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| 2. |
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| 3. |
- Audolfsson, Thorir, et al.
(författare)
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Nerve Transfers for Facial Transplantation : a cadaveric study for motor and sensory restoration
- 2013
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Ingår i: Plastic and reconstructive surgery (1963). - 0032-1052 .- 1529-4242. ; 131:6, s. 1231-1240
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUNDRestoration of facial animation and sensation are highly important for the outcome after facial allotransplantation. The identification of healthy nerves for neurotization, through recipient to donor nerve coaptation, is of particular importance for successful nerve regeneration within the allograft. However, due to the severity of the initial injury and resultant scar formation, a lack of healthy nerve stumps in the recipient is a commonly encountered problem. In this study, we evaluate the technical feasibility of performing nerve transfers in facial transplantation for both sensory and motor neurotization.METHODSFifteen fresh cadaver heads were used in this study. The study was divided in two parts. First, the technical feasibility of nerve transfer from the cervical plexus (CP) to the mental nerve (MN) and the masseter nerve (MaN) to the buccal branches of the facial nerve (BBFN) was assessed. Next, we performed nerve transfers in simulated face transplants to describe the surgical technique focusing on sensory restoration of the midface and upper lip by neurotization of the infraorbital nerve (ION), sensory restoration of the lower lip by neurotization of the MN, and smile reanimation by neurotization of the BBFN.RESULTSIn all specimens coaptation of at least one of branches of the CP to the mental nerve was possible as well as between the masseter nerve to the buccal branch of the facial nerve. In simulated face transplant procedures nerve transfers of the supraorbital nerve (SON) to the infraorbital nerve (ION), cervical plexus branches to the mental nerve, and masseter nerve to facial nerve are all technically possible.CONCLUSIONNerve transfers are a technically feasible option that could theoretically be used in face transplantation either as a primary nerve reconstruction when there are no available healthy nerves, or as a secondary procedure for enhancement of functional outcomes. The supraorbital nerve, branches of the cervical plexus and the masseter nerve are nerves usually located out of the zone of injury and can be selected as neurotizers for the infraorbital nerve, mental nerve and buccal branch of the facial nerve respectively.
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| 4. |
- Borgquist, Ola, et al.
(författare)
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The influence of low and high pressure levels during negative pressure wound therapy on wound contraction and fluid evacuation.
- 2011
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Ingår i: Plastic and Reconstructive Surgery. - 0032-1052. ; 127:2, s. 551-559
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Negative pressure wound therapy (NPWT) promotes healing by drainage of excessive fluid and debris and also by mechanical deformation of the wound edge tissue. The most commonly used negative pressure is -125 mmHg. However, this pressure may cause pain and ischemia, and the pressure often needs to be reduced. The aim of the present study was to examine wound contraction and fluid removal during low and increasing levels of negative pressures. METHODS: A peripheral wound was created in 70 kg pigs. The immediate effects of NPWT (-10 to -175 mmHg) on wound contraction and fluid removal was studied in eight pigs. The long-term effects on wound contraction were studied in eight additional pigs during 72 hours of NPWT at -75 mmHg. RESULTS: The wound contraction and fluid removal increased gradually with increasing levels of negative pressure until reaching a steady state. Maximum wound contraction was observed at -75 mmHg. When NPWT was discontinued, after 72 hours of therapy, the wound surface area was smaller than before therapy. Maximum wound fluid removal was observed at -125 mmHg. Higher pressures did not further reduce wound surface area or fluid volume. The time required for evacuation of 50% of the maximal fluid drained for a specific pressure level was longer for low negative pressures (∼45 s for pressures below -50 mmHg) than for high negative pressures (∼15-20 s for pressures above -50 mmHg). CONCLUSIONS: NPWT facilitates drainage of wound fluid and exudates and results in mechanical deformation of the wound edge tissue which is known to stimulate granulation tissue formation. Maximum wound contraction is achieved already at -75 mmHg, and this may be a suitable pressure for most wounds. In wounds with large volumes of exudate, higher pressure levels may be needed for the initial treatment period.
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| 5. |
- Borgquist, Ola, et al.
(författare)
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Wound edge microvascular blood flow during negative-pressure wound therapy: examining the effects of pressures from -10 to -175 mmHg.
