Cognitive brain activity before and after surgery in meningioma patients.

Neuropsychological studies have demonstrated that meningioma patients frequently exhibit cognitive deficits before surgery and show only limited improvement after surgery. Combining neuropsychological with functional imaging measurements can shed more light on the impact of surgery on cognitive brain function. We aimed to evaluate whether surgery affects cognitive brain activity in such a manner that it may mask possible changes in cognitive functioning measured by neuropsychological tests. Twenty-three meningioma patients participated in a fMRI measurement using a verbal working memory task as well as three neuropsychological tests focused on working memory, just before and 3 months after surgery. A region of interest based fMRI analysis was used to examine cognitive brain activity at these timepoints within the central executive network and default mode network. Neuropsychological assessment showed impaired cognitive functioning before as well as 3 months after surgery. Neuropsychological test scores, in-scanner task performance as well as brain activity within the central executive and default mode network were not significantly different between both timepoints. Our results indicate that surgery does not significantly affect cognitive brain activity in meningioma patients the first few months after surgery. Therefore, the lack of cognitive improvement after surgery is not likely the result of compensatory processes in the brain. Cognitive deficits that are already present before surgery appear to be persistent after surgery and a considerable recovery period. Our study shows potential leads that comprehensive cognitive evaluation can be of added value so that cognitive functioning may become a more prominent factor in clinical decision making.

Reliability and validity of handheld structured light scanners and a static stereophotogrammetry system in facial three-dimensional surface imaging.

Several new systems for three-dimensional (3D) surface imaging of the face have become available to assess changes following orthognathic or facial surgery. Before they can be implemented in practice, their reliability and validity must be established. Our aim, therefore, was to study the intra- and inter-system reliability and validity of 3dMD (stereophotogrammetry), Artec Eva and Artec Space Spider (both structured light scanners). Intra- and inter-system reliability, expressed in root mean square distance, was determined by scanning a mannequin's head and the faces of healthy volunteers multiple times. Validity was determined by comparing the linear measurements of the scans with the known distances of a 3D printed model. Post-processing errors were also calculated. Intra-system reliability after scanning the mannequin's head was best with the Artec Space Spider (0.04 mm Spider; 0.07 mm 3dMD; 0.08 mm Eva). The least difference in inter-system reliability after scanning the mannequin's head was between the Artec Space Spider and Artec Eva. The best intra-system reliability after scanning human subjects was with the Artec Space Spider (0.15 mm Spider; 0.20 mm Eva; 0.23 mm 3dMD). The least difference in inter-system reliability after scanning human subjects was between the Artec Eva and Artec Space Spider. The most accurate linear measurement validity occurred with the Artec Space Spider. The post-processing error was 0.01 mm for all the systems. The Artec Space Spider is the most reliable and valid scanning system.

[Adjunctive aesthetic procedures in orthognathic surgery]. / Esthetische aangezichtschirurgie gecombineerd met orthognathische chirurgie.

In addition to function, occlusion and airway volume, aesthetics play an important role in the planning and execution of orthognathic surgery. To improve the aesthetic outcome of orthognathic surgery, there are several procedures that can be combined with orthognathic surgery secondarily, or in the same operation. These include: lipofilling, dermal fillers, facial implants, liposuction, ear corrections, eyelid corrections, or a lip lift. Patients often appreciate it when the options for additional procedures are discussed. However, both undertreatment and overtreatment can lead to unfavorable outcomes. Proper care and thoroughness are of course required, as to not change the characteristic facial aspects of a patient too much.

Postoperative skeletal stability at the one-year follow-up after splintless Le Fort I osteotomy using patient-specific osteosynthesis versus conventional osteosynthesis: a randomized controlled trial.

The purpose of this study was to assess the 1-year skeletal stability of the osteotomized maxilla after Le Fort I surgery, comparing conventional osteosynthesis with patient-specific osteosynthesis. Patients were assigned to a conventional or patient-specific osteosynthesis group using prospective randomization. The primary outcome was the three-dimensional change in postoperative skeletal position of the maxilla between the 2-week and 1-year follow-up cone beam computed tomography scans. Fifty-eight patients completed the protocol for the 2-week postoperative analysis, and 27 patients completed the 1-year follow-up study protocol. Of the 27 patients completing the entire protocol, 13 were in the conventional group and 14 in the patient-specific osteosynthesis group. The three-dimensional translation analysis showed that the use of the patient-specific osteosynthesis resulted in a skeletally stable result, comparable to that of conventional miniplate fixation. For both the patient-specific osteosynthesis and conventional miniplate fixation groups, median translations of less than 1 mm and median rotations of less than 1° were observed, indicating that both methods of fixation resulted in a stable result for the 27 patients examined. For the Le Fort I osteotomy, the choice between patient-specific osteosynthesis and conventional osteosynthesis did not affect the postoperative skeletal stability after 1 year of follow-up.

Patient-reported aesthetic outcomes of upper blepharoplasty: a randomized controlled trial comparing two surgical techniques.

