Validated 5 - Point photonumeric scales for the assessment of hand atrophy.

OBJECTIVE: Quantifying the degree of dorsal hand atrophy is a challenging endeavor, but often necessary, in both the clinical and the research setting. The aim of this investigation was to create and consecutively validate a 5-point photonumeric scale for assessment of dorsal hand atrophy. MATERIAL AND METHODS: A medical team created a novel 5-point photonumeric scale. Twelve international raters were involved in the digital validation, while five raters performed a live validation. RESULTS: For the digital validation of the Croma Hand Atrophy Assessment Scale, a total of 72 subjects (58 females, 14 males) with a mean age of 43.0 ± 14.4 years [18-73 years] were assessed. For the live validation, 88 subjects (73 females, 15 males) with a mean age of 45.0 ± 14.1 years [20-73 years] were rated. The results revealed almost perfect intra-rater (ICC: 0.90 [95% CI: 0.88-0.92]) and inter-rater agreements (ICC: 0.85 [95% CI: 0.81-0.89] and 0.86 [95% CI:0.82-0.89]) in the digital validation and substantial intra-rater (ICC: 0.79 [95% CI: 0.75-0.82]) and inter-rater agreements (ICC: 0.75 [95% CI: 0.68-0.81] and ICC: 0.67 [95% CI: 0.54-0.77]) in the live validation. CONCLUSION: The created scale to assess dorsal hand atrophy has been shown to provide substantial-to-almost perfect agreement in the digital and live validation cycles and reached comparable intra-rater and inter-rater agreement to already published and validated scales. It is expected that the created scale will help physicians and researchers in the assessment of hand atrophy in the clinical and research setting in the future.

Validated 5-point photonumeric scales for the assessment of the periorbital region.

OBJECTIVE: The objective of this investigation was to create and validate 5-point photonumeric scales for the assessment of dynamic crow's feet, static crow's feet, and infraorbital hollows. MATERIAL AND METHODS: Three novel 5-point photonumeric scales were created by a medical team. A total of 12 raters from all over the world performed a digital validation, and a total of 5 raters a live validation of the created scale. RESULTS: The statistical analysis revealed almost perfect intra-rater and inter-rater reliability in the digital validation of the scales for the assessment of static and dynamic crow's feet as well as infraorbital hollows. In the live validation, both crow's feet scales showed almost perfect intra-rater reliability, while the Croma Infraorbital Hollow Assessment Scale showed substantial intra-rater reliability. Inter-rater reliability was substantial for all three scales in the live validation. All three scales, the Croma Dynamic Crow's Feet Assessment Scale, Croma Static Crow's Feet Assessment Scale, and Croma Infraorbital Hollow Assessment Scale, were validated digitally and in a live setting. CONCLUSION: The created scales to assess infraorbital hollowing, dynamic and static crow's feet have been shown to provide substantial to almost perfect agreement in the digital and live validation and can thus be considered as helpful tools in the clinical and research setting. While technical methods and appliances to assess the degrees of severity of age-dependent features are advancing, validated scales are of great importance due to their ease of use and, as shown by the validations, reliability, and reproducibility.

Validated 5-point photonumeric scales for the assessment of the jowls and chin.

OBJECTIVE: The objective of this investigation was to create and to examine the reproducibility and validity of 5-point photonumeric assessment scales that allow objective assessment of chin retrusion and jawline sagging using a digital and a live validation. MATERIAL AND METHODS: Two new 5-point photonumeric scales created to assess chin projection and jawline sagging were validated by 12 experts in a digital validation and by 5 experts in a live validation setting. Intra-rater agreement and inter-rater agreement were assessed. RESULTS: For the digital validation, an almost perfect intra-rater (Kappa: 0.89 [95% CI: 0.86-0.91]) and almost perfect inter-rater agreement in both sessions (Kappa: 0.80 [95% CI: 0.74-0.86] and 0.80 [95% CI: 0.74-0.86]) was achieved for the Croma Chin Projection Assessment Scale, while intra-rater agreement (Kappa: 0.88 [95% CI: 0.85-0.91]) was almost perfect for the Croma Jawline Sagging Assessment Scale and inter-rater agreement being substantial in the first session (Kappa: 0.76 [95% CI: 0.71-0.81]) and almost perfect in the second session (Kappa: 0.81 [95%CI: 0.76-0.85]). For the live validation, intra-rater agreement was almost perfect for the Croma Chin Projection Assessment Scale (Kappa: 0.82 [95%CI: 0.74-0.90]) and the Croma Jawline Sagging Assessment Scale (Kappa: 0.83 [95%CI: 0.77-0.89]), while inter-rater agreement was substantial in both sessions for both scales. CONCLUSION: The created chin and jawline photonumeric grading scales are valid and reliable tools for assessing chin projection and jawline sagging. The scales will be of value for standardized chin evaluation and quantifying outcomes in clinical research and daily practice.

