Quality of life and subjective donor-site morbidity in patients after a free fibula flap.

INTRODUCTION: We evaluated the subjective donor-site morbidity and quality of life in patients with a free fibula flap (FFF) reconstruction in terms of self-reported symptoms, function and quality of life, and we compared inclusion vs. exclusion of the flexor hallucis longus (FHL) muscle in the graft, primary wound closure vs. skin graft and the occurrence vs. absence of donor-site complications. METHODS: In this cross-sectional study, patients who underwent a mandibula or maxilla reconstruction with a FFF between 2011 and 2021, were included. Symptoms and function were measured with the Foot and Ankle Outcome Score (FAOS) and quality of life with both FAOS and a Visual Analogue Scale (VAS). RESULTS: Thirty-four patients were included in the analyses (mean age 59 years, 59% males). Most patients underwent a mandibular reconstruction for a malignancy. The median FAOS domain scores ranged between 92.9 (interquartile range (IQR) 77.7-100.0) and 100.0 (IQR 88.2-100.0) points, and the median VAS score was 86.5 points. No statistically significant differences were found between inclusion vs. exclusion of the FHL, primary wound closure vs. graft and occurrence vs. absence of donor-site complications. An unfavorable trend was seen for inclusion of the FHL in the flap on recreational functioning, and quality of life. CONCLUSION: Patients who underwent a FFF experience little donor-site morbidity and high quality of life, as measured by FAOS and VAS.

Foreign body reaction triggered by cytotoxic T lymphocyte-associated protein 4 blockade 25 years after dermal filler injection.

Foreign body reactions are regularly seen as a late complication of cosmetic treatment with synthetic dermal fillers. Often this foreign body reaction is triggered by a systemic infection, but other systemic triggers are also reported. In this case report, we present a woman in her 60s who was treated with ipilimumab for metastatic melanoma. After two courses of treatment she developed painless facial nodules. A foreign body reaction to dermal fillers was suspected because the patient had received cosmetic treatment with dermal fillers 25 years previously. This reaction was confirmed by excision and histological examination. In the absence of other known triggers, this case revealed immunotherapy (ipilimumab) and subsequent activation of the adaptive immune system as potential triggers of foreign body reactions to dermal fillers. Immunotherapy is increasingly used as anticancer treatment for an increasing number of tumour types. Furthermore, synthetic dermal fillers have frequently been used in the past. Therefore, physicians should be aware of this late-occurring complication of synthetic filler treatment in patients who develop skin lesions during immunotherapy.

Body mass index, chronological age and hormonal status are better predictors of biological skin age than arm skin autofluorescence in healthy women who have never smoked.

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 < 0·001). 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.

Nasolabial fold augmentation with SMAS graft.

This case report shows a new technique for inserting superficial musculoaponeurotic system (SMAS) tissue as autologous filling of deep nasolabial folds during an SMAS or minimal access cranial suspension (MACS) facelift procedure with satisfying aesthetic results. The technique avoids visible scars on the cheek and does not require insertion through a potential contaminated area such as nasal mucosa.

Cerebral consequences of dynamic immobilisation after primary digital flexor tendon repair.

Current treatment protocols for flexor tendon injuries of the hand generally result in an acceptable function, which can be quantified by objective parameters such as range of motion. The latter does not always match the patients' subjective experiences of persisting dysfunction. This raises the question whether changes in the cerebral control of movement might contribute to the perceived deficit. The main objective of the present positron emission tomography (PET) study was to characterise the cerebral responses in movement-associated areas during simple finger flexion immediately after dynamic immobilisation and after a subsequent 6-week period of active training. Ten subjects with flexor tendon injury participated in the PET study. Electromyography (EMG) recordings were made during finger flexion and extension in an additional subject. The main finding was that the (ventral) putamen contralateral to flexor movement was not activated immediately after release from splinting, while such activation reappeared after a period of training. This indicates a temporary loss of efficient motor control of over-learnt movements. The increase of unwanted co-contractions during flexion in a first EMG session, and not during extension, supports a concept of lost skills.

Clinical implications of cerebral reorganisation after primary digital flexor tendon repair.

After flexor tendon injury, most attention is given to the quality of the tendon repair and postoperative early passive dynamic mobilisation. Schemes for active mobilisation have been developed to prevent tendon adhesions and joint stiffness. This paper describes five patients to demonstrate the cerebral consequences of immobilisation allowing only passive movements, which implies a prolonged absence of actual motor commands. At the end of such immobilisation, PET imaging revealed reduced blood flow in specific motor areas, associated with temporary loss of efficient motor control. Effective motor control was regained after active flexion exercises which was reflected in normalised cerebral activations. This suggests that temporary, reversible cerebral dysfunction may affect the outcome of flexor tendon injuries.

Changes in speed of information processing in the brain following tendon repair.

The objective of this study was to measure the "preparation time" that is the speed of information processing in the brain, and discuss the relevance of this parameter in the restoration of hand function following flexor tendon repair. The preparation time of 48 healthy adult participants was measured twice at a 6-week interval and compared with that of 12 patients after flexor tendon repair. There was no difference between the left and right hands of the healthy participants. The correlation between repeated measurements was high, although healthy participants performed 2.6% faster 6 weeks after the first measurement. After 6 weeks of immobilisation, patients showed a significant deterioration with respect to the speed of information processing by the brain on both the injured and uninjured sides compared with healthy participants, who had improved between the first and the second measurements. The results indicate that a period of lack of normal use of the hand leads to a change in cerebral control of hand movements.

Functional dominance of finger flexion over extension, expressed in left parietal activation.

Sensory stimuli may elicit a widely distributed parietal-premotor circuitry underlying task-related movements such as grasping. These stimuli include the visual presentation of an object to be grasped, as well as the observation of grasping performed by others. In this study, we used functional Magnetic Resonance Imaging (fMRI) to test whether the performance of simple finger flexion, contrasted to extension, might similarly activate higher-order circuitry associated with grasping. Statistical Parametric Mapping (SPM) showed that flexion, compared to extension, was related with significant activation of the left posterior parietal cortex and posterior insula, bilaterally. This pattern supported our hypothesis that simple finger flexion has a specific relation with circuitry involved in preparing manual tasks. Although the two motor conditions showed major overlap in the primary motor cortex, increased flexion-related activation at the precentral motor-premotor junction further supported its association with higher-order motor control.

Cerebral reorganisation of human hand movement following dynamic immobilisation.

Surgical treatment of a flexor tendon lesion of the hand is followed by a 6-week period of dynamic immobilisation. This is achieved by the elastic strings of a Kleinert splint, enabling only passive and no active flexor movements. After such immobilisation, the appearance of a temporary clumsy hand indicates decreased efficiency of cerebral motor control. Using PET we identified the recruitment of contralateral parietal and cingulate activations specifically related to the suboptimal character of these hand movements. After 6-8 weeks, normalised movement was related with contralateral putamen activation. Activations of the sensorimotor cortex and cerebellum were present during both scanning sessions. Changes in the pattern of cerebral activations reflect functional reorganisation. The shift from cortical to striatal involvement, observed in the group of four patients, generates the concept of unlearned movements being relearned.