Kim Alexander Tønseth

Curve progression and spinal growth in brace treated idiopathic scoliosis

The risk of progression of idiopathic scoliosis is correlated primarily to factors that predict potential remaining skeletal growth. The aim of the current study was to evaluate spinal growth, measured as the length of the scoliotic spine on serial longitudinal radiographs, and its relationship to progression of the scoliotic curve. The retrospective study was based on measurements made on standing anteroposterior radiographs of 60 patients with adolescent idiopathic scoliosis. In all patients, a Boston brace was prescribed during the followup period. Despite brace treatment, a significantly greater average progression rate of the scoliotic curve was seen in periods of rapid to moderate growth (≥ 10 mm per year) compared with periods of small or no growth (< 10 mm per year). The difference in progression rates concerned the increase of the Cobb angle and the increase of lateral deviation and axial rotation. These findings indicate the length of the spine measured on subsequent radiographs is an excellent parameter to determine spinal growth and thus an excellent predictor of scoliosis progression. With the presented growth charts, which were derived from the measured individual growth velocity values of the patients in the study, it is possible to predict future spinal growth at different chronologic ages.

Autologous fat transplantation to the velopharynx for treating persistent velopharyngeal insufficiency of mild degree secondary to overt or submucous cleft palate

BACKGROUND Autologous fat transplantation to the velopharynx has been described in a few smaller studies including heterogeneous groups of patients for the treatment of velopharyngeal insufficiency (VPI). The aim of this study was to evaluate speech and to measure velopharyngeal closure with magnetic resonance imaging (MRI) in patients who underwent autologous fat transplantation for the treatment of persistent VPI of mild degree secondary to overt or submucous cleft palate. METHODS A prospective study of 16 patients with persistent VPI of mild degree secondary to overt or submucous cleft palate who underwent autologous fat transplantation to the velopharynx. The patients were injected with a median of 5.6 (3.8-7.6) ml autologous fat to the velopharynx. Pre- and 1-year postoperative audio recordings were blinded for scoring independently by three senior speech therapists. Hypernasality, hyponasality, nasal turbulence and audible nasal emission were scored on a five-point scale. Pre- and 1-year postoperative MRIs were obtained during vocal rest and during phonation in 12 patients. Data measured were the velopharyngeal distance in the sagittal plane and the velopharyngeal gap area in the axial plane. RESULTS Hypernasality improved significantly (p=0.030), but not audible nasal emission (p=0.072) or nasal turbulence (p=0.12). The velopharyngeal distance during phonation decreased significantly (p=0.013), but not the velopharyngeal gap area (p=0.16). There was no significant correlation between speech and MRI results. CONCLUSION Autologous fat transplantation to the velopharynx improved hypernasality significantly, but not audible nasal emission or nasal turbulence in patients with persistent VPI of mild degree secondary to overt or submucous cleft palate. Given the low number of patients and the lack of a control group, the value of fat transplantation for the treatment of mild VPI is not proven for sure.

Speech and Magnetic Resonance Imaging Results Following Autologous Fat Transplantation to the Velopharynx in Patients With Velopharyngeal Insufficiency

Objective To measure velopharyngeal closure with magnetic resonance imaging (MRI) and to evaluate speech when treating velopharyngeal insufficiency (VPI) with autologous fat transplantation to the velopharynx. Patients Nine patients were recruited. Six patients had undergone cleft palate repair and subsequently developed VPI. Three were noncleft patients of which one had developed VPI after nasopharyngeal cancer treatment; another patient had developed VPI after combined adenotonsillectomy, and a third patient had VPI of unknown etiology. Main outcome measure Preoperative and 1-year postoperative MRIs were obtained during vocal rest and during phonation. Data measured were the velopharyngeal distance in the sagittal plane and the velopharyngeal gap area in the axial plane. Preoperative and 1-year postoperative audio recordings were blinded for scoring independently by three senior speech therapists. Results When comparing preoperative and 1-year postoperative MRI during phonation we found a significant reduction of the median velopharyngeal distance from 4 to 0 mm (p = .011), and a significant reduction of the median velopharyngeal gap area from 42 to 34 mm2 (p = .038). Nasal turbulence improved significantly (p = .011). Hypernasality/hyponasality and audible nasal emission did not change significantly. Conclusions Autologous fat transplantation to the velopharynx resulted in a significant reduction of the velopharyngeal distance and the velopharyngeal gap area during phonation, as measured by MRI. This was in accordance with a significant improvement in nasal turbulence. However, hypernasality and audible nasal emission did not change significantly and could not be correlated to the MRI findings.

