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This study aimed to determine the association between the echogenicity of Dupuytren’s disease nodules and myofibroblast load, and between echogenicity and nodule hardness. Thirty-eight nodules were assessed sonographically. The echogenicity of nodules was measured objectively with Image J (grey-value) and subjectively by visual inspection (hypo-, mixed and hyper-echogenicity). These findings were compared with myofibroblast load measured by histopathological analysis. In a different cohort, 97 nodules were assessed for grey-value and nodule hardness using a tonometer. There was a moderate, significant, negative association between grey-value and myofibroblast load and the subjective visual measurements corresponded to this finding. There was also a moderate, significant, negative association between grey-value and nodule hardness. Ultrasound and tonometry may be useful in the selection of patients for possible future preventive treatments.

Item does not contain fulltext INTRODUCTION: Facial function correlates with quality of life in facial palsy. Previous studies have examined a linear relationship; based on clinical experience, we hypothesize a curved regression (i.e. quadratic or cubic) will be more fitting to show the correlation between quality of life and facial function. METHODS: We compared the fit of a linear regression model between Sunnybrook scores (facial function) and FaCE and FDI scores (quality of life) to a quadratic and cubic regression model in 125 patients cross-sectionally. RESULTS: A total of 125 patients were included, 53.6% female with a mean (standard deviation) age of 56.6 (16.7) and a median (interquartile range) duration of palsy of 6.6 (1.5; 18.3) years. The quadratic regression proved a significant improvement over a linear regression analysis in the model using the FaCE total score (linear R(2) =.346, quadratic R(2) = .378, p = .033) and the FDI physical score (linear R(2) = .245, quadratic R(2) =.276, p = .034). The cubic regression analysis was no significant improvement over a quadratic regression. DISCUSSION: The relationship between facial function and quality of life in facial palsy is not linear meaning that there is a lot of variation in QoL in cases with severe and moderate facial impairment. This is most applicable to patients suffering from post-paralysis synkinesis, proving the highly individually experienced burden of synkinesis. As the relationship is not linear it should not be included as such in future research studies.

Dupuytren’s disease is a chronic, progressive fibroproliferative condition of the hand fascia which results in digital contraction. So far, treatments do not directly interfere with the (myo)fibroblasts that are responsible for the formation of the collagen-rich cords and its contraction. Here we investigated whether verteporfin (VP) is able to inhibit the activation and subsequent differentiation of DD nodular fibroblasts into myofibroblasts. Fibroblasts were isolated from nodules of 7 Dupuytren patients. Cells are treated (1) for 48 h with 5 ng/ml transforming growth factor β1 (TGF-β1) followed by 48 h with/without 250 nM VP in the absence of TGF-β1, or treated (2) for 48 h with TGF-β1 followed by 48 h with/without VP in the presence of TGF-β1. mRNA levels were measured by means of Real-Time PCR, and proteins were visualized by means of Western blotting and/or immunofluorescence. Quantitative data were statistically analyzed with GraphPad Prism using the paired t-test. We found that fibroblasts activated for 48 h with TGF-β1 show a decrease in mRNA levels of COL1A1, COL3A1, COL4A1, PLOD2, FN1EDA, CCN2 and SERPINE1 when exposed for another 48 h with VP, whereas no decrease is seen for ACTA2, YAP1, SMAD2 and SMAD3 mRNA levels. Cells exposed for an additional 48 h with TGF-β1, but now in the presence of VP, are not further activated anymore, whereas in the absence of VP the cells continue to differentiate into myofibroblasts. Collagen type I, fibronectin-extra domain A, α-smooth muscle actin, YAP1, Smad2 and Smad3 protein levels were attenuated by both VP treatments. We conclude that VP has strong anti-fibrotic properties: it is able to halt the differentiation of fibroblasts into myofibroblasts, and is also able to reverse the activation status of fibroblasts. The decreased protein levels of YAP1, Smad2 and Smad3 in the presence of VP explain in part the strong anti-fibrotic properties of VP. Verteporfin is clinically used as a photosensitizer for photodynamic therapy to eliminate abnormal blood vessels in the eye to attenuate macular degeneration. The antifibrotic properties of VP do not rely on photo-activation, as we used the molecule in its non-photoinduced state.

BackgroundLotus petal flaps (LPF) may be used for the reconstruction of extralevator abdominoperineal defects that cannot be closed primarily. Limited data are available on how perineal reconstruction with the LPF impacts on patients’ quality of life (QoL), sexual functioning, and physical functioning.MethodsA cross-sectional study was performed following perineal reconstruction with the LPF. The QoL of patients having undergone LPF reconstruction was compared with a control group in which perineal defects were closed without flaps. Sexual and physical functioning (presence of perineal herniation and range of motion [ROM] of the hip joints) could only be evaluated in the LPF group. Psychometrically sound questionnaires were used. Physical functioning was evaluated subjectively with binary questions and objectively by physical examination.ResultsOf the 23 patients asked to participate, 15 (65%) completed the questionnaires and 11 (47%) underwent physical examination. In the control group, 16 patients were included. There were no significant differences in QoL between the LPF and control groups. Within the LPF group, 33% of patients were sexually active postoperatively compared with 87% preoperatively. No perineal herniation was found. The ROM of the hip joints was bilaterally smaller compared with the generally accepted values.ConclusionsConclusions should be made with care given the small sample size. Despite a supposedly larger resection area in the LPF group, QoL was comparable in both groups. Nonetheless, reconstruction seemed to affect sexual function and physical function, not hampering overall satisfaction.

Background: Predicting progression of Dupuytren disease becomes relevant in an upcoming era with progression-preventing treatment. This study aimed to determine the course of Dupuytren disease and identify factors associated with progression. Methods: Two hundred fifty-eight patients with Dupuytren disease participated in this prospective cohort study, obtaining 17,645 observations in 5 years. Outcomes were disease extent (surface area) and contracture severity (total passive extension deficit). Demographics, lifestyle, health status, exposure to manual work, and genetic risk scores were gathered as potential predictors. Subject-specific, mixed-effects models were used to estimate disease course, and logistic regression with least absolute shrinkage and selection operator was used to evaluate factors associated with the presence of progression. Results: On average, Dupuytren disease was progressive in all finger rays with regard to area [yearly increase, 0.07 cm(2) (95% CI, 0.02 to 0.13 cm(2)) to 0.25 cm(2) (95% CI, 0.11 to 0.39 cm(2))]. Progression in total passive extension deficit was only present on the small finger side [yearly increase, 1.75 degrees (95% CI, 0.30 to 3.20 degrees) to 6.25 degrees (95% CI, 2.81 to 9.69 degrees)]. Stability or regression in area and total passive extension deficit was observed in 11 and 13 percent and 16 and 15 percent (dominant and nondominant hands), respectively. Smoking, cancer, genetic risk score, and hand injury were univariate associated with progression in area, but after multivariate variable selection, none of these associations remained. No predictors for progression in total passive extension deficit were found. Conclusions: Dupuytren disease is progressive, especially with respect to disease extent. Progression in contracture severity is mainly present on the small finger side of the hand. None of the traditional risk and diathesis factors were associated with progression, indicating that new hypotheses about Dupuytren disease progression might be needed.

Background Vulvoperineal defects resulting from surgical treatment of (pre)malignancies may result in reconstructive challenges. The vertical rectus abdominis muscle flap and, more recently, the fasciocutaneous lotus petal flap are often used for reconstruction in this area. The goal of this review is to compare the postoperative complications of application of these flaps.Methods:A comprehensive literature search of the PubMed, MEDLINE and Cochrane Library databases was performed until 6 June 2020. Search terms included the lotus petal flap, vertical rectus abdominis muscle flap and the vulvoperineal area. Articles were independently screened by two researchers according to the PRISMA-guidelines.Results:A total of 1074 citations were retrieved and reviewed, of which 55 were included for full text analysis. Following lotus petal flap reconstructions, the complication rate varied from 0.0% to 69.9%, with more complications concerning the recipient site compared with the donor site complications (26.0% versus 4.5%). Following vertical rectus abdominis muscle flap reconstructions the complication rate varied between 0.0% and 85.7% with almost twice the number of recipient site complications compared to donor site complications (37.1% versus 17.8%).Conclusions:Overall, the lotus petal flap has lower complication rates at both the donor and the recipient site compared with the vertical rectus abdominis muscle flap. When both options seem viable, the lotus petal flap procedure may be preferred on the basis of the reported lower complication rates.