- 2010
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Ingår i: Plastic and Reconstructive Surgery. - 0032-1052. ; 125:2, s. 502-509
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Negative-pressure wound therapy is believed to accelerate wound healing by altered wound edge microvascular blood flow. The current standard negative pressure is -125 mmHg. However, this pressure may cause pain and ischemia and often has to be reduced. The aim of the present study was to examine the blood flow effects of different levels of negative pressures (-10 to -175 mmHg). METHODS: Wound edge microvascular blood flow was studied in a peripheral wound model in eight 70-kg pigs on application of negative-pressure wound therapy. Blood flow was examined, using laser Doppler velocimetry, in subcutaneous and muscle tissue at 0.5, 2.5, and 5 cm from the wound edge. RESULTS: Blood flow changed gradually with increasing negative pressure until reaching a steady state. Blood flow decreased close to the wound edge (0.5 cm) and increased farther from the wound edge (2.5 cm). At 0.5 cm, blood flow decreased 15 percent at -10 mmHg, 64 percent at -45 mmHg, and 97 percent at -80 mmHg. At 2.5 cm, blood flow increased 6 percent at -10 mmHg, 32 percent at -45 mmHg, and 90 percent at -80 mmHg. Higher levels of negative pressure did not have additional blood flow effects (p > 0.30). No blood flow effects were seen 5 cm from the wound edge. CONCLUSIONS: Blood flow changes gradually when the negative pressure is increased. The levels of pressure for negative-pressure wound therapy may be tailored depending on the wound type and tissue composition, and this study implies that -80 mmHg has similar blood flow effects as the clinical standard, -125 mmHg.
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| 6. |
- Chubb, Daniel, et al.
(författare)
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The Efficacy of Clinical Assessment in the Postoperative Monitoring of Free Flaps : A Review of 1140 Consecutive Cases
- 2010
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Ingår i: Plastic and reconstructive surgery (1963). - 0032-1052 .- 1529-4242. ; 125:4, s. 1157-1166
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Tidskriftsartikel (refereegranskat)abstract
- Background: Effective postoperative monitoring of the vascular pedicle to a free flap can potentiate rapid return to the operating room in the setting of compromise, allowing for the potential to salvage the flap. The only ubiquitous method for postoperative monitoring of free flaps is clinical bedside monitoring, but although the use of clinical monitoring may be inferred in large reported series of free flaps, there has been little discussed in the literature of specific clinical outcome measures. Methods: The authors present their experience with 1140 consecutive cases of free tissue transfer and the use of clinical monitoring as a sole method of monitoring, and subgroup analysis of different recipient sites. Results: There were 94 take-backs, four of which had no pedicle compromise (false-positives) and there were four false-negatives. The overall flap salvage rate was 62.8 percent and the false-positive rate was 0.4 percent. Subgroup analyses demonstrated statistically significant differences between recipient sites for the false-positive rates: fewer false-positives with breast reconstruction cases (p < 0.05) and significantly more false-positives in the extremity group (p < 0.05). There was an improved flap salvage rate in cases of venous compromise compared with arterial compromise (69 percent versus 51 percent, p = 0.015). Conclusions: This largest reported series to date provides an outcome-based analysis of postoperative monitoring for free flaps, providing a benchmark standard against which adjunctive monitoring techniques can be compared. Future studies need to be assessed in the context of individual recipient sites, with significant differences in monitoring outcomes between sites.
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| 7. |
- Docherty-Skogh, Ann-Charlott, et al.