Microcirculatory evaluation of deep inferior epigastric artery perforator flaps with laser Doppler perfusion imaging in breast reconstruction

Abstract We have made a quantitative analysis of the microcirculation in the classic perfusion zones of the deep inferior epigastric artery perforator (DIEAP) flap on 10 consecutive women having breast reconstruction with a unilateral DIEAP. Laser Doppler perfusion imaging was used for operative scans. Data were recorded 10 minutes after successful microanastomosis. The mean (SD) perfusion for each perfusion zone was calculated. Zone I = 44.2 (6.2); zone II = 35.1 (10.3); zone III = 39.9 (9.2); and zone IV = 21.9 (10.0). There were significant differences between zones I, II, and III and zone IV (p < 0.001), and zones I and II (p = 0.02). However, there was no significance between zones I and III (p = 0.9), and zones II and III (p = 0.6). The perfusion of zone IV was significantly lower than those in all other zones, which is in keeping with clinical practice in which zone IV is normally discarded to avoid partial necrosis of the flap in unilateral breast reconstruction. Higher values are expected in zone I than zone III, and in zone II than zone III. However, we could not confirm this. We conclude that there are no differences in skin perfusion between zones I and III, and zones II and III. However, the perfusion of zone IV was significantly less than that in all other zones immediately after revascularisation of the DIEAP flap.

Monitoring microcirculatory changes in the deep inferior epigastric artery perforator flap with laser Doppler perfusion imaging.

Microcirculatory changes were monitored in 20 deep inferior epigastric artery perforator (DIEAP) flaps during unilateral breast reconstruction until the seventh postoperative day using laser Doppler perfusion imaging. Measurements were recorded according to the zonal classification by Scheflan and Dinner. The cutaneous territory zone IV was discarded during insetting due to marginal circulation. The highest perfusion levels were found the first postoperative day for both zones I and III. Postoperative perfusion values were significantly higher for these zones compared with zone II. Immediately after revascularization, zone I was significantly better perfused than both II and III. However, the perfusion in zone III stabilized at the level of zone I in the postoperative phase. Evaluating microcirculatory changes in the DIEAP flap with laser Doppler perfusion imaging showed that zones I and III have higher perfusion levels than zone II in the postoperative phase.

Spontaneous reinnervation of deep inferior epigastric artery perforator flaps after secondary breast reconstruction

The deep inferior epigastric artery perforator (DIEAP) flap is the gold standard of free flaps in breast reconstruction. However, until now little attention has been paid to reinnervation of the flap. The aim of this study was to examine the spontaneous reinnervation of the DIEAP flap after breast reconstruction. The study was cross-sectional, and included 29 women who had all previously had secondary reconstruction with a DIEAP flap after mastectomy for breast cancer. Pressure thresholds were analysed on the skin island of the flap using Semmes-Weinstein monofilaments. The measurements showed measurable sensation in 29 of the 30 flaps. Nine patients had normal or diminished light touch in one or more areas. We also found significant better pressure sensitivity when the medial was compared to the lateral side and the inferior to the superior side of the flap. Our data showed that DIEAP flaps reinnervate after breast reconstruction although there is no sensory nerve repair. We suggest that nerve ingrowth takes place from the sides and this seems to be more pronounced in the inferomedial part of the flap.

Ultrasonographic evaluation of the rectus abdominis muscle after breast reconstruction with the DIEP flap

The aim of this study was to evaluate whether the dissection of the vascular pedicle of the deep inferior epigastric perforator (DIEP) flap could induce secondary muscle atrophy. Evaluation of the rectus abdominis muscle was performed using ultrasonography, and the muscle thickness was measured as an expression of muscle substance. This was performed at 4 levels: below the xiphoid process, at the umbilicus level, above the symphysis, and between the 2 last mentioned (central zone). The results were expressed as the ratio of the muscle thickness on the operated side where dissection of the vascular pedicle was performed to the thickness of the contralateral not operated muscle. Thirteen patients were included with a mean follow up of 20 months (range, 7–42months). The combined measurements showed that the thickness of the muscle as a whole was significantly reduced on the operated side compared with the opposite side. Broken down to the specific levels, the greatest reduction in thickness, approximately 10%, was found at the xiphoid process and above the symphysis. We conclude that performing the dissection of the vascular pedicle of the DIEP flap gives a small but significant degree of muscular atrophy.

