Stephanie Thibaudeau

Utility outcome scores for unilateral facial paralysis.

BackgroundFacial paralysis is a debilitating condition. Dynamic and static facial reanimation remains a challenge for plastic surgeons and requires important resources. Our objective was to quantify the health state utility assessment (ie, utility score outcomes) of living with unilateral facial paralysis. MethodsUtility assessments using visual analog scale, time trade-off, and standard gamble were used to obtain utility outcome scores for unilateral facial paralysis from a prospective sample of the general population and medical students. ResultsA total number of 123 individuals prospectively participated in the study. All measures (visual analog scale, time trade-off, and standard gamble) for unilateral facial paralysis [0.56 ± 0.18, 0.78 ± 0.21, and 0.79 ± 0.21 respectively] were significantly different (P < 0.0001) from the corresponding outcome scores for monocular blindness [0.61 ± 0.21, 0.83 ± 0.21, and 0.85 ± 0.18, respectively] and binocular blindness [0.33 ± 0.18, 0.65 ± 0.28, and 0.65 ± 0.29, respectively]. Linear regression analysis using age, race, income, and education as predictors of each of the utility scores for facial paralysis showed no statistical significance. ConclusionsIn samples of the general population and medical students, all utility score outcome measures for facial paralysis were lower than those for monocular blindness. Our sample population, if faced with unilateral facial paralysis, would theoretically undergo facial reanimation procedures with a willingness to sacrifice 8 years of life and be willing to undergo a procedure with a 21% chance of mortality to attain perfect health, respectively.

Utility scores for facial disfigurement requiring facial transplantation [outcomes article].

Background: Controversy exists as to whether the benefits of facial transplantation outweigh the risk of continuous immunosuppression. Utility scores [range, 0 (death) to 1 (perfect health)] are a standardized tool with which to objectify health states or diseases and can help answer such controversy. Methods: An Internet-based utility assessment study using visual analogue scale, time trade-off, and standard gamble was used to obtain utilities for facial disfigurement requiring facial transplantation from a sample of the general population and medical students at McGill University. Average utility scores were compared using t test, and linear regression was performed using age, race, and education as independent predictors of each of the utility scores. Results: A total of 307 people participated in the study. All measures (visual analogue scale, time trade off, and standard gamble) for facial disfigurement (0.46 ± 0.02, 0.68 ± 0.03, and 0.66 ± 0.03, respectively) were significantly different (p < 0.001) from the corresponding ones for monocular blindness (0.62 ± 0.02, 0.83 ± 0.02, and 0.82 ± 0.02, respectively) and binocular blindness (0.33 ± 0.02, 0.62 ± 0.03, and 0.61 ± 0.03, respectively). Age was inversely proportional to the utility scores in all groups (p < 0.01), decreasing a utility score of 0.006 for every increase in year of age. Conclusion: A sample of the general population and medical students, if faced with facial disfigurement, would undergo a face transplant procedure with a 34 percent chance of death and be willing to trade 12 years of their life to attain perfect health.

The impact of living with a functional and aesthetic nasal deformity after primary rhinoplasty: a utility outcomes score assessment.

BackgroundRevision rhinoplasty for functional deformities can be both an aesthetic and reconstructive surgical challenge. We set out to quantify the health state utility assessment of living with the physical appearance of nasal asymmetry along with having nasal obstruction. The use of utility scores has helped to establish the health burden of living with various medical conditions. We sought to quantify living with a health state of nasal asymmetry with nasal obstruction after primary rhinoplasty using utility outcome scores. MethodsWe used previously validated utility outcome measures to quantify the health burden of this clinical scenario in 128 prospective subjects. These subjects were from a sample of the population and medical students recruited to complete a survey to determine the utility outcome score of revision rhinoplasty using visual analog scale (VAS), time trade-off (TTO), and standard gamble (SG) tests to obtain utility scores for revision rhinoplasty. Linear regression and Student t test were used for statistical analysis. ResultsAll measures (VAS, TTO, and SG) for functional nasal deformity (0.80 ± 0.13, 0.90 ± 0.12, and 0.91 ± 0.13, respectively) of the 128 prospective subjects participating in this online study were significantly different (P < 0.005) from the corresponding scores for monocular blindness (0.63 ± 0.15, 0.85 ± 0.16, and 0.85 ± 0.19, respectively) and binocular blindness (0.38 ± 0.18, 0.66 ± 0.25, and 0.69 ± 0.24, respectively). Being white was inversely related to the VAS utility scores for rhinoplasty (P < 0.05). Additionally, female sex was positively correlated to the TTO score. Age, income, and education were not predictors of utility scores. ConclusionsIn a sample of the population and medical students, VAS, TTO, and SG utility scores for revision rhinoplasty were determined and can be compared objectively with other health states and diseases with known utility scores. In a preoperative setting, women were objectively willing to potentially “trade” more years of life to treat a functional nasal deformity. If faced with a deformed nose after primary rhinoplasty, our sample population would consent to undergo a revision rhinoplasty procedure with a theoretical 9% chance of mortality and were willing to trade 3.6 years of their remaining life.