(författare)
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Bone morphogenetic protein-2 delivered by hyaluronan-based hydrogel induces massive bone formation and healing of cranial defects in minipigs
- 2010
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Ingår i: Plastic and reconstructive surgery (1963). - 0032-1052 .- 1529-4242. ; 125:5, s. 1383-1392
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Tidskriftsartikel (refereegranskat)abstract
- Background: Reconstruction of large craniofacial bone defects is a challenge using bone transplants or alloplastic materials. The use of bone morphogenetic protein (BMP)-2 together with a suitable carrier is an attractive option that may facilitate new bone formation. The authors have developed a hydrogel that is formed in situ by the cross-linking of multifunctional hyaluronic acid and polyvinyl alcohol derivatives mixed with hydroxyapatite nanoparticles, in the presence of BMP-2. The aim of this study was to evaluate the suitability of the hydrogel as a carrier for BMP-2 in repairing critical size cranial defects in a minipig model. Methods: Cranial defects (2 × 4 cm) were created in 14 minipigs. The experimental groups were as follows: group 1, craniotomy and application of 5 ml of hydrogel with 1.25 mg of BMP-2 (n = 6); group 2, craniotomy and application of 5 ml of hydrogel without BMP-2 (n = 6); and group 3, craniotomy with no further treatment (n = 2). Results: After 3 months, computed tomographic and histologic examinations were performed. There was spontaneous ossification in the untreated group, but the healing was incomplete. The hydrogel alone demonstrated no further effects. The addition of 1.25 mg of BMP-2 to the hydrogel induced a greater than 100 percent increase in bone volume (p = 0.003) and complete healing of the defects. Histologic examination revealed compact lamellar bone in the BMP group without intertrabecular fibrous tissue, as was seen in the other groups. The hydrogel was resorbed completely within 3 months and, importantly, caused no inflammatory reaction. Conclusion: The injectable hydrogel may be favorable as a BMP-2 carrier for bone reconstruction.
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| 8. |
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| 9. |
- Hagert, Elisabet, et al.
(författare)
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Upper extremity nerve entrapments: the axillary and radial nerves - clinical diagnosis and surgical treatment.
- 2014
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Ingår i: Plastic and Reconstructive Surgery. - 0032-1052 .- 1529-4242. ; 134:1, s. 71-80
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Tidskriftsartikel (refereegranskat)abstract
- Non-traumatic pain in the shoulder, arm and hand (brachialgia) is a common complaint in the field of musculoskeletal disorders, where nerve entrapment constitutes a possible cause. The effect of nerve compression is dose-dependent; hence a low-level compression will only result in decreased endoneurial circulation, neural edema and a Seddon's grade-IV weakness, but won't be revealed in nerve conduction or magnetic resonance imaging studies. Due to technical limitations, several clinical options to diagnose compression neuropathies in the upper extremity have been proposed. These include blinded-controlled studies on manual muscle testing to delineate level of nerve compression, and scratch-collapse test (SCT) to verify the level of compression. In this manuscript, we describe the clinical examination and surgical techniques to diagnose and treat entrapments of the axillary and radial nerves.
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| 10. |
- Huisstede, Bionka M A, et al.
(författare)
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Dupuytren disease : european hand surgeons, hand therapists, and physical medicine and rehabilitation physicians agree on a multidisciplinary treatment guideline: results from the HANDGUIDE Study
- 2013
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Ingår i: Plastic and reconstructive surgery (1963). - : Ovid Technologies (Wolters Kluwer Health). - 0032-1052 .- 1529-4242. ; 132:6, s. 964e-976e
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND:Multidisciplinary treatment guidelines for Dupuytren disease can aid in optimizing the quality of care for patients with this disorder. Therefore, this study aimed to achieve consensus on a multidisciplinary treatment guideline for Dupuytren disease.METHODS:A European Delphi consensus strategy was initiated. A systematic review reporting on the effectiveness of interventions was conducted and used as an evidence-based starting point for this study. In total, 39 experts (hand surgeons, hand therapists, and physical medicine and rehabilitation physicians) participated in the Delphi consensus strategy. Each Delphi round consisted of a questionnaire, an analysis, and a feedback report.RESULTS:After four Delphi rounds, consensus was achieved on the description, symptoms, and diagnosis of Dupuytren disease. No nonsurgical interventions were included in the guideline. Needle and open fasciotomy, and a limited fasciectomy and dermofasciectomy, were seen as suitable surgical techniques for Dupuytren disease. Factors relevant for choosing one of these surgical techniques were identified and divided into patient-related (age, comorbidity), disease-related (palpable cord, previous surgery in the same area, skin involvement, time of recovery, recurrences), and surgeon-related (years of experience) factors. Associations of these factors with the choice of a specific surgical technique were reported in the guideline. Postsurgical rehabilitation should always include instructions and exercise therapy; postsurgical splinting should be performed on indication. Relevant details for the use of surgical and postsurgical interventions were described.CONCLUSION:This treatment guideline is likely to promote further discussion on related clinical and scientific issues and may therefore contribute to better treatment of patients with Dupuytren disease.