Evaluation of patients after treatment of arterial priapism with selective micro-embolization

Objective. Arterial (high-flow) priapism is characterized by a prolonged non-painful erection without sexual arousal as a result of unregulated inflow of blood to the corpus cavernosum. Treatment is based on decreasing this elevated inflow, primarily by means of selective arteriography and embolization. The aim of this study was to evaluate the treatment of patients with arterial priapism. Material and methods. In the period between 1990 and 2004, 10 patients with arterial priapism were admitted to our department. The mean age when priapism developed was 32 years (range 11–62 years). Eight patients were treated with selective embolization, one was operated on and one refused treatment. Nine patients completed a standardized questionnaire which included the International Index of Erectile Function (IIEF-5). The mean follow-up time after treatment was 70 months. Results. All patients treated with selective embolization achieved reduced tumescence. Six out of eight patients had an improved IIEF-5 score after treatment. In nine men, the etiology of the arterial priapism was perineal trauma. In one case, an anomaly with an accessory artery to the corpus cavernosum was diagnosed, which required surgery, and in one case recurrence of the priapism necessitated a second embolization. Conclusions. Selective embolization results in reduced tumescence and an improvement in erectile function in patients with arterial priapism. Trauma to the perineum was the main etiology in this study.

Patient-reported outcomes after breast reconstruction with deep inferior epigastric perforator flaps.

We assessed patient-reported outcomes in 34 women who had had their breasts reconstructed with a deep inferior epigastric perforator (DIEP) flap, and compared them with those of 24 patients who were waiting for breast reconstruction. Both groups completed the Short Form 36 (SF-36) questionnaire. The DIEP flap group also assessed their preoperative conditions retrospectively and completed a study-specific questionnaire. The DIEP group reported higher SF-36 mental health scores after the operation than before, but no difference on other SF-36 scales. There was no difference on any SF-36 scale between patients who had had DIEP flaps and those waiting for reconstruction. Most of the DIEP group was satisfied with their bodies, the appearance of their breasts after reconstruction, and would have chosen operation again. In conclusion, there was little improvement in generic health-related quality of life after reconstruction with a DIEP flap. However, patients’ satisfaction was high after the procedure.

Superiorly based pharyngeal flap for treatment of velopharyngeal insufficiency in patients with 22q11.2 deletion syndrome.

BackgroundThere are no previous blinded studies for comparison of preoperative versus postoperative perceptual speech assessments when using a pharyngeal flap for treating velopharyngeal insufficiency (VPI) in patients diagnosed with 22q11.2 deletion syndrome. The aim of the study was to evaluate the effect of superiorly based pharyngeal flap surgery on speech in these patients using blinded judgments of experienced speech therapists. MethodsA retrospective study of 12 consecutive patients who had undergone pharyngeal flap surgery for treatment of VPI between 2002 and 2009 was conducted. Seven girls and 5 boys between 4 and 15 (median, 6) years old at the time of surgery were included in the study. Six patients were born with a submucous cleft palate (including 2 occult), and 1 patient, with an overt cleft palate. The remaining 5 patients had no signs of a palatal pathology. All palatal clefts had been repaired before pharyngeal flap surgery except in 2 patients with occult submucous cleft palate. Preoperative and postoperative audio recordings were blinded for scoring independently by 3 senior speech therapists. ResultsThere was a significant improvement in hypernasality (P = 0.002), audible nasal emission (P = 0.033), weak pressure consonants (P = 0.008), and speech intelligibility (P = 0.021) after pharyngeal flap surgery. Hyponasality did not develop significantly with surgery. One patient was diagnosed with obstructive sleep apnea. ConclusionsSuperiorly based pharyngeal flap resulted in a significant speech improvement in 12 consecutive patients with 22q11.2 deletion syndrome having VPI.