Importance Understanding how the quality of life of adults (≥18 years) with peripheral facial palsy can be estimated using clinician measures of facial function and patient-reported variables might aid in counseling patients and in conducting research. Objectives To analyze associations between clinician-graded facial function and patient-reported quality of life in adults with peripheral facial palsy, compare associations between facial function and the physical and social functions of quality of life, and examine factors that might influence the associations. Data Sources A literature search was conducted in PubMed, Embase, CINAHL, Web of Science and PsycInfo on June 4, 2020, with no restrictions on the start date. Study Selection Twenty-three studies reporting an association between clinician-graded facial function and patient-reported quality of life in adults with peripheral facial palsy were included. Facial function instruments included the House-Brackmann, Sunnybrook Facial Grading System, and electronic clinician-graded facial function assessment. Quality-of-life instruments included the Facial Disability Index and Facial Clinimetric Evaluation Scale. Data Extraction and Synthesis Data extraction and qualitative synthesis were performed according to the Meta-analysis of Observational Studies in Epidemiology guidelines. Record screening, data extraction, and quality assessments were done by 2 researchers independently. Data were pooled using random-effects models. Main Outcomes and Measures The main outcome was the association between facial function and quality of life, quantified by Pearsonr, Spearman ρ, or regression analysis. Results In total, 23 studies (3746 participants) were included. In the 21 studies that reported on the sex of the cohorts, there were 2073 women (57.3%). Mean or median age ranged from 21 to 64 years and mean or median duration of palsy ranged from newly diagnosed to 12 years. Bell palsy (n = 1397), benign tumor (n = 980), and infection (n = 257) were the most common etiologic factors. Pooled correlation coefficients were 0.424 (95% CI, 0.375-0.471) to 0.533 (95% CI, 0.447-0.610) between facial function and Facial Clinimetric Evaluation Scale total, 0.324 (95% CI, 0.128-0.495) to 0.397 (95% CI, 0.242-0.532) between facial function and Facial Clinimetric Evaluation Scale social function, 0.423 (95% CI, 0.322-0.514) to 0.605 (95% CI, −0.124-0.910) between facial function and Facial Disability Index physical function, and 0.166 (95% CI, 0.044-0.283) to 0.208 (95% CI, 0.031-0.373) between facial function and Facial Disability Index social function. Conclusions and Relevance Associations noted in this systematic review and meta-analysis were overall low to moderate, suggesting that only a small part of quality of life is explained by facial function. Associations were higher between facial function and physical function than social function of quality of life.

Dupuytren disease (DD), a fibroproliferative disorder of the palmar fascia that causes flexion contractures in the fingers, is prevalent in people of North-Western European descent and less so in other ethnicities. DD is a complex disorder, influenced by genetic risk variants. We aimed to study if the marked differences in prevalences in DD between ethnic (sub)groups could be explained by differences in allele frequencies of the 26 known genetic risk variants of DD. Therefore, genetic risk scores (GRS) composed of the 26 DD risk variants were calculated for the 26 populations from the 1000 Genomes database and correlated to observed DD prevalences from literature. For comparison, GRSs were generated for 10,000 sets of 26 random SNPs and also correlated to the observed DD prevalences to determine the significance of the observed correlation. To determine whether differences in allele frequencies between ethnicities were caused by natural selection, fixation indices (Fst) were calculated from the 26 SNPs and from the sets of 26 random SNPs for comparison. Observed prevalences could be determined from literature for 10 populations. Their correlation with the GRS composed of DD SNPs proved to be 0.60 (p = 0.0003). The Fsts between British and other populations were low for European, ad mixed American, and South-Asian populations, and moderate for East-Asians. African populations were significantly different from expected values determined from the random sets. In conclusion, the 26 known genetic risk variants associated with DD explain for a substantial part (R-2 = 0.36) the differing DD prevalences observed between ethnicities.

KEY POINTS: Synkinesis can decrease quality of life in facial palsy patients. Patient-perceived severity of synkinesis may be of additional value in predicting facial palsy related-quality of life. We analyzed the additional value of the SAQ total score (perceived severity of synkinesis) in predicting FaCE total scores (quality of life) in 92 patients cross-sectionally. SAQ total score accounted for a relatively large improvement in the prediction of FaCE total scores (R2 change = 0.113, total R2 = 0.428). Patient-perceived severity synkinesis should be included in clinical management and studies of synkinesis. This article is protected by copyright. All rights reserved.

Objectives/Interrogation: Activity of Dupuytren nodules may be measured with ultrasound. It has been suggested that early nodules appear hypo-echogenic, whereas older nodules appear iso- to hyper-echogenic. The aim of this study was to analyse whether echogenicity of Dupuytren nodules can be used[for full text, please go to the a.m. URL], 14th Triennial Congress of the International Federation of Societies for Surgery of the Hand (IFSSH), 11th Triennial Congress of the International Federation of Societies for Hand Therapy (IFSHT), 11th Triennial Congress of the International Federation of Societies for Hand Therapy (IFSHT)

Background and Aims:The aim of this study was to evaluate the effect of smoking and body mass index on the occurrence of complications after alloplastic breast reconstruction.Materials and Methods:A consecutive series of 56 patients treated with immediate or delayed alloplastic breast reconstruction, including six cases combined with latissimus dorsi flap, at three hospitals between 2012 and 2018 were included. Complications were scored and defined according to Clavien–Dindo. To evaluate the impact of smoking, body mass index, and other potential risk factors on the occurrence of any and severe complications, univariate and multivariate logistic regression analyses were applied to estimate odds ratios and 95% confidence intervals.Results:In 56 patients, 22 patients had a complication. As much as 46% of smokers had severe complications compared to 18% of non-smokers. Of patients with body mass index ⩾ 25, 40% had severe complications compared to 10% with body mass index adjusted = 8.0, p = 0.02). Patients with body mass index ⩾ 25 had almost 10 times more severe complications compared to patients with body mass index ⩽ 25 (ORadjusted = 9.9, p = 0.009). No other risk factors were significant.Conclusion:Smoking and body mass index ⩾ 25 both increased the complication rate to such an extent that patients should be informed about their increased risk for complications following alloplastic breast reconstruction and on these grounds surgeons may delay alloplastic breast reconstruction. It is an ethical dilemma whether one should deny overweight and obese patients and those who smoke an immediate alloplastic breast reconstruction. For both life style interventions, adequate guidance should be made available.

BACKGROUND: Literature suggests that patient-informing process prior to obtaining surgical informed consent (SIC) does not function well. This study aimed to provide insight into the current practice of SIC in the Netherlands.METHODS: This is a prospective, observational, and multicenter study, conducted in one academic and two non-academic teaching hospitals in the Netherlands. Audio recordings were made during outpatient consultations with patients presenting with Dupuytren Disease. The recorded informing process was scored according to a checklist. Written documentation of the SIC process in the patient's chart was compared to these scored checklists. Time spent on SIC during the consultations was also recorded.RESULTS: A total of 41 outpatient consultations were included in the study. Consultations were conducted by 25 plastic surgeons and their residents. Average time spent on SIC was 55.6% of the total consultation time. Considerable variation was observed concerning the amount and type of information given and discussed. In 59% of the consultations, discrepancies were observed between written documentation of consultations and audio recordings. Information on treatment risks, the postoperative period, and the operating surgeon was addressed the least.CONCLUSION: Despite a relatively large part of the consultation time being spent on SIC, patients received scarce information concerning treatment risks, postoperative period, and who their operating surgeon would be. Discrepancies were observed between the written documentation of SIC and information recorded on the audio recordings. This occurred predominantly in one hospital that used a pre-made list of 'discussed information' in its digital patient chart.