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| 11. |
- Pejler, Gunnar
(författare)
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The Role of Mouse Mast Cell Proteases in the Proliferative Phase of Wound Healing in Microdeformational Wound Therapy
- 2014
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Ingår i: Plastic and Reconstructive Surgery. - 0032-1052 .- 1529-4242. ; 134, s. 459-467
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Tidskriftsartikel (refereegranskat)abstract
- Background: Stored in the secretory granules of cutaneous mouse mast cells are mouse mast cell proteases (mMCP-4, -5, and -6). Using transgenic mouse lines that lacked these enzymes, it was shown that mMCP-4 and mMCP-5 modulate the outcome of burn-induced skin injury. Whether or not these proteases also play a role in the repair of surgically damaged skin, with or without microdeformational wound therapy, remains to be determined.Methods: Wild-type C57BL/6 mice and transgenic C57BL/6 mouse lines lacking mMCP-4, -5, or -6 were subjected to surgical wounding of their skin. Wounds were splinted with a stabilizing patch, and the mice received either microdeformational wound therapy (n = 5) or occlusive dressing (n = 5) for 7 days. Wound healing parameters were assessed in the proliferative phase.Results: Cell proliferation in the wounded wild-type mice receiving microdeformational wound therapy was 60 +/- 3 percent. Cell proliferation was only 35 +/- 5 percent, 25 +/- 5 percent, and 45 +/- 4 percent for the treated mMCP-4, mMCP-5, and mMCP-6 null mice, respectively (p = 0.005). Blood vessel sprouting was higher in the control mice with microdeformational wound therapy (170 +/- 40 vessels/high-power field) compared with mouse mast cell protease 6 null mice with microdeformational wound therapy (70 +/- 20 vessels/high-power field; p = 0.005), and higher in the control mice with occlusive dressing (110 +/- 30 vessels/high-power field) compared with mMCP-4 null mice with occlusive dressing (50 +/- 20 vessels/high-power field; p = 0.01). Qualitatively, the granulation tissue of all the protease-deficient groups receiving microdefoimational wound therapy was disrupted.Conclusion: Results suggest that mouse mast cell proteases 4, 5, and 6 are mediators of the critical role mast cells play in microdefoi national wound therapy in the proliferative phase of healing.
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| 12. |
- Rodriguez Lorenzo, Andres, et al.
(författare)
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Comparative study of single-, double-, and triple-nerve transfer to a common target : experimental study of rat brachial plexus
- 2011
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Ingår i: Plastic and reconstructive surgery (1963). - 0032-1052 .- 1529-4242. ; 127:3, s. 1155-1162
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND:The purpose of this study was to investigate the recovery of a common target motor function after different single and combined motor nerve transfers in rat brachial plexus model.METHODS:The musculocutaneous nerve and biceps muscle were chosen as the target for neurotization. The phrenic, pectoral, and suprascapular nerves were selected as the neurotizers. Forty-two Sprague-Dawley rats were randomly assigned to seven groups (six rats in each group): single-neurotizer transfer (three groups), double-neurotizer transfer (three groups), and triple-neurotizer transfer (one group). The contralateral intact forelimb was used as a control. Functional outcomes were measured by grooming test, electrophysiological study, muscle contraction strength, muscle weight, and axon counts.RESULTS:At 12 weeks, 40 operative rats were studied (two had died). In the single-neurotizer transfer, all three transfers showed no significant difference in motor recovery of the biceps. In the double-neurotizer transfer groups, the worst results were seen in group 6 (combined pectoral and suprascapular nerve transfer) despite increasing axon counts.CONCLUSIONS:This study may potentially suggest: (1) single-neurotizer transfer will not have synergistic or antagonistic effects; (2) two neurotizers with functional antagonism will significantly downgrade motor recovery of the neurotized muscle despite increasing axon counts; (3) multiple motor neurotizer transfers may not always provide a better outcome, although increasing axons may outweigh antagonistic effects; and (4) phrenic nerve transfer alone did not upgrade the functional outcome despite its automatic discharge. Any nerve transfer combined with phrenic nerve transfer, however, showed improved functional results.
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| 13. |
- Rozen, Shai, et al.