Utility Outcome Assessment of the Aging Neck following Massive Weight Loss

Objective The authors set out to quantify the health state utility assessment of living with the physical appearance of the aging neck following massive weight loss. Described utility scores may help to establish the health burden of the aging neck in the growing bariatric patient population. Study Design Prospective cohort observational study. Setting Tertiary referral medical center. Subjects and Methods Three validated tools were used to determine utility scores for living with an aging neck: visual analog scale (VAS), time trade-off (TTO), and standard gamble (SG). A 5-point Likert scale was used to evaluate the subjects’ ease of understanding. A prospective sample of volunteers from the general population and medical students was used for this assessment. Results In total, 118 prospective volunteers were included in the survey. All measures (VAS, TTO, SG); (0.89 ± 0.07, 0.94 ± 0.08, and 0.95 ± 0.10, respectively) varied (P < .0001) from the corresponding ones for monocular blindness (0.62 ± 0.18, 0.87 ± 0.15, and 0.85 ± 0.20, respectively) and binocular blindness (0.32 ± 0.18, 0.66 ± 0.25, and 0.64 ± 0.28, respectively). Conclusion The authors objectified the health state of living with an aging neck in the massive weight loss patient with utility scores (TTO, 0.94) comparable with those living with obstructive sleep apnea. This sample population, if faced with an aging neck following massive weight loss, would undertake a neck rejuvenation procedure with a theoretical 5% chance of mortality and would be willing to trade 2.1 years of remaining life-years to attain this procedure.

The effects of breast reduction on successful breastfeeding: A systematic review

BACKGROUND There is not yet a consensus in defining the ability to breastfeed up to the recommended duration of 6 months after reduction mammaplasty. We reviewed the literature to study the possibility for successful and exclusive breastfeeding for this duration. METHOD A systematic review of literature was performed using the Ovid Medline Database and the PubMed database to retrieve all published original articles that studied the effects of reduction mammaplasty on breastfeeding from 1950 to December 2008. RESULTS There appears to be no difference in breastfeeding capacity after reduction mammaplasty compared to women of the North American general population during the first month postpartum. Difficulties related to breastfeeding appear to be mostly explained by psychosocial issues related to advice and coaching received by healthcare workers during breastfeeding as well as other patient personal considerations. CONCLUSION Women who have children after having had breast reduction surgery should be encouraged to breast feed. Consensus on the defining successful breastfeeding is required and we suggest using the definition of six months of exclusive breastfeeding as recommended by the WHO.

The impact of living with severe lower extremity lymphedema: a utility outcomes score assessment.

BackgroundDebilitating lower extremity lymphedema can be either congenital or acquired. Utility scores are an objective measure used in medicine to quantify degrees of impact on an individual’s life. Using standardized utility outcome measures, we aimed to quantify the health state of living with severe unilateral lower extremity lymphedema. MethodsA utility outcomes assessment using visual analog scale, time trade-off, and standard gamble was used for lower extremity lymphedema, monocular blindness, and binocular blindness from a sample of the general population and medical students. Average utility scores were compared using a paired t test. Linear regression was performed using age, race, and education as independent predictors. ResultsA total of 144 prospective participants were included. All measures [visual analog scale, time trade-off, and standard gamble; expressed as mean (SD)] for unilateral lower extremity lymphedema (0.50 ± 0.18, 0.76 ± 0.22, and 0.76 ± 0.21, respectively) were significantly different (P < 0.001) from the corresponding scores for monocular blindness (0.64 ± 0.18, 0.84 ± 0.16, and 0.83 ± 0.17, respectively) and binocular blindness (0.35 ± 0.17, 0.61 ± 0.28, and 0.62 ± 0.26, respectively). ConclusionsWe found that a sample of the general population and medical students, if faced with severe lymphedema, is willing to theoretically trade 8.64 life-years and undergo a procedure with a 24% risk of mortality to restore limb appearance and function to normal. These findings provide a frame of reference regarding the meaning of a diagnosis of severe lower extremity lymphedema to a patient and will allow objective comparison with other health states.