IMPORTANCE Study of the association of regional facial dysfunction with quality of life will lead to a better understanding of quality of life in facial palsy.OBJECTIVE To determine the association of regional facial dysfunction with facial palsy-related quality of life.DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort analysis included patients with flaccid and nonflaccid (synkinetic) facial palsy treated at a tertiary care facial nerve center; the flaccid facial palsy group included 529 patients, and the nonflaccid facial palsy group included 391 patients. Data were included from all patients with facial palsy who had an eFACE score and Facial Clinimetric Evaluation (FaCE) scale total score acquired at the same time from February 1, 2014, through October 31, 2017. Linear regression analysis was performed to calculate the amount of variance in quality of life explained by the severity of facial palsy (eFACE). A relative weight analysis was performed for the contribution of each individual eFACE item in estimating quality of life.MAIN OUTCOMES AND MEASURES Facial palsy severity was measured using all 15 individual eFACE items (rated on a scale of 0 to 200, where 0 represents complete flaccidity, 100 represents a balanced aesthetic appearance, and 200 represents the worst imaginable hypertonia of a patient with synkinesis, with a transformation used for values from 101 to 200), and facial palsy-related quality of life was measured using the FaCE scale total score (range, 0 [worst] to 100 [best]).RESULTS Data of 920 individual patients (59.5% female; mean [SD] age, 48.6 [16.6] years) were available. The eFACE composite score accounted for 21.2% of the quality-of-life variance in the flaccid group and 13.9% in the nonflaccid group. With the use of all 15 individual eFACE items, these proportions increased to 29.7% and 16.8%, respectively. In both groups, oral commissure movement with smile was found to be the most important contributing item (relative weight, 0.108 [95% CI, 0.075-0.148] for the flaccid group and 0.025 [95% CI, 0.005-0.052] for the nonflaccid group). Items related to the function of periocular muscles were found to be of low importance.CONCLUSIONS AND RELEVANCE The present study suggests that the function of individual facial regions is not equally important for estimating facial palsy-related quality of life. The ability to smile is of greatest importance among patients with flaccid and nonflaccid facial palsy. The true importance of periocular function in the estimation of quality of life should be studied further in future research.

With novel promising therapies potentially limiting progression of Dupuytren's disease (DD), better patient stratification is needed. We aimed to quantify DD development and progression after seven years in a population-based cohort, and to identify factors predictive of disease development or progression.All surviving participants from our previous prevalence study were invited to participate in the current prospective cohort study. Participants were examined for presence of DD and Iselin's classification was applied. They were asked to complete comprehensive questionnaires. Disease progression was defined as advancement to a further Iselin stage or surgery. Potential predictive factors were assessed using multivariable regression analyses. Of 763 participants in our original study, 398 were available for further investigation seven years later.We identified 143/398 (35.9%) participants with DD, of whom 56 (39.2%) were newly diagnosed. Overall, 20/93 (21.5%) previously affected participants had disease progression, while 6/93 (6.5%) patients showed disease regression. Disease progression occurred more often in patients who initially had advanced disease. Multivariable regression analyses revealed that both ectopic lesions and a positive family history of DD are independent predictors of disease progression. Previous hand injury predicts development of DD.Disease progression occurred in 21.5% of DD patients in our study. The higher the initial disease stage, the greater the proportion of participants who had disease progression at follow-up. Both ectopic lesions and a positive family history of DD predict disease progression. These patient-specific factors may be used to identify patients who might benefit from treatment that prevents progression. Cite this article

Layperson assessments are becoming increasingly important in the evaluation of surgical procedures of the face, including smile reanimation. In this study, the authors set out to answer 3 questions: (1) are esthetic scores more dependent on the assessor or the person that is being assessed, (2) how does smile reanimation change esthetic scores, (3) do sex and age of the patient and assessor explain some of the esthetic outcomes?Thirty-five assessors scored pre and postoperative photographs of 21 facial palsy patients undergoing smile reanimation. Linear mixed-effect models were used to investigate the effects of assessor and patient factors on esthetic outcome assessments, to examine changes after smile reanimation, and to determine whether sex and age explained part of the esthetic outcomes.Fifty-eight percent of variation in the esthetic scores can be explained by some assessors being more positive in their esthetic scoring compared to other assessors. Twenty-nine percent was attributed to patient baseline esthetic scores. Overall esthetic scores improved after smile reanimation. Sex and age of the patient and assessor could not explain variation in the esthetic scores.Esthetic appearance highly depends on "who is looking.'' These findings are important for preoperative counseling, and for those treating and educating patients with facial palsy.

Little is known about facial function assessments of inexperienced observers in facial palsy. In this observational study learning curve was examined of two inexperienced observers assessing facial function of 100 patients using the Sunnybrook Facial Grading System. Interobserver agreement gradually improved over time, stabilizing after approximately 70 assessments. Best agreement on the voluntary movement subscore was observed, followed by synkinesis and resting symmetry subscores. Inexperienced observers can perform facial function assessments in facial palsy, but should be adequately trained first.

Three-dimensional stereophotogrammetry is not much used in assessing facial palsy and a comprehensive understanding of sources of variation in these measurements is lacking. The present study assessed intra- and interobserver reliability of a novel three-dimensional stereophotogrammetry measurement of facial asymmetry and examined sources of variation in these outcomes. Three photographs (rest, closed mouth smile, and maximum smile) were made of 60 participants, 30 facial palsy patients and 30 control subjects. All images were analyzed twice by 2 observers independently, to determine intra- and interobserver reliability. Variance component analysis was performed to investigate sources of variation in the outcomes. Intraobserver reliability was good with intraclass correlation coefficients ranging from 0.715 to 0.999. Interobserver reliability ranged from 0.442 to 0.929. Reliability of the smile image measurements was not clearly different from the rest images. Variation in measurement results was largely due to the status of a participant, facial palsy versus control. When splitting the sample, the facial expression was a major source of variation. Acceptable reliability of the proposed 3D facial asymmetry measurement was found, in facial palsy patients and control subjects. Interobserver reliability was marked less compared to intraobserver reliability. For follow-up data only one observer should assess 3D stereophotogrammetry measurements.

Purpose: In the future, it is expected that treatment of Dupuytren disease (DD) may shift toward control of early disease. Ultrasound might be an accurate method to measure the outcome of such treatment. The aim of this study was to assess the reliability of sonographic measurement of palmar nodules. Methods: Fifty patients with nodules characteristic for early disease were assessed with ultrasound by 2 observers. Four different aspects of DD nodules were measured in the transversal and sagittal planes, width, depth, circumference, and area. The intra- and interobserver reliabilities were calculated using the intraclass correlation coefficient (ICC). The standard error of measurement (SEM) and the smallest detectable change (SDC) were also calculated for each aspect. Results: The intraobserver reliability was good (ICC, 0.724 [0.562–0.833] to 0.886 [0.808–0.934]), except for width in the sagittal direction (ICC, 0.671 [0.484–0.799]). The interobserver reliability was moderate (ICC, 0.385 [0.126–0.596] to 0.757 [0.538–0.869]). The intraobserver ICCs of area were highest (transverse, 0.847 [0.744–0.893]; sagittal, 0.886 [0.808–0.934]). The SEM and SDC of area were 6.1 and 16.9 mm2 in the transverse and 8.0 and 22.2 mm2 in the sagittal plane. Conclusions: The intraobserver reliability of sonographic assessment of DD nodules is good. The measurement of area is the most reliable and is, therefore, recommended for future studies. However, even single-observer measurements have a clear dispersion, and a change beyond 16.9 (61%) and 22.2 mm2 (79%) has to be observed in the transverse and sagittal planes, respectively, before it can be considered as regression or progression. Clinical relevance: Repeated ultrasonographic measurements in DD should ideally be done by a single observer, using area of the nodule in the sagittal plane. Change beyond 16.9 (transverse) and 22.2 (sagittal) mm2 can be considered as a real change in nodule size.

Background: This review aimed to meta-analyze the quality of life of alloplastic versus autologous breast reconstruction, when measured with the BREAST-Q. Methods: An electronic PubMed and EMBASE search was designed to find articles that compared alloplastic versus autologous breast reconstruction using the BREAST-Q. Studies that failed to present BREAST-Q scores and studies that did not compare alloplastic versus autologous breast reconstruction were excluded. Two authors independently extracted data from the included studies. A standardized data collection form was used. Quality was assessed using the Newcastle-Ottawa Scale. The mean difference and 95 percent confidence intervals between breast reconstruction means were estimated for each BREAST-Q subscale. Forest plots and the I2statistic were used to assess heterogeneity and funnel plot publication bias. The Z test was used to assess overall effects. Results: Two hundred eighty abstracts were found; 10 articles were included. Autologous breast reconstruction scored significantly higher in the five subscales than alloplastic breast reconstruction. The Satisfaction with Breasts subscale indicated the greatest difference, with a mean difference of 6.41 (95 percent CI, 3.58 to 9.24; I2= 70 percent). The Satisfaction with Results subscale displayed a mean difference of 5.52. The Sexual Well-Being subscale displayed a mean difference of 3.85. The Psychosocial Well-Being subscale displayed a mean difference of 2.64. The overall difference in physical well-being was significant, with high heterogeneity (mean difference, 3.33; 95 percent CI, 0.18 to 6.48; I2= 85). Conclusion: Autologous breast reconstruction had superior outcomes compared with alloplastic breast reconstruction as measured by the BREAST-Q.