Dog-ear's prevention during Inverted-T breast lift and reduction.

There are several techniques for the prevention of dog-ear. All of the techniques have their own disadvantages, since mostly they lengthen the wound. The current technique prevents dog ear during inverted-T breast lift and reduction without lengthening the wound or creating tension while closing the wound.

Correlation between MRI results and intraoperative findings in patients with silicone breast implants.

BACKGROUND: Silicone gel breast implants may silently rupture without detection. This has been the main reason for magnetic resonance imaging (MRI) of the augmented or reconstructed breast. The aim of the present study was to investigate the accuracy of MRI for implant rupture. METHODS: Fifty consecutive patients with 85 silicone gel implants were included in the study. The mean age of the patients was 51 (range 21-72) years, with a mean duration of implantation of 3.8 (range 1-28) years. All patients underwent clinical examination and breast MRI. Intraoperative implant rupture was diagnosed by the operating surgeon. RESULTS: Nineteen of the 50 patients suffered from clinical symptoms. An implant rupture was diagnosed by MRI in 22 of 85 implants (26%). In seven of 17 removed implants (41%), the intraoperative diagnosis corresponded with the positive MRI result. However, only 57% of these patients were symptomatic. Ultrasound imaging of the harvested implants showed signs of interrupted inner layers of the implant despite integrity of the outer shell. By microsurgical separation of the different layers of the implant shell, we were able to reproduce this phenomenon and to produce signs of implant rupture on MRI. CONCLUSION: Our results show that rupture of only the inner layers of the implant shell with integrity of the outer shell leads to a misdiagnosis on MRI. Correlation with clinical symptoms and the specific wishes of the patient should guide the indication for implant removal.

Hypertrophy of the breast: a problem of beauty or health?

BACKGROUND: Despite the complex health burden for women with breast hypertrophy, medical directors of health insurance companies are not convinced that this procedure is of medical benefit for patients. Therefore, coverage of cost by the health insurance companies is no longer guaranteed. The purpose of this study is to evaluate the influence of breast weight on the physical and psychological morbidity of women and to prove the medical necessity of reduction mammaplasty. METHODS: We performed a cohort study of 50 women with various breast sizes, a mean age of 28 years (range 20-40 years), and a body mass index (BMI) <25. Breast weight was measured, the spine was investigated by magnetic resonance imaging (MRI), and a spine score of clinical symptoms was assessed. The Beck Depression Inventory (BDI) was used to evaluate psychological impairment. Pathological findings have been correlated with breast weight, and the risk of developing a morphological or psychological disorder independence of the breast weight was calculated. RESULTS: The incidence of degenerative spine disorders and the extent of depressive symptoms are correlated with increasing breast weight. CONCLUSIONS: The data show that high breast weight has a negative influence on the physical and psychological morbidity of women. This objective evidence in support of the medical necessity of reduction mammaplasty should guide managed care organizations' methods for determining coverage for reduction mammaplasty.

Crucial aspects of smoking in wound healing after breast reduction surgery.

BACKGROUND: The aim of this study was to investigate the influence of cigarette smoking on wound-healing in patients undergoing breast reduction. METHODS: In our prospective study, 50 patients (25 smokers, 25 nonsmokers) scheduled for breast reduction have been evaluated. Urine cotinine levels were measured to analyse perioperative smoking habits. Urine samples were taken preoperatively and on the fourth postoperative day. Cotinine as a metabolite of nicotine allows precise evaluation of nicotine exposure. To assess the progress of woundhealing we classified secreting, instable, inflamed or necrotic wound conditions, which required a dressing after the tenth postoperative day as impaired wound healing. For statistical analysis non-parametrical tests for independent and dependent data were used. RESULTS: Ten of 25 smokers presented impaired wound healing compared to 4 of 25 nonsmokers. The median cotinine level of smokers was 1964 (783/3963)ng/cc preoperatively and 432 (148/1695)ng/cc postoperatively. Nonsmokers had a preoperative cotinine level of 18 (7/37)ng/cc and 15 (4/34)ng/cc postoperatively. Smokers who developed impaired wound-healing showed higher levels of cotinine pre- (2117 ng/cc) and especially postoperatively (485 ng/cc) compared to smokers with regular woundhealing (1614 ng/cc and 389 ng/cc). Both differences in cotinine levels were statistically significant (p=0.03 and p=0.02). CONCLUSIONS: The data of the present study confirm the negative effect of smoking on wound healing in patients undergoing breast reduction.

