treated surgically with complete trapeziectomy and suspension arthroplasty were included. Two CMC1 ligaments were collected from these subjects: the anterior oblique ligament (AOL) and the dorsal radial ligament (DRL). Following immunofluorescent triple staining techniques using markers p75, PGP9.5 and DAPI, the ligamentous innervation and mechanoreceptor populations were analyzed (study I-II). In study III, biomechanical assessment of the role of isometric muscle load on CMC1 was performed by a FASTRAK® motion tracking device. In study IV, two intrinsic (the first dorsal interosseous muscle; DI, abductor pollicis brevis; APB,) and two extrinsic muscles (extensor pollicis longus; EPL, abductor pollicis longus, APL) were examined in healthy subjects using electromyographic (EMG) analysis during functional thumb tasks. Post-stimulus reactions following stimulation of the DRL were analyzed for each muscle and each thumb position. RESULTS: The CMC1 ligaments investigated displayed a varying degree of innervation. AOL presented with little innervation and was mainly composed of incoherent connective tissue and scarce collagen fibers, whereas DRL presented with abundant innervation and well-organized collagen (study I). Unclassifiable mechanoreceptors were the most frequent type of receptor found in AOL and DRL. No significant difference in the innervation between the proximal and distal portions of these osteoarthritic ligaments was identified (study II). The first dorsal interosseous muscle (FDI or DI) produced the highest level of distal migration and the least dorsoradial translation of the base of the first metacarpal. APL was identified as the main destabilizer as it increases dorsoradial misalignment (study III). Following stimulation of the DRL, significant (p<0.05) post-stimulus changes were found in all four muscles (DI, APB, APL, EPL) and positions tested. A mass inhibitory reaction was observed during tip pinch whilst key pinch produced rapid co-contractions. During palmar pinch a rapid inhibitory response was evoked in antagonistic muscles (study IV). CONCLUSIONS: Ligaments from osteoarthritic patients displayed alterations in distribution and type of mechanoreceptors as compared to previous studies on normal joints. The results reinforce DRL’s proprioceptive and stabilizing role for the CMC1 joint. Isometric load of CMC1 indicates that DI promotes joint congruency by reducing dorsoradial translation, whereas APL acts in an opposing manner as a destabilizing force. Ligamento-muscular reflexes were observed following the stimulation of DRL. Thus, the dorsoradial ligament, in addition to being the primary static stabilizer of the joint, also possesses proprioceptive qualities. The post-stimulus reactions detected in DI, APB, APL and EPL are indicative of protective ligamento-muscular pathways, which facilitate neuromuscular functions and the maintenance of joint stability. CLINICAL RELEVANCE: Patients with CMC1 osteoarthritis constitute a large group. Their symptoms are of varying severity, where some can be addressed within the scope of primary care units, whilst others are in need of operative treatment. Patients with CMC1 osteoarthritis often present with impaired neuromuscular functions, reduced range of motion, weakness, joint and ligamentous pathology as well as pain, which affect their daily activities. Understanding the proprioceptive and neuromuscular characteristics of the basal thumb joint is therefore essential in deciphering the complex pathophysiology of the basal thumb joint.
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| 3. |
- Rein, Susanne, et al.
(författare)
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Alteration of ligamento-muscular reflex patterns after cutaneous and periarticular desensitization of the basal thumb joint : An electromyographic study
- 2023
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Ingår i: Journal of Hand Surgery-American Volume. - : Elsevier BV. - 0363-5023 .- 1531-6564. ; 48:6
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Tidskriftsartikel (refereegranskat)abstract
- PURPOSE: Stimulation of the dorsoradial ligament (DRL) of the first carpometacarpal joint (CMC-1) has shown a ligamento-muscular reflex pathway between the DRL and CMC-1 stabilizing muscles in healthy volunteers. However, it remains unclear how this ligamento-muscular reflex pattern is altered after anesthetizing sensory skin receptors and administering a further periarticular block around the CMC-1 joint, which may influence the dynamic aspects of joint stability.METHODS: Ligamento-muscular reflexes were obtained from the extensor pollicis longus, abductor pollicis longus, abductor pollicis brevis, and the first dorsal interosseous muscles in 10 healthy participants after establishing superficial anesthesia of the skin around the CMC-1. The DRL was stimulated with a fine wire electrode while EMG activities were recorded during isometric tip, key, and palmar pinch. The measurements were repeated after an additional periarticular CMC-1 block using 5 ml of 1% lidocaine. Average EMG values were analyzed to compare the prestimulus and poststimulus activity.RESULTS: Statistically significant changes in poststimulus EMG activity were observed in all 4 muscles and all 3 tested thumb positions. A markedly reduced activity in all 4 muscles was observed in the palmar position, followed by the tip and key pinch positions. Almost no reactions were observed in the first 20 ms poststimulus for all muscles in all positions.CONCLUSIONS: Superficial skin anesthesia and an additional periarticular CMC-1 block anesthesia resulted in a reduced ligamento-muscular reflex pattern in all 4 muscles.CLINICAL RELEVANCE: Ligamento-muscular reflexes play an important role in dynamic CMC-1 joint stability. The elimination of early reactions, those considered joint-protective reflexes, is a potential risk factor for developing osteoarthritis or injury because it results in an inability to adequately protect and stabilize the joint in sudden movements.