BACKGROUND: Dupuytren, Peyronie, and Ledderhose diseases are related fibroproliferative disorders characterized by abnormalities in the connective tissue of the palm of the hand, the tunica albuginea of the penis, and the sole of the foot, respectively. Concomitant prevalence rates of these diseases have only been described in a few small populations. This article aims to report on a large population and to raise awareness in surgeons treating Dupuytren disease for concurring related fibroproliferative disorders.METHODS: Patients diagnosed as having Dupuytren disease were recruited from outpatient clinics in the northern part of the Netherlands from 2007 to 2016. Questionnaires concerning demographics, clinical characteristics, the coexistence of Ledderhose and/or Peyronie diseases, and other factors were filled in by the participants and by plastic surgeons.RESULTS: For 730 men with Dupuytren disease, the surgeons' reported prevalence rate of Peyronie disease was 7.8 percent and of Ledderhose disease was 16.1 percent. The participants themselves reported prevalence rates of 8.8 percent for Peyronie disease and of 22.0 percent for Ledderhose disease.CONCLUSIONS: In the Dupuytren patient cohort, the prevalence of Peyronie disease was lower than that described in the literature. The prevalence of Ledderhose disease corresponded with the rates from the literature. However, both were underreported by plastic surgeons, which calls for a rise in awareness, recognition, and referral to a urologist when the conditions are bothersome or symptomatic.

Purpose Patient-reported outcome measures are essential in the evaluation of facial palsy. Aim of this study was to translate and validate the Facial Disability Index (FDI) for use in the Netherlands. Methods The FDI was translated into Dutch according to a forward-backward method. Construct validity was assessed by formulating 22 hypotheses regarding associations of FDI scores with the Facial Clinimetric Evaluation scale, the Synkinesis Assessment Questionnaire, the Short Form-12 and the Sunnybrook Facial Grading System. Validity was considered adequate if at least 75% (i.e. 17 out of 22) of the hypotheses were confirmed. Additionally, confirmatory factor analysis was performed. Cronbach’s α was calculated as a measure of internal consistency. Participants were asked to fill out the FDI a second time after 2 weeks to analyse test-retest reliability. Lastly, smallest detectable change was calculated. Results In total, 19 hypotheses (86.4%) were confirmed. Confirmatory factor analysis showed acceptable fit for the two factor structure of the original FDI (root mean square error of approximation = 0.064, standardized root mean square residual = 0.081, comparative fit index = 0.925, Chi-square = 50.22 with 34 degrees of freedom). Internal consistency for the FDI physical function scale was good (α > 0.720). Internal consistency for the FDI social/well-being scale was slightly less (α > 0.574). Test-retest reliability for both scales was good (intraclass correlation coefficients > 0.786). Smallest detectable change at the level of the individual was 17.6 points for the physical function and 17.7 points for the social/well-being function, and at group level 1.9 points for both scales. Conclusion The Dutch version FDI shows good psychometric properties. The relatively large values for individual smallest detectable change may limit clinical use. The translation and widespread use of the FDI in multiple languages can help to compare treatment results internationally.

Peyronie's disease (PD) is a fibroproliferative disease of the penis. Since little is known about the molecular pathogenesis of PD, we compared the biochemical make-up of PD plaques with normal tunica albuginea to clarify pathological processes in the scarred tissue. Protein and mRNA levels were measured in plaques and in unaffected pieces of the tunica albuginea. We investigated the presence of myofibroblasts, the deposition of collagens, and some key elements of Wnt and YAP1 signaling at protein level. The expression of 45 genes, all related to collagen homeostasis and extracellular matrix proteins, was quantified. In plaques, more myofibroblasts were present, and we observed an activation of Wnt signaling and YAP1 signaling. Increased levels of the collagens types I and III confirm the fibrotic nature of plaques. The mRNA ratio of collagen types III, IV, and VI to type I was increased. The expression of lysyl hydroxylase 3 was higher, whereas a decreased expression level was seen for fibronectin and cathepsin K. The biochemical composition of plaques was different from unaffected tunica albuginea: the relative and absolute abundance of various extracellular matrix proteins were changed, as well as the quality of collagen and the level of the collagen-degrading enzyme cathepsin K.

ObjectiveResection of (pre) malignant lesions in the vulvoperineal area may result in large defects that cannot be closed primarily. The lotus petal flap technique is widely used for reconstruction. The aim of this study was to evaluate both quality of life (QoL) and sexual functioning of patients who underwent the lotus petal flap procedure, because no data are available on this topic.MethodsA cross-sectional study was performed on all eligible patients (N = 38) who underwent the lotus petal flap procedure between 2005 and 2016. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30, Female Sexual Function Index, and Body Image Scale were used to evaluate QoL and sexual functioning. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 and Female Sexual Function Index scores were compared with scores of age-matched healthy women.ResultsTwenty-six patients (68%) responded. The mean (SD) age was 65.5 (16.3) years, and the median follow-up time was 38.5 months (range 16–141 months). Quality of life scores were lower compared with healthy women in the domains physical, role, and social functioning. Sexual activity rates were comparable with healthy women; however, sexual functioning was worse. Although patients were satisfied about their sexual life, pain was reported.ConclusionsPatients who underwent vulvar reconstructive surgery with lotus petal flaps seem to have a lower QoL compared with healthy women. Patients report more pain during sexual activity but are satisfied about their sexual functioning. These results should be included in preoperative counseling and follow-up of future patients eligible for vulvar reconstruction with a lotus petal flap.

Clinicians struggle with limited efficacy and durability of standard treatments when treating patients with Dupuytren disease diathesis. Alternative treatments such as low-dose radiation therapy in early phase of disease, supplemental pharmacotherapy with anti-inflammatory and/or anti-mitotic drugs, as well as other pharmacologic targets, and more aggressive surgery such as dermofasciectomy all have been reported with variable success or with serious side effects that hamper their standard use. This article gives an overview of the available literature.

The temporalis muscle transposition is a reliable, one-stage reanimation technique for longstanding facial paralysis. In the variation described by Rubin, the muscle is released from the temporal bone and folded over the zygomatic arch towards the modiolus. This results in unsightly temporal hollowing and zygomatic bulging. We present a modification of this technique, which preserves the temporal fat pad in its anatomical location as well as conceals temporal hollowing and prevents zygomatic bulging.The data of 23 patients treated with this modification were analysed. May classification was used for evaluation of mouth reanimation. Experts and patients scored visibility of the contour deformity on a 100-mm visual analogue scale (VAS) (score 0 = poor/100 = best). 3D images of the face were used to measure temporal hollowing and zygomatic bulging. 3D images were compared to those of controls with a similar gender and age distribution.After a median follow-up of 5.7 years, all patients achieved symmetry at rest. Eleven patients achieved symmetry while smiling with closed lips (May classification "Good"). A median (interquartile range [IQR]) VAS score of 19 (6; 41) was given by experts and 25 (5; 59) by patients themselves. 3D volumes of zygomatic bulging differed from those of control subjects, although all volume differences were small (medianOn the basis of our results, we conclude that our modified Rubin temporalis transposition technique provides an elegant way to conceal bulging over the zygomatic arch and prevents temporal hollowing, without the need for fascial extensions to reach the modiolus. (C) 2018 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Data of a prospective longitudinal cohort study including 233 Dupuytren’s patients was used to determine: (1) whether the Unité Rhumatologique des Affections de la Main scale and Michigan Hand outcomes Questionnaire can detect change in hand function due to Dupuytren’s disease progression and to compare their abilities; (2) the concurrent validity, reliability, responsiveness and interpretability of the Dutch Unité Rhumatologique des Affections de la Main. The Unité Rhumatologique des Affections de la Main and Michigan Hand outcomes Questionnaire had comparable measurement properties, and were both able to distinguish participants with disease progression from those without progression (resp. U = 1252.5, p = 0.008, and U = 1086.0, p Level of evidence: II