(författare)
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Obturator Nerve Anatomy and Relevance to One-Stage Facial Reanimation : Limitations of a Retroperitoneal Approach
- 2013
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Ingår i: Plastic and reconstructive surgery (1963). - 0032-1052 .- 1529-4242. ; 131:5, s. 1057-1064
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Tidskriftsartikel (refereegranskat)abstract
- Background: Single-stage facial reanimation with a partial gracilis muscle coapted to the contralateral facial nerve seems an optimal surgical solution yet has not supplanted the two-stage approach. Insufficient obturator nerve length may limit reach to sizable contralateral facial nerve branches (possibly necessitating interposition nerve grafting), compromise optimal muscle positioning, or risk nerve coaptation under tension. This study evaluates whether retroperitoneal obturator nerve dissection would effectively lengthen the nerve, thus obviating the aforementioned limitations. Methods: Ten hemifaces and obturator nerves of five cadavers were dissected. Facial measurements included modiolus to contralateral facial nerve branches of sufficient size at the vertical line of the lateral orbital rim. Obturator nerve measurements included gracilis neurovascular hilum to (1) obturator canal entry point (ab), (2) intraobturator canal point where additional adductor branches are inseparable by internal neurolysis (ac), and (3) retroperitoneal point of separation between anterior and posterior obturator branches (ad). Obturator nerve reach for cross-facial nerve coaptation was assessed. Results: Successful coaptation was achieved with obturator nerve dissection to point b approximately 20 percent of the time, to point c 60 to 70 percent of the time, and to retroperitoneal point d 90 to 100 percent of the time Conclusions: Successful coaptation to large contralateral facial nerve branches is feasible in 90 to 100 percent of cases if the entire anterior obturator branch is harvested. However, the increased risk of retroperitoneal dissection and sacrifice of additional adductor branches decreases the viability of this approach. Obturator canal dissection (point c) provides reach in 60 to 70 percent of cases, but short interposition nerve grafting may prove necessary.
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| 14. |
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| 15. |
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| 16. |
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| 17. |
- Smit, Jeroen M., et al.
(författare)
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Advancements in Free Flap Monitoring in the Last Decade : A Critical Review
- 2010
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Ingår i: Plastic and reconstructive surgery (1963). - 0032-1052 .- 1529-4242. ; 125:1, s. 177-185
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Forskningsöversikt (refereegranskat)abstract
- Background: The authors conducted a review of the recent literature on the monitoring of free flaps to create an overview of the current monitoring devices and their potential as an ideal monitoring method. Methods: A literature-based study was conducted using the PubMed and Cochrane databases. The following search terms were used: "flap" and "monitoring." All monitoring methods found between January of 1999 and January of 2009 were evaluated. Monitoring methods that were described in five or more clinical reports were further investigated. Results: The advantages and disadvantages of conventional monitoring methods, the implantable Doppler system, color duplex sonography, near-infrared spectroscopy, microdialysis, and laser Doppler flowmetry are presented. Furthermore, an overview is given of their potential as ideal monitoring method. Conclusions: The implantable Doppler system, near-infrared spectroscopy, and laser Doppler flowmetry appear to be the best monitoring devices currently available. As most of the publications on monitoring have focused on the reliability of the systems, future research should also address their cost efficiency.
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| 18. |
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| 19. |
- Smit, Jeroen M., et al.
(författare)
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Introduction of the Implantable Doppler System Did Not Lead to an Increased Salvage Rate of Compromised Flaps : A Multivariate Analysis
- 2010
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Ingår i: Plastic and reconstructive surgery (1963). - 0032-1052 .- 1529-4242. ; 125:6, s. 1710-1717
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Tidskriftsartikel (refereegranskat)abstract
- Background: The Cook-Swartz implantable Doppler system was introduced at the Uppsala University Hospital to ease free flap monitoring and improve salvage rates by an earlier detection of vascular compromise. The aim of the current analysis was to investigate whether the system indeed improved the salvage rate of revisions. Methods: All cases that needed revision among a consecutive series of patients being monitored with the implantable Doppler system between June of 2006 and January of 2009 were compared with a similar set of patients operated on before the introduction of the implantable Doppler system over an equal time span monitored with conventional methods. Data were extracted from the medical files of the patients. Logistic regression was used to identify factors associated with the outcome of the revision. Values of p < 0.05 were considered statistically significant. Results: A total of 327 flaps were monitored with the implantable Doppler system, of which 35 needed revision. In the control group, 303 flaps were included, of which 40 needed revision. The revision was successful in 69 percent of the cases in the implantable Doppler system group; in the group monitored by only conventional methods, this rate was 60 percent. Univariate analysis showed no statistical difference between these success rates (p = 0.441; odds ratio, 1.455; 95 percent confidence interval, 0.560 to 3.775). Multivariate analysis did not show a statistical difference either (p = 0.799; odds ratio, 1.143; 95 percent confidence interval, 0.410 to 3.182). Conclusion: The introduction of the implantable Doppler system did not lead to a significant increase in the salvage rate of revised flaps.