Management strategies for peripheral iatrogenic nerve lesions.

For diagnostic or therapeutic reasons, various medical procedures may cause iatrogenic injury of peripheral nerves. The authors treated 82 patients for iatrogenic nerve injury between 1990 and 2000. The main reasons for iatrogenic nerve injury were surgical failure, traction or pressure lesions, hematoma, or inadequate positioning of the patient. The authors performed neurolysis in 67 cases, which included reconstruction by nerve graft in 26 patients and direct coaptation of the nerve in 3 patients. Their postoperative results emphasize the importance of early diagnosis and adequate treatment of iatrogenic peripheral nerve damage for optimal functional recovery. The authors highlight the different causes for iatrogenic injury in this study to alert surgeons as well as other medical specialists to simple strategies for avoiding nerve injury. They also indicate the need for physicians to make themselves familiar with early diagnostic steps for detecting iatrogenic injuries, like electroneurographic studies, and to document physical examinations well, to deal with this problem most effectively.

Clinical and ultrasound evaluation of donor site morbidity after tram-flap for breast reconstruction.

The TRAM-flap has become a well-established method for breast reconstruction. Even though the aesthetic result is superior to implant reconstruction, a main disadvantage is the potential risk to create weakness of the abdominal wall. For evaluation of abdominal wall function, an imaging method has to be used which is able to prove functional properties of the remaining muscle. This study was undertaken in order to verify if ultrasound imaging is a reasonable method to examine muscle movements after TRAM-flap procedures in addition to clinical examination. In 8 patients, a DIEP-flap, in 11 patients, a free TRAM-flap, and in 3 patients, a pedicled TRAM-flap were used for breast reconstruction. Patients were examined 10-72 months (mean, 32 months) after surgery. Ultrasound imaging of the abdominal wall was performed in longitudinal as well as cross sections (multifrequent, 13 Mhz; Siemens Elegra, Erlangen, Germany). The diameter of the remaining muscle was measured 2 cm below the rib bow, at the level of the umbilicus, and at the level of the skin scar. The operated side was compared to the nonoperated contralateral side. In order to evaluate the contractility of the remaining rectus muscle, patients were invited to perform sit-ups during ultrasound monitoring of muscle movement. Clinically the functional testing was performed by the method of Janda (Muskelfunktionsdiagnostik, 2nd ed. Berlin: Volk- und Gesundheit; 1986). The abdominal wall was inspected for bulging or hernia formation. Additionally, patients answered a six-scale self-designed questionnaire concerning the impairment of daily living and pain. Muscle contractility as well as muscle diameter were graded into four degrees from 0-3. The highest degree of 3 with normal muscle contractility and muscle diameter was found in 1 of 5 patients after DIEP-flap. Degree 2, with reduced muscle contractility and reduced muscle diameter, was found in 10 of 22 patients, especially after unilateral TRAM-flap. Degree 1, with no muscle contractility and remaining muscle, and degree 0, with scar tissue, were found in 11 patients. Impairment in daily-life activity was found in 10 patients, while 8 patients complained of pain. Muscle strength scored by the method of Janda (Muskelfunktionsdiagnostik, 2nd ed. Berlin: Volk- und Gesundheit; 1986) reached 4 and 5 in 19 patients after all kinds of flap harvesting; 3 patients reached Janda 2 and 3 after unilateral free TRAM or unilateral DIEP-flap. In one patient, a hernia was detected after unilateral DIEP-flap; 10 patients showed bulging of the abdominal wall. Functional testing of the abdominal wall by the method of Janda as well as CT-scans or MRI for evaluation of the remaining muscle is reported in the literature. As there is a need for cost reduction in medical treatment, we were looking for a more cost-effective evaluation method compared to CT-scan or MRI. Ultrasound imaging of the donor site after TRAM-flap harvesting in order to evaluate the remaining function of the rectus muscle is not yet reported in the literature. We consider ultrasound imaging to be superior to CT-scan or MRI in terms of functional evaluation and cost effectiveness.