Supplemental Digital Content is available in the text., Background: The role of diabetes mellitus, liver disease, and epilepsy as risk factors for Dupuytren disease remains unclear. In this systematic review and meta-analysis, the strength and consistency of these associations were examined. Methods: The MEDLINE, EMBASE, and Web of Science databases were searched for articles reporting an association between Dupuytren disease and diabetes mellitus, liver disease, and epilepsy published before September 26, 2016. The frequencies of Dupuytren disease and diabetes mellitus, liver disease, and epilepsy were extracted, as was information on potential confounders. Generalized linear mixed models were applied to estimate pooled odds ratios, adjusted for confounders. Heterogeneity between studies was quantified using an intraclass correlation coefficient and was accounted for by a random effect for study. Results: One thousand two hundred sixty unique studies were identified, of which 32 were used in the meta-analyses. An association between Dupuytren disease and diabetes mellitus was observed (OR, 3.06; 95 percent CI, 2.69 to 3.48, adjusted for age), which was stronger for type 1 diabetes mellitus than for type 2 diabetes mellitus but was not statistically significant (p = 0.24). An association between Dupuytren disease and liver disease was observed (OR, 2.92; 95 percent CI, 2.08 to 4.12, adjusted for sex). Dupuytren disease and epilepsy were associated, yielding an OR of 2.80 (95 percent CI, 2.49 to 3.15). Heterogeneity between studies was moderate to low. Conclusions: These findings demonstrate an association between Dupuytren disease and diabetes mellitus, liver disease, and epilepsy. Prospective, longitudinal studies are needed to elucidate the pathways causing these associations.

Summary Nerve reconstructions are the preferred technique for short-standing facial paralysis, most commonly using the contralateral facial nerve or ipsilateral hypoglossal nerve. The hypoglossal nerve provides a strong motor signal, whereas the signal of a cross-face nerve graft is weaker but spontaneous. Spontaneity in facial expression is believed to be important for psychological wellbeing. Therefore, a combination of the two procedures incorporates the best of both: a strong motor signal and a spontaneous smile. This study aimed to objectify this expected benefit. Of the 20 patients who received a hypoglossal–facial nerve anastomosis from 1995 to 2015 in our institutions, 12 patients were included in this study, 5 with and 7 without a cross-face nerve graft. The outcomes were compared using photographs, disease-specific quality of life (Facial Clinimetric Evaluation (FaCE) scale), a self-reported synkinesis scale (Synkinesis Assessment Questionnaire) and the presence of a spontaneous smile. Significant differences were found in preoperative excursion of the affected side of the mouth and the change in excursion. Median Total FaCE scores were considerably larger (18.3 points) for patients who underwent the combined procedure. A spontaneous smile was observed both with ( n = 2) and without ( n = 1) a cross-face nerve graft. The addition of a cross-face nerve graft to a hypoglossal–facial nerve anastomosis resulted in a positive trend in disease-specific quality of life. This benefit could also be present with the combination of a cross-face nerve graft with another nerve transfer such as a masseteric-facial nerve anastomosis.

Background: Percutaneous needle fasciotomy is a minimally invasive treatment modality for Dupuytren disease. In this study, the authors analyzed the efficacy and complication rate of percutaneous needle fasciotomy using a statistical method that takes the multilevel structure of data, regarding multiple measurements from the same patient, into account.Methods: The data of 470 treated rays from 451 patients with Dupuytren disease that underwent percutaneous needle fasciotomy were analyzed retrospectively. The authors described the early postoperative results of percutaneous needle fasciotomy and applied linear mixed models to compare mean correction of passive extension deficit between joints and efficacy of primary versus secondary percutaneous needle fasciotomy.Results: Mean preoperative passive extension deficits at the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints were 37, 40, and 31 degrees, respectively. Mean preoperative total passive extension deficit was 54 degrees. Results were excellent, with a mean total passive extension deficit correction of 85 percent. Percutaneous needle fasciotomy was most effective for metacarpophalangeal joints and less effective for proximal interphalangeal and distal interphalangeal joints. Secondary percutaneous needle fasciotomy was as effective as primary percutaneous needle fasciotomy. Complications were rare and mostly minor.Conclusion: The results of this study confirm that percutaneous needle fasciotomy is an effective and safe treatment modality for patients with mild to moderate disease who prefer a minimally invasive procedure.

The anatomy in the region of the palmodigital junction has been relatively little studied, but it is very relevant for the surgical treatment of Dupuytren’s disease. To study the microanatomy of the palmodigital junction, we dissected 26 cadaveric digits from 13 human cadaveric hands using microsurgical techniques. The dynamics of the different ligaments were studied in three hands preserved by Thiel’s method. We found a structure, which we propose to name the ‘palmodigital spiralling sheet’ (PSS), which has not been described before. It has a spiralling course around the neurovascular bundle giving rise to a neurovascular tunnel distally in the palm of the hand. It is formed proximally by fibres from the pretendinous band and the intrinsic muscle fascias and distally is in continuity with Cleland’s and Grayson’s ligaments. As such it connects the palmar and digital fascias. Its spiralling course stabilizes the neurovascular bundle in the healthy hand, but can displace it in Dupuytren’s disease, which may contribute to the development of spiral cords.

Background As treatment of Dupuytren disease (DD) is expected to shift towards prevention of progression, the use of imaging in patients with DD becomes more important. In this systematic review an overview is given of the different methods for and applications of imaging for DD that have been described. Methods The MEDLINE and EMBASE databases were searched for articles reporting the use of imaging in patients with DD, published before May 17, 2018. Studies were systematically examined in two rounds by two observers according to the PRISMA systematic. All studies containing original data on imaging for DD were considered for inclusion. Results Three hundred and seven unique studies were identified, of which 23 were included in the study. Only studies on the use of ultrasound (US) and magnetic resonance imaging (MRI) were identified. Broadly, articles could be divided into 5 categories. Seven studies were found on diagnosis, two on measurement of disease extent, four on measurement of disease activity, seven on guidance of minimally invasive procedures and five studies on evaluation of treatment. According to the Oxford CEBM, the levels of evidence were low, ranging from level 3 to 5. Conclusions A variety of applications for US and MRI for patients with DD has been described. Based on the results of this review, the largest value for imaging lies in the measurement of disease activity and the follow-up of treatment of patients with early stage disease. Unfortunately, the overall level of evidence of the available literature was low. Future research is necessary to define the exact value of US and MRI in the management of patients with DD.

Syndactyly correction without skin grafting is advocated because it prevents graft-related complications and donor site morbidity. In this cross-sectional study, we compared satisfaction among patients who underwent correction with and without skin grafting to determine preference based on subjective and objective parameters. Retrospective chart analysis was performed among 27 patients (49 webs) who were seen at follow-up after a median follow-up period of 7.4 years, at which the Patient and Observer Scar Assessment Scale, the Withey score and a satisfaction survey were used. Notably, there were no significant differences in complication rates or observer rated scar scores. Although the need for an additional surgical procedure was higher after skin grafting, patient-rated satisfaction scores were similar irrespective of the use of grafting. Our data suggest that corrections can best be performed without skin grafts if seeking to minimize the need for an additional procedure, but that the use of skin grafts does not appear to affect patient satisfaction. Level of evidence: IV