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| 20. |
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| 21. |
- Staalesen, Trude, 1974, et al.
(författare)
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Development of excess skin and request for body-contouring surgery in postbariatric adolescents.
- 2014
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Ingår i: Plastic and reconstructive surgery. - 1529-4242 .- 0032-1052. ; 134:4, s. 627-36
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Tidskriftsartikel (refereegranskat)abstract
- Background: Little is known about the development of excess skin and requests for body-contouring surgery after bariatric surgery in adolescents. Methods: Forty-seven of 86 adolescents that had undergone gastric bypass surgery answered two questionnaires regarding excess skin and requests for and performed body-contouring surgery. An objective assessment of the amount of excess skin was also performed. The results were compared to earlier results from postbariatric adults. Results: The most common overall problem in adolescents was the feeling of having an unattractive body (91 percent). The most common locations for developing excess skin were the upper arms and thighs according to the measurements. Five of 47 adolescents had undergone body-contouring surgery, and 88 percent of the others desired one or more body-contouring operations. Correlations were found between the objectively measured excess skin and the subjectively experienced amount of excess skin. Correlations were also found between the measured excess skin and the experienced discomfort of excess skin for the abdomen, breast/chest, upper arms, and chin. Conclusions: The authors’ results indicate that bariatric surgery in adolescents often leads to severe problems associated with excess skin in both sexes. Thus, the commonly held belief that young people do not develop excess skin to the same extent as adults is strongly questioned. Health care professionals must address the current imbalance between requests for and the performance of body-contouring surgery in adolescents.
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| 22. |
- Yafi, Amr, et al.
(författare)
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Postoperative Quantitative Assessment of Reconstructive Tissue Status in a Cutaneous Flap Model Using Spatial Frequency Domain Imaging
- 2011
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Ingår i: Plastic and reconstructive surgery (1963). - : Ovid Technologies (Wolters Kluwer Health). - 0032-1052 .- 1529-4242. ; 127:1, s. 117-130
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Tidskriftsartikel (refereegranskat)abstract
- Background:The purpose of this study was to investigate the capabilities of a novel optical wide-field imaging technology known as spatial frequency domain imaging to quantitatively assess reconstructive tissue status.Methods:Twenty-two cutaneous pedicle flaps were created on 11 rats based on the inferior epigastric vessels. After baseline measurement, all flaps underwent vascular ischemia, induced by clamping the supporting vessels for 2 hours (either arteriovenous or selective venous occlusions); normal saline was injected into the control flap and hypertonic-hyperoncotic saline solution was injected into the experimental flap. Flaps were monitored for 2 hours after reperfusion. The spatial frequency domain imaging system was used for quantitative assessment of flap status over the duration of the experiment.Results:All flaps demonstrated a significant decline in oxyhemoglobin and tissue oxygen saturation in response to occlusion. Total hemoglobin and deoxyhemoglobin were increased markedly in the selective venous occlusion group. After reperfusion and the administration of solutions, oxyhemoglobin and tissue oxygen saturation in those flaps that survived gradually returned to baseline levels. However, flaps for which oxyhemoglobin and tissue oxygen saturation did not show any signs of recovery appeared to be compromised and eventually became necrotic within 24 to 48 hours in both occlusion groups.Conclusions:Spatial frequency domain imaging technology provides a quantitative, objective method of assessing tissue status. This study demonstrates the potential of this optical technology to assess tissue perfusion in a very precise and quantitative way, enabling wide-field visualization of physiologic parameters. The results of this study suggest that spatial frequency domain imaging may provide a means for prospectively identifying dysfunctional flaps well in advance of failure.
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