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| 4. |
- Tallroth, Linda, et al.
(författare)
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Assessment of local tissue water in breasts following breast reconstruction with an expander prosthesis or DIEP flap
- 2022
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Ingår i: Journal of Plastic Surgery and Hand Surgery. - 2000-656X. ; 56:4, s. 217-223
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Tidskriftsartikel (refereegranskat)abstract
- The role of breast oedema in breast reconstruction is unknown. Therefore, our aim was to investigate local tissue water (LTW) and breast oedema-related symptoms in breasts reconstructed with either an expander prosthesis (EP) or with a deep inferior epigastric perforator (DIEP) flap at a minimum of one year postoperatively. Sixty-eight patients randomised to breast reconstruction with an EP or DIEP flap completed follow-up. Objective evaluation was performed at a mean of 25 (standard deviation, SD 9.5) months following breast reconstruction, and included measurements of breast volume and LTW with the MoistureMeterD® instrument. The patients completed the BREAST-Q questionnaire pre- and postoperatively. No significant differences in LTW were found when comparing EP and DIEP flap reconstructed breasts. The reconstructed breasts had an increase in LTW compared with the non-operated contralateral breasts. The BREAST-Q responses related to breast oedema symptoms were overall low and the median responses ranged from 1 to 2. A score of 1 indicated that symptoms were experienced 'None of the time'. Our findings indicate that mastectomy followed by breast reconstruction inflicts damage on the lymphatic system, shown as an increase in LTW. However, no breast oedema-related symptoms were reported in the BREAST-Q questionnaire, and therefore, we consider our objective results to be below a potential threshold for symptomatic breast oedema. A threshold for clinical indication of breast oedema remains to be defined.
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| 5. |
- Tallroth, Linda, et al.
(författare)
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Breast softness in patients randomised to postmastectomy breast reconstruction with an expander prosthesis or DIEP flap
- 2021
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Ingår i: European Journal of Plastic Surgery. - : Springer Science and Business Media LLC. - 0930-343X .- 1435-0130. ; , s. 1-8
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Tidskriftsartikel (refereegranskat)abstract
- Background Objectively measured breast softness in reconstructed breasts and its relation to patients’ subjective satisfactionwith breast softness has not yet been investigated. The aim of this study was to evaluate breast softness in patients 1 yearfollowing delayed breast reconstruction with an expander prosthesis (EP) or deep inferior epigastric perforator (DIEP) fap,using objective and subjective methods.Methods Seventy-three patients were randomised to breast reconstruction with an EP or DIEP fap between 2012 and 2018.Of these, 69 completed objective evaluation at a mean of 25 (standard deviation, SD 9.4) months following breast reconstruction. Objective evaluation included measurements of breast volume, jugulum-nipple distance, clavicular-submammary folddistance, ptosis and Baker scale grading. Breast softness was assessed with applanation tonometry. Subjective evaluationwas performed using the BREAST-Q questionnaire.Results Objectively, DIEP faps were signifcantly softer than EP breast reconstructions. Non-operated contralateral breastswere signifcantly softer compared with reconstructed breasts. In the subjective evaluation, the median score on the question(labelled 1.h) “How satisfed or dissatisfed have you been with the softness of your reconstructed breast (s)?” was higher inthe DIEP fap group corresponding to greater satisfaction in this group. A fair correlation was found between the applanationtonometry and the patient-reported satisfaction with the reconstructed breast’s softness (rs=0.37).Conclusions In terms of breast softness, breast reconstructions with DIEP faps result in more satisfed patients. Concerningapplanation tonometry as an objective tool for
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| 6. |
- Tallroth, Linda, et al.