Supplemental Digital Content is available in the text., Background: Dupuytren’s disease is a very common, highly heritable palmar fibromatosis. In a recent genome-wide association study, 26 single-nucleotide polymorphisms were found to be associated with development of Dupuytren’s disease. The authors generated a weighted genetic risk score based on the genotype at these single-nucleotide polymorphisms. In two independent cohorts, they tested the association among high weighted genetic risk score, clinical features that predict a high risk of recurrence, and recurrence after surgery. Methods: Clinical data were obtained from patient questionnaires and clinical records, with missing data accounted for by imputation. Genotyping was performed as part of the recent genome-wide association study. Logistic regression was performed to study the association among weighted genetic risk score, high-risk clinical features, and recurrence, with a weighted genetic risk score analyzed as a continuous variable, and also grouped into four categories. Results: Using univariable logistic regression, a high weighted genetic risk score was associated with the presence of all high-risk clinical features: early age of onset, bilateral disease, ectopic disease, and a positive family history (p ≤ 0.004). After multivariable logistic regression accounting for these factors, an increased weighted genetic risk score was still associated with the need for repeated Dupuytren’s disease surgery (p = 0.004). Conclusions: The authors’ results suggest that a weighted genetic risk score is useful in predicting the risk of disease recurrence, and may be used by surgeons to personalize prognostication. In the future, a weighted genetic risk score may be useful for determining the most appropriate initial surgical procedure in patients with Dupuytren’s disease. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Background: In longstanding facial palsy, gracilis free functional muscle transfer (FFMT) is currently considered to be the gold standard in smile reanimation. An alternative to muscle free flaps is local muscle transposition, with the temporalis muscle transposition being the preferred procedure, because of its direction of pull when transposed. The present study aimed to compare outcomes of gracilis FFMT neurotised by the masseteric nerve and temporalis muscle transposition in longstanding facial palsy using patient-reported and aesthetic outcomes.Methods: A cross-sectional comparison of gracilis FFMT and temporalis muscle transpositions was performed. Pre- and postoperative excursion measures were obtained. Patients were asked to answer a satisfaction questionnaire, quality of life questionnaire (FaCE scale) and a depression and anxiety questionnaire (HADS). Laypeople were asked to rate the pre- and postoperative aesthetic appearance.Results: Of 28 eligible patients, 10 gracilis and 12 temporalis patients participated. No significant differences were found between both groups in postoperative quality of life or depression/anxiety. Layperson observers judged the aesthetic appearance to be similar.Conclusion: In the present study, gracilis FFMT did not lead to superior quality of life and aesthetic outcomes compared to temporalis muscle transpositions. The facial nerve specialist should perform the procedure he or she expects to lead to optimal results for the patient. (C) 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Dupuytren disease is a fibrotic disorder characterized by contraction of myofibroblast-rich cords and nodules in the hands. The Hippo member Yes-associated protein 1 (YAP1) is activated by tissue stiffness and the profibro tic transforming growth factor-beta 1, but its role in cell fibrogenesis is yet unclear. We hypothesized that YAP1 regulates the differentiation of dermal fibroblasts into highly contractile myofibroblasts and that YAP1 governs the maintenance of a myofibroblast phenotype in primary Dupuytren cells. Knockdown of YAP1 in transforming growth factor-beta 1-stimulated dermal fibroblasts decreased the formation of contractile smooth muscle alpha-actin stress fibers and the deposition of collagen type I, which are hallmark features of myofibroblasts. Translating our findings to a clinically relevant model, we found that YAP1 deficiency in Dupuytren disease myofibroblasts resulted in decreased expression of ACTA2, COL1A1, and CCN2 mRNA, but this did not result in decreased protein Levels. YAP1-deficient Dupuytren myofibroblasts showed decreased contraction of a collagen hydrogel. Finally, we showed that YAP1 Levels and nuclear localization were elevated in affected Dupuytren disease tissue compared with matched control tissue and partly co-localized with smooth muscle alpha-actin-positive cells. In conclusion, our data show that YAP1 is a regulator of myofibroblast differentiation and contributes to the maintenance of a synthetic and contractile phenotype, in both transforming growth factor-beta 1-induced myofibroblast differentiation and primary Dupuytren myofibroblasts.

Importance: Knowledge of factors associated with health-related quality of life in patients with facial palsy may aid in better interpreting outcomes of research and treatment.Objective: To identify factors associated with health-related quality of life in patients with facial palsy.Design, Setting, and Participants: The inclusion period for participants in this cross-sectional study at the University Medical Center Groningen, a tertiary referral center for facial reanimation surgery, was March 1 to June 1, 2019. Patients aged at least 18 years with facial palsy who had undergone surgery for facial palsy between January 1, 2007, and January 1, 2018, and patients visiting the outpatient clinic of the University of Groningen Department of Plastic Surgery for their facial palsy between March 1 and June 1, 2019, were also asked to participate. Of 276 patients invited, 145 gave informed consent. Twenty patients did not respond after consent, 3 patients withdrew from the study, and 1 patient was wrongly included.Main Outcomes and Measures: Health-related quality of life was measured using the Facial Clinimetric Evaluation Scale and the Facial Disability Index (physical score and social score). Facial function was assessed with the Sunnybrook Facial Grading System. Other variables were investigated using validated questionnaires, including the Duke University Religion Index, Ten-Item Personality Inventory, and Hospital Anxiety and Depression Scale. Multivariable linear regression analyses with stepwise backward selection were performed to identify associations with health-related quality of life. Because 44 Sunnybrook composite scores were missing, a sensitivity analysis was performed that excluded the Sunnybrook composite scores from the multivariable analysis.Results: In total, 121 patients with facial palsy were included; their median age was 62 years (interquartile range, 48-71 years), and 63 (52%) were women. Sunnybrook composite score (β = 0.4; 95% CI, 0.2-0.5), extraversion (β = 2.6; 95% CI, 0.4-4.8), and anxiety (β = -2.4; 95% CI, -4.1 to -0.8) were associated with the Facial Clinimetric Evaluation Scale total score (R2 = 0.380; 95% CI, 0.212-0.548). The Sunnybrook composite score was associated with the Facial Disability Index physical score (β = 0.2; 95% CI, 0.0-0.4) (R2 = 0.084; 95% CI, -0.037 to 0.205). Bilateral facial palsy (β = -21.2; 95% CI, -32.3 to -10.1), extraversion (β = 2.7; 95% CI, 1.3-4.1), conscientiousness (β = 2.7; 95% CI, 0.2-5.2), emotional stability (β = 3.3; 95% CI, 1.7-4.8), and depression (β = -1.3; 95% CI, -2.5 to -0.1) were associated with the Facial Disability Index social score (R2 = 0.400; 95% CI, 0.262-0.538). In the sensitivity analysis, the Sunnybrook composite score was associated with age (Spearman ρ = -0.252).Conclusions and Relevance: Bilateral facial palsy, age, severity of facial palsy, mental distress, and personality traits should be taken into account in future research and treatment of patients with facial palsy.

Background As life expectancy is increasing and healthy ageing becomes more and more important, skin ageing is a growing topic of interest from both a medical and a commercial point of view. The urgency to unravel the causes of skin ageing is rising. However, there is a lack of objective, simple, noninvasive methods to assess biological skin age - a term introduced to describe how old someone looks, covering both the appearance and function of the skin. A rapid, noninvasive assessment of biological skin age would greatly facilitate the execution of the studies required to find the causes of skin ageing.Objectives To find an objective, easy-to-apply method to assess biological skin age.Methods Skin age score (SAS) was compared with skin autofluorescence, a measure of advanced glycation end products in the skin, and several subject characteristics in 32 healthy, white women with little sun-exposed skin and no history of smoking.Results A moderate, positive correlation (R-2 = 0.32, P = 0.001) between SAS and skin autofluorescence-based biological skin age was found. However, the variation in biological skin age according to SAS could be explained better by body mass index, chronological age and hormonal status (R-2 = 0.86, P Conclusions In the current setting skin autofluorescence did not contribute better to the prediction of biological skin age than chronological age. Biological skin age was best predicted by body mass index, chronological age and hormonal status, and this approach provides a considerable simplification of the application of biological skin age.

Background: Breast reconstruction is an appropriate option offered to women who are diagnosed with breast cancer or gene mutations. It may be accomplished with implants or autologous procedures. This cross-sectional study evaluated the satisfaction and quality of life in addition to complications and secondary corrections in women after successful autologous or alloplastic (implant) breast reconstruction.Methods: Women were included after successful breast reconstruction. The BREAST-Q instrument and standardized questionnaires on depression, recurrence concerns, and anxiety were sent by mail to the participants. In addition, data were collected on complications and secondary corrections. Multiple regression analysis and chi-square tests were applied to evaluate differences between the autologous breast reconstruction group (n = 47) and the implant breast reconstruction group (n = 45).Results: Women with a successful autologous reconstruction were significantly more satisfied with their reconstructed breasts than women with successful alloplastic breast reconstruction as measured with the BREAST-Q satisfaction with breasts module (p = 0.023). More women with an autologous breast reconstruction required secondary correction than women with an implant breast reconstruction (p = 0.012). Other findings did not differ between the two groups.Conclusions: Autologous breast reconstruction leads to more satisfaction than does implant breast reconstruction, notwithstanding that women with an autologous breast reconstruction more often required a secondary correction. The study found no ideal breast reconstruction suitable for all patients. However, this study may inform patients and medical teams in making decisions about breast reconstruction. This pilot study indicated several questions that we plan to further investigate in a larger prospective study.