Management of Soft Tissue Defects of the Hand

Soft tissue coverage of the hand remains a challenging problem to the hand surgeon, but advances in the field of microsurgery have provided improved thin, pliable, durable flaps that offer cosmetic reconstructive options. The reconstructive elevator is poised to replace the reconstructive ladder, thereby allowing early reconstruction by the best available option. This reviews focus on the variety of pedicled, free fasciocutaneous, and venous flaps available for successful soft tissue coverage of the hand.

18-month outcomes of heterologous bilateral hand transplantation in a child: a case report

BACKGROUND Although heterologous vascular composite allotransplantation has become a burgeoning treatment option for adult amputees, there have been no successful cases previously reported in children. Here, we describe the surgical, immunological, and neurorehabilitation details with functional outcomes 18 months after heterologous bilateral hand and forearm transplantation in an 8-year-old child with quadrimembral amputations and a previous kidney transplant. METHODS 2 years of extensive preparation by medical and surgical teams preceded the hand-forearm transplantation of this child. The initial immunosuppressive protocol included thymoglobulin, tacrolimus, prednisone, and mycophenolate mofetil. In July, 2015, our vascularised composite allotransplantation team did the first bilateral hand and forearm transplantation in a child, an 8-year-old boy with previous living-related kidney transplantation. The surgery included four teams working simultaneously on the donor and recipient limbs, aided by customised cutting guides that aimed to reduce ischaemia time. Following an extended length of time in hospital, skin biopsies and close monitoring of renal function and drug concentrations occurred weekly for the first 3 months and were slowly tapered to monthly, and then quarterly. Skin biopsies were also done when tissue rejection was suspected. Paediatric-specific rehabilitation techniques were applied to promote patient engagement during rehabilitation. Progress was assessed by monthly sensory and motor function tests during routine clinic visits and with serial functional brain imaging studies, including structural brain MRI, magnetoencephalography and transcranial magnetic stimulation. FINDINGS The surgery lasted 10 h and 40 min. Vascular revision of the ulnar artery was required a few hours postoperatively. There were no further immediate postsurgical complications. Rejection episodes occurred throughout the first year but were reversed. An increase in serum creatinine led to the addition of sirolimus at 3 months after transplantation with concomitant reduction in tacrolimus targets. Sensibility to light touch was present by 6 months after transplantation. Intrinsic hand muscle innervation was present by 7-10 months after transplantation. At 18 months, the child had exceeded his previous adapted abilities. As of 18 months after transplantation surgery he is able to write and feed, toilet, and dress himself more independently and efficiently than he could do before transplantation. He remains on four immunosuppressive medications and functional neuroimaging studies have shown motor and somatosensory cortical reorganisation. INTERPRETATION Hand transplantation in a child can be surgically, medically, and functionally successful under carefully considered circumstances. Long-term data on the functional trajectory, neurological recovery, psychological sequelae, and the potential late effect of immunosuppression are still needed to support broader implementation of paediatric vascular composite allotransplantation. FUNDING The Childrens Hospital of Philadelphia.

A Scapholunate Ligament–Sparing Technique Utilizing the Medial Femoral Condyle Corticocancellous Free Flap to Reconstruct Scaphoid Nonunions With Proximal Pole Avascular Necrosis

This article demonstrates a technique for the treatment of scaphoid fracture waist and proximal pole nonunions with avascular necrosis using a free vascularized medial femoral condyle flap. We present our surgical technique and representative case examples in which the scapholunate ligament, a key structure required to preserve carpal kinematics, is spared.

Hand and Wrist Fractures in the Elderly

Distal radius fractures are among the most common fractures sustained by elderly individuals. As the population ages and elderly individuals continue to remain active, prevention and treatment of hand and wrist fractures become increasingly important. Prevention is aimed at maintaining and improving bone health. The goals of treatment are to provide a painless limb with good function. Treatment principles are based on whether the fracture is open or closed, whether the fracture is stable or unstable, and whether the degree of malalignment will impact function. There is no consensus regarding the treatment of distal radius fractures in elderly patients. For those fractures which are deemed appropriate for operative fixation, the literature supports volar locking plate fixation. While surgical treatment improves alignment, it does not appear to be the case that radiographic assessment is associated with better clinical outcomes.