(författare)
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Evaluation of an assessment scale for aesthetic outcome in breast reconstructions based on digital photos in both 2D and 3D format
- 2023
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Ingår i: Journal of Plastic Surgery and Hand Surgery. - 2000-656X. ; 57:1-6, s. 427-433
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Tidskriftsartikel (refereegranskat)abstract
- The aesthetic outcome is crucial in a breast reconstruction. Our aim was to evaluate the intra- and interrater reliability of an aesthetic outcome assessment scale with digital photos of breast reconstructions in two-dimensional (2D) and three-dimensional (3D) format. Thirty-three women with delayed breast reconstructions, consecutively participating in a five-year follow-up between November 2019 and June 2021, were included in the study. Of these, 14 were reconstructed with an expander prosthesis (EP) and 19 with a deep inferior epigastric perforator (DIEP) flap. Photos of the breasts were assessed in 2D and 3D format by expert, layman and patient panels. Data were analysed with the weighted kappa (wk) statistics. The intrarater agreements were moderate to substantial, with wk between 0.66 and 0.73 for the panels. Within the panels, the interrater agreements were 0.46–0.62. Moderate agreements were found between the matched 2D and 3D format photos (wk 0.62–0.66). The patient panel graded scar appearance worse in 3D compared with 2D format. In all panels, there was a tendency towards DIEP flap reconstructions receiving higher aesthetic outcome grades compared with EP. Thus, the aesthetic outcome assessment scale demonstrated acceptable agreements between the individual panellists and within the panels. Scars captured in 3D format may provide a greater resemblance to the reality compared with 2D. Implications for clinics remain to be further studied.
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| 7. |
- Tallroth, Linda, et al.
(författare)
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Expander prosthesis and DIEP flaps in delayed breast reconstruction : Sensibility, patient-reported outcome, and complications in a five-year randomised follow-up study
- 2023
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Ingår i: Journal of Plastic Surgery and Hand Surgery. - 2000-656X. ; 58, s. 101-109
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Tidskriftsartikel (refereegranskat)abstract
- Breast reconstruction is a given choice for many women following mastectomy. There are a multitude of methods available today, and thus, comparative studies are essential to match patients with suitable methods. The aim of this study was to compare 5-year outcomes following delayed breast reconstruction with expander prosthesis (EP) and with deep inferior epigastric perforator (DIEP) flaps. Seventy-three patients, previously randomised to either a permanent EP or a DIEP flap breast reconstruction, were invited for a 5-year follow-up. Assessments included symmetry measurements, breast sensibility with Semmes-Weinstein monofilaments and patient-reported outcome (PRO) with the BREAST-Q. Complications within the first 5 postoperative years were recorded. Additionally, BREAST-Q questionnaires were collected from non-randomised patients with an EP breast reconstruction. Between 2019 and 2022, 65 patients completed the follow-ups. Symmetry and PRO were significantly higher in the DIEP flap group. However, EP-reconstructed breasts were significantly more sensate and demonstrated areas with protective sensibility, unlike the DIEP flap breasts. The overall complication rates were comparable between the two groups (p = 0.27). Regression analysis identified body mass index as a risk factor for reoperation in general anaesthesia and for wound infection. No significant differences were found in a comparison of the randomised and the non-randomised EP groups' BREAST-Q results. This randomised 5-year follow-up study found PRO to be favourable following a DIEP flap reconstruction and sensibility to be better in EP reconstructions. The complication rates were comparable; however, longer follow-ups are warranted to cover the complete lifespans of the two breast reconstruction methods.
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| 8. |
- Tocco-Tussardi, Ilaria, et al.
(författare)
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Radical treatment of extensive nevoid hyperkeratosis of the areola and breast with surgical excision after mild response to topical agents : A case report
- 2016
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Ingår i: International Journal of Surgery Case Reports. - : Elsevier BV. - 2210-2612. ; 28, s. 117-120
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Tidskriftsartikel (refereegranskat)abstract
- INTRODUCTION: Nevoid hyperkeratosis of the nipple and/or areola (NHNA) is a benign lesion with a female predominance and an aesthetically disturbing appearance. Spontaneous remission is not reported and medical treatments proposed so far have shown variable results. PRESENTATION OF CASE: We describe a rare case of an extensive variant of NHNA covering almost the entire breasts' surface. At present, only three other reports are present in the literature. Medical treatment proved not completely effective and the patient was also affected by a significant breast asymmetry hypertrophy. Therefore, NHNA was managed surgically with excision of the areolar affected portions while performing breast reduction-lift. The result was satisfactory and without recurrence of lesions at 5-year follow-up. DISCUSSION: This case reported favorable outcomes of surgery for NHNA. Reports of success with these procedures are still limited, but the promising results in terms of radicality and aesthetic outcome suggest it should be offered to patients as a viable therapeutic option. CONCLUSION: Indications for surgical treatment of NHNA can be: unsatisfying response to topical agents; young patients who want to restore the aesthetic appearance of the breast; and patients with concomitant indication for corrective surgery of the breast. Advantages are: predictable time of healing; predictable final result; radical excision of the affected tissue; and possibility of histologic analysis of the whole areola. In rare cases of lesions extending to the breast, preliminary treatment with topical agents can limit the extent of excision. Management and treatment should always be tailor-made for each individual case.
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