Objectives: Mediastinitis and sternumdehiscence are serious complications after open heart surgery, causing an increase in hospital stay, utilization of health care resources, and mortality. The defect that results after sternal wound debridement frequently necessitates tissue-flap coverage, for which pectoralis major transposition currently is the preferred method. In this study, the postoperative outcome and individual characteristics of patients undergoing pectoralis major transposition were analyzed to identify predictors of complications after wound closure.Methods: A retrospective chart review was conducted, covering a 7-year period, focusing on patient and operation characteristics. All patientswith sternum dehiscence, who underwent pectoralis major transposition, were included. All postoperative wound complications were graded according to the Clavien-Dindo classification of surgical complications. Complications were further divided in major and minor. Mortality was defined as death within 30 days after sternal wound repair or during hospital stay.Results: In total, 77 patients underwent a pectoralis major transposition repair of the sternum. Thirty-eight patients (49%) developed a wound complication of which 21 (27%) had a major wound complication. Mortality was 9%. Further analyses of our data showed that smoking and length of operation time were predictors of wound complications (P = 0.018 and P = 0.01). Female sex showed a relation with wound redehiscence (P = 0.014). Postoperative bleeding, for which reoperation was necessary, occurred more often when the humeral insertion of the pectoralis major flap was divided (P = 0.004).Conclusions: Tissue-flap coverage of the sternum using pectoralis major advancement flaps is a procedure that is still hampered by a high postoperative complication incidence. Female sex, smoking, detachment of the humeral insertion and operation time are associated with postoperative wound complications. These results may contribute in improving operative strategy. Also the use of the Clavien-Dindo classification makes underestimation of the complication rate unlikely in this study. The classification can easily be used in future studies, which will enhance comparability of results.

Secondary breast reconstruction is increasingly performed after postmastectomy radiotherapy. Damage to blood vessel walls is one of the adverse effects of irradiation therapy, which may jeopardize reconstructive free flap surgery. It would be of great importance to be informed about the quality of the recipient vessel before reconstructive surgery. The aim of this study was to prospectively assess the value of preoperative angiography in the assessment of radiation-induced arterial damage and to relate the findings to the degree of vascular damage found during the operation and with histology. This study included women who had been treated with thoracic radiotherapy and required free flap breast reconstruction. Preoperative angiographic, intraoperative quality and histological findings of vessels were scored and compared together with the occurrence of postoperative complications. In 34 patients a total of 40 free flaps breast reconstruction were performed. Total 21 internal mammary arteries had been within the field of irradiation. In only two out of six patients with aberrant angiographies the internal mammary artery has been within the field of irradiation. This study concludes that damage to the internal mammary vessels cannot always be detected preoperatively by angiography, or even by intraoperative examination.

Purpose The aim of this study was to analyze the durability of the treatment results of the thumb and first web contractures in Dupuytren disease with collagenase Clostridium histolyticum.Methods Twelve patients (14 hands) were followed for an average of 35 months (range, 24-42 months). Two patients (3 hands) were excluded, yielding 11 hands available for assessment. Nondurability was defined as a worsening of at least 20 degrees of passive extension deficit at a treated joint or any decrease greater than 5 mm in intermetacarpal head distance, both relative to 30 days after injection or as intervention to correct new/worsening contracture. Durability was compared with that of a historic cohort of treated finger contractures.Results Five out of 11 patients with a metacarpophalangeal or interphalangeal joint contracture or first web contracture had a nondurable result at an average of 35 months. Results obtained at metacarpophalangeal joints of thumbs were more durable than those of interphalangeal joints. Most of the recurrences occurred in interphalangeal joints.Conclusions Treatment of thumb and first web contractures was not durable in nearly half of the cases at an average follow-up of 35 months, and durability was clearly less than that of treated finger contractures. Copyright (C) 2019 by the American Society for Surgery of the Hand. All rights reserved.

PURPOSE: Grayson ligament has been described as a common pathway for digital contracture in Dupuytren disease. Its anatomical descriptions in the literature are, however, inconsistent.METHODS: We have performed a microsurgical dissection study in 20 fresh-frozen and thawed digits to revisit the anatomy of Grayson ligaments. We also performed dissections in Thiel-preserved hands to be able to study the changes in tension of the ligaments during flexion and extension of the finger.RESULTS: We found the ligaments originally described by Grayson to be the best developed part of a trabecular network of fibers, originating in continuity with the outer adventitial layer of the flexor tendon sheath and running toward their insertions into the skin in multiple planes, all volar to the neurovascular bundle. The most dorsal fibers, which cover the neurovascular bundles, form a chevron shape with its midline apex pointing distally in an extended finger. During flexion, the fibers become more transversely oriented.CONCLUSIONS: We found Grayson ligament comprises a trabecular network of fibers, instead of a ligament, with a dynamic fiber orientation on the volar side of the finger. The main function of this network of fibers seems to be the stabilization of the skin and fat pad in digit extension while the relaxation in flexion allows the skin and volar fat pad to adapt optimally to the form of the object that is held.CLINICAL RELEVANCE: The new insights in the anatomy of Grayson trabecular network of fibers may be of importance in the understanding of the pathological anatomy of Dupuytren disease.

Background: Dupuytren disease is a fibroproliferative disease of palmar fascias of the hand. The prevalence of Dupuytren disease and the association with potential risk factors have been the subject of several studies, although there is a paucity of such data from The Netherlands.Methods: To study the prevalence of Dupuytren disease, the authors drew a random sample of 1360 individuals, stratified by age, from the northern part of The Netherlands. Of this sample, 763 individuals aged 50 to 89 years participated in this cross-sectional study. The authors examined both hands for signs of Dupuytren disease, and a questionnaire was conducted to identify potential risk factors. The effects of these risk factors were investigated using logistic regression analysis. Additional analyses were performed to develop a logistic prediction model for the prevalence of Dupuytren disease.Results: The prevalence of Dupuytren disease was 22.1 percent. Nodules and cords were seen in 17.9 percent, and flexion contractures were present in 4.2 percent of the study population. Prevalence increased with age, from 4.9 percent in participants aged 50 to 55 years to 52.6 percent among those aged 76 to 80 years. Men were more often affected than women; 26.4 percent versus 18.6 percent, respectively (p = 0.007). Other significant risk factors were previous hand injury, excessive alcohol consumption, familial occurrence of Dupuytren disease, and presence of Ledderhose disease.Conclusions: The results show a high prevalence of Dupuytren disease in The Netherlands, particularly the nodular form. Using the developed logistic prediction model, the prevalence of Dupuytren disease can be estimated, based on the presence of significant risk factors.

Background:Dupuytren's disease (DD) is a fairly prevalent yet under-recognised disorder of the palmar fascia, resulting in fixed-flexion contractures of joints in the hand. Numerous population-based studies have been conducted in countries around the world, and published prevalence estimates vary widely. Nevertheless, most studies have shown that the prevalence of DD increases with age. Because the global population is aging, the prevalence of DD will also continue to increase.Scope:Patients with DD typically present to a variety of physicians, generalists and specialists alike. Thus, it is critical that providers have clear guidance on the early recognition of signs and symptoms, comprehensive evaluation of potential risk factors, differential diagnosis and when to refer a patient for treatment. Treatment options range from minimally invasive injections with collagenase to surgery.Findings:Results from a large-scale study of the surgical management of DD in Europe indicate that most DD diagnoses and referrals are made by general practitioners, but there is much inter-country variation. Different patient-and physician-based factors affect diagnosis rates and referral pathways. Different healthcare systems and regulations are also influential. A simple management algorithm is provided herein and explained.Conclusion:It is important for generalists to understand the natural history of DD and the potential benefits of early referral and treatment. General practitioners should diagnose and/or refer patients with DD to a specialist as early as possible to optimise disease management and treatment outcomes.

Background/aimDupuytren disease is a fibroproliferative hand condition. The role of exposure to vibration as a risk factor has been studied with contradictory results. Since field hockey is expected to be a strong source of hand-arm vibration, we hypothesised that long-term exposure to field hockey is associated with Dupuytren disease.MethodsIn this cross-sectional cohort study, the hands of 169 male field hockey players (IQR: 65–71 years) and 156 male controls (IQR: 59–71 years) were examined for signs of Dupuytren disease. Details about their age, lifestyle factors, medical history, employment history and leisure activities were gathered. Prior to the analyses, the groups were balanced in risk factors using propensity score matching. The association between field hockey and Dupuytren disease was determined using a subject-specific generalised linear mixed model with a binomial distribution and logit link function (matched pairs analysis).ResultsDupuytren disease was observed in 51.7% of the field hockey players, and in 13.8% of the controls. After propensity score matching, field hockey playing as dichotomous variable, was associated with Dupuytren disease (OR=9.42, 95% CI 3.01 to 29.53). A linear dose-response effect of field hockey (hours/week x years) within the field hockey players could not be demonstrated (OR=1.03, 95% CI 0.68 to 1.56).DiscussionWe found that field hockey playing has a strong association with the presence of Dupuytren disease. Clinicians in sports medicine should be alert to this less common diagnosis in this sport.

Purpose The course of Dupuytren disease (DD) is thought to be progressive; however, the course differs for each patient. The purpose of this study was to study the rate and pattern of progression of DD.Methods We prospectively analyzed the course of DD at intervals of 3 to 6 months in 247 Dutch participants with primary DD by measuring the surface area of nodules and cords and the total passive extension deficit. The association between surface area and Tubiana stage was tested with generalized estimating equations. Latent class models were used to study different clusters in changes regarding the course of the disease.Results The variance in disease course between participants was large. Regarding the change in surface area (in all fingers) and total passive extension deficit (in the ring and little finger), different clusters were observed. Progression of disease was seen but there were also signs of stability and even regression. Patients with a smaller surface area at baseline were more likely to exhibit regression.Conclusions This study showed that DD is not always progressive and that up to 75% of patients have a different short-term disease course, such as stability or even regression of disease. This should be taken into account when evaluating the effects of treatment for early-phase DD and in the design of future studies. Furthermore, this information may be useful when counseling patients. (Copyright (C) 2016 by the American Society for Surgery of the Hand. All rights reserved.)

During myogenesis, human satellite cells differentiate and form multinucleated myotubes, while a fraction of the human satellite cells enter quiescence. These quiescent satellite cells are able to activate, proliferate and contribute to muscle regeneration. Post-transcriptional regulation of myogenesis occurs through specific myogenic microRNAs, also known as myomiRs. Although many microRNAs are involved in myotube formation, little is known on the involvement of microRNAs in satellite cells entering quiescence. This current study aims to investigate microRNA involvement during differentiation of human satellite cells, specifically proliferating satellite cells entering quiescence. For this, clonally expanded human satellite cells were differentiated for 5 days, after which myotubes and quiescent satellite cells were separated through FACS sorting. Next, a microRNA microarray comparison of proliferating satellite cells, myotubes and quiescent satellite cells was performed and verified through qRT-PCR. We show that during human satellite cell differentiation, microRNAs are globally downregulated in quiescent satellite cells compared to proliferating satellite cells, in particular microRNA-106b, microRNA-25, microRNA-29c and microRNA-320c. Furthermore, we show that during myogenesis microRNA-1, microRNA-133, microRNA-206 and microRNA-486 are involved in myotube formation rather than satellite cells entering quiescence. Finally, we show an overall decrease in total mRNA in quiescent satellite cells, and an indication that RNaseL regulation plays a role in promoting and maintaining quiescence. Given the importance of quiescent satellite cells in skeletal muscle development and regenerative medicine, it is imperative to distinguish between myotubes and quiescent satellite cells when investigating skeletal muscle development, especially in microRNA studies, since we show that microRNAs are globally downregulated in quiescent human satellite cells.

Purpose Increasing options to treat Dupuytren disease include percutaneous needle fasciotomy (PNF), a minimally invasive technique that has proven to be effective for the treatment of primary disease. However, its effect on recurrent disease is not clear. Methods We studied 30 patients with recurrent Dupuytren disease in 40 fingers, with a mean follow-up of 4.4 years. Primary outcome measures were total passive extension deficit reduction and interval to a second recurrence, defined as an increase of more than 30° compared with the result at the end of the previous treatment. We noted complications. Results Total passive extension reduction was 76%. Percutaneous needle fasciotomy was especially effective for the metacarpophalangeal joint, with an average reduction of 93%, whereas the average reduction in the proximal interphalangeal joint was 57%. A total of 50% of patients did not develop a secondary recurrence during follow-up. The other 50% did, and we treated recurrence within an average of 1.4 years after PNF. By means of PNF, we postponed tertiary treatment an average of 2.9 years starting from the initial treatment for Dupuytren disease. We successfully treated all secondary recurrences by limited fasciectomy, according to patients' wishes. We noted no major adverse effects. Conclusions Percutaneous needle fasciotomy can be applied effectively for recurrent disease; 50% of patients remain free of recurrence for a mean of 4.4 years. If a secondary recurrence occurs, it does so relatively early after treatment. Patients must therefore be willing to accept this uncertainty in the context of the advantages of PNF, such as fast recovery, low complication rate, and minimal invasiveness. Type of study/level of evidence Therapeutic IV.

Item does not contain fulltext BACKGROUND: In this retrospective study, we analyzed the outcomes of different types of treatment of fingertip injuries and compared them after a mean follow-up of 4.5 years. METHODS: A total of 53 patients (59 injuries) were included in this study. The fingertip injuries were classified according to Allen classification. The patients were categorized into three groups based on the treatment: reconstructive group, bone-shortening group, and conservative group. As objective assessments, strength, sensibility, and goniometry were measured; as subjective assessments, cold intolerance, nail deformation, and aesthetics were measured. RESULTS: The mean reduction in strength, the Semmes-Weinstein monofilament test, and the reduction in mobility for the injured fingers compared with those of the uninjured finger were not significantly different between the groups. Cold intolerance was reported in 50 (84.7%) of the 59 fingers, and in almost 90% of all the cases, there was some kind of nail distortion. For the cold intolerance and nail distortions, there was no difference between the groups. The aesthetic outcomes judged by patients and surgeon were comparable. CONCLUSION: In conclusion, the outcome of treatment of Allen II, III, and IV fingertip injuries was irrespective of the treatment chosen. In an era where the enormous variety of surgical options suggests that treatment with a flap is the best, this outcome is at least surprising. LEVEL OF EVIDENCE: Therapeutic study, level IV. 01 juni 2012

Innovative strategies based on regenerative medicine, in particular tissue engineering of skeletal muscle, are promising for treatment of patients with skeletal muscle damage. However, the efficiency of satellite cell differentiation in vitro is suboptimal. MicroRNAs are involved in the regulation of cell proliferation and differentiation. We hypothesized that transient overexpression of microRNA-1 or microRNA-206 enhances the differentiation potential of human satellite cells by downregulation quiescent satellite cell regulators, thereby increasing myogenic regulator factors. To investigate this, we isolated and cultured human satellite cells from muscle biopsies. First, through immunofluorescent analysis and quantitative reverse transcription-polymerase chain reaction (qRT-PCR), we showed that in satellite cell cultures, low Pax7 expression is related to high MyoD expression on differentiation, and, subsequently, more extensive sarcomere formation, that is, muscle differentiation, was detected. Second, using qRT-PCR, we showed that microRNA-1 and microRNA-206 are robustly induced in differentiating satellite cells. Finally, a gain-of-function approach was used to investigate microRNA-1 and microRNA-206 potential in human satellite cells to improve differentiation potential. As a proof of concept, this was also investigated in a three-dimensional bioartificial muscle construct. After transfection with microRNA-1, the number of Pax7 expressing cells decreased compared with the microRNA-scrambled control. In differentiated satellite cell cultures transfected with either microRNA-1 or microRNA-206, the number of MyoD expressing cells increased, and alpha-sarcomeric actin and myosin expression increased compared with microRNA-scrambled control cultures. In addition, in a three-dimensional bioartificial muscle construct, an increase in MyoD expression occurred. Therefore, we conclude that microRNA-1 and microRNA-206 can improve human satellite cell differentiation. It represents a potential novel approach for tissue engineering of human skeletal muscle for the benefit of patients with facial paralysis.