It is not yet established whether additional orbicularis oculi muscle excision leads to better patient-reported aesthetic outcomes (PRO) compared to a skin-only resection blepharoplasty. A double-blind randomized controlled trial of upper blepharoplasty, with or without muscle excision, was performed on 54 White European patients who assessed the procedure via PRO. FACE-Q questionnaires covering eyes in general, upper eyelids, forehead and eyebrows, overall face, age appearance appraisal, age appraisal, social functioning, satisfaction with the outcome, and adverse effects were completed preoperatively and at 6 and 12 months after upper blepharoplasty. The Patient and Observer Scar Assessment Scale was used to assess scarring. The FACE-Q scores for skin-only and skin/muscle upper blepharoplasty were similar regarding the upper eyelids, forehead and eyebrows, overall face, patient perceived aging and age, social functioning, and satisfaction with the results, and also increased for both procedures with time. The FACE-Q score regarding the eyes in general was higher in the skin-only group at the 12-month follow-up. Scarring and adverse effects did not differ between the groups. Additional muscle resection does not seem to influence patient satisfaction. Thus, when performing an upper blepharoplasty, there is no need for additional muscle resection as a routine procedure to improve patient satisfaction.

Correction to: Automatic identification of atypical clinical fMRI results.

The above article was published online with an incorrect affiliation.

Fatigue in brain tumor patients, towards a neuronal biomarker.

BACKGROUND: Many brain tumor patients suffer from fatigue which severely affects their quality of life. There is a lack of objective measurements for fatigue in brain tumor patients. We aimed to find a neurophysiological correlate for fatigue in brain tumor patients. For this purpose, we correlated brain activity associated with phasic alertness with self-reported ratings of fatigue. METHODS: Patients with a meningioma, a low-grade glioma or a high-grade glioma (N = 63) participated in this fMRI study. Brain activity in the central executive network (CEN) and default mode network (DMN) associated with phasic alertness was correlated with self-reported fatigue measured with the multidimensional fatigue inventory (MFI-20). Follow-up analyses were performed for MFI-20 domain scores, individual regions within CEN and DMN, and the tumor sub-groups separately. RESULTS: MFI-20 scores correlated significantly with DMN activity associated with phasic alertness, but not with CEN activity. These results were consistent for each tumor sub-group. Within the DMN, the correlations were strongest in left and right lingual cortex, left and right cuneus, and right precuneus. DISCUSSION: Self-reported fatigue in brain tumor patients was associated with objective measurements of brain activity, specifically the DMN activity related to phasic alertness. This association represents an important step in the development of a biomarker for fatigue in brain tumor patients, and possibly for other patients that suffer from fatigue.

Automatic identification of atypical clinical fMRI results.

PURPOSE: Functional MRI is not routinely used for neurosurgical planning despite potential important advantages, due to difficulty of determining quality. We introduce a novel method for objective evaluation of fMRI scan quality, based on activation maps. A template matching analysis (TMA) is presented and tested on data from two clinical fMRI protocols, performed by healthy controls in seven clinical centers. Preliminary clinical utility is tested with data from low-grade glioma patients. METHODS: Data were collected from 42 healthy subjects from seven centers, with standardized finger tapping (FT) and verb generation (VG) tasks. Copies of these "typical" data were deliberately analyzed incorrectly to assess feasibility of identifying them as "atypical." Analyses of the VG task administered to 32 tumor patients assessed sensitivity of the TMA method to anatomical abnormalities. RESULTS: TMA identified all atypical activity maps for both tasks, at the cost of incorrectly classifying 3.6 (VG)-6.5% (FT) of typical maps as atypical. For patients, the average TMA was significantly higher than atypical healthy scans, despite localized anatomical abnormalities caused by a tumor. CONCLUSION: This study supports feasibility of TMA for objective identification of atypical activation patterns for motor and verb generation fMRI protocols. TMA can facilitate the use and evaluation of clinical fMRI in hospital settings that have limited access to fMRI experts. In a clinical setting, this method could be applied to automatically flag fMRI scans showing atypical activation patterns for further investigation to determine whether atypicality is caused by poor scan data quality or abnormal functional topography.

[Neck phlegmon with an odontogenic cause]. / Een halsflegmone met dentogene oorzaak.

BACKGROUND: When an odontogenic infection extends into the neck, a life-threatening situation may develop as a result from airway obstruction, sepsis or mediastinitis. However, this is quite rare. Prompt treatment is important to minimise these complications. CASE DESCRIPTION: A 49-year-old woman presented to the oral and maxillofacial surgery outpatient clinic of a general hospital with extensive abscesses in the neck after a molar extraction. Because of the aggressive course of the disease, the patient was transferred to a university hospital. After several surgeries, during which the neck was widely opened and drained, tracheostomy and admission to the intensive care department, the infection was under control. CONCLUSION: In case of a patient with a progressive swelling in the neck, an odontogenic cause should be considered. When, in addition to the swelling, there are also signs of worsening, such as fever, swallowing problems and locked jaw, the patient should be urgently referred to an oral and maxillofacial surgeon.

The use of xenografts to prevent inferior border defects following bilateral sagittal split osteotomies: three-dimensional skeletal analysis using cone beam computed tomography.

The aim of this retrospective study was to investigate grafting in the osteotomy gap during bilateral sagittal split osteotomy (BSSO), using a xenograft and fibrin glue. Hard tissue defects in the inferior mandibular border were assessed using cone beam computed tomography scans taken 1 week and 1year postoperatively. The study group of 20 patients underwent bone grafting during BSSO (mean age 26.1years; mean horizontal displacement 8.5mm) and the control group of 20 patients did not (mean age 30.2 years; mean horizontal displacement 7.6mm). The mean height of the mandibular defects was significantly lower in the study group, but there was no significant difference in volume measurements between the groups. Grafting had a negligible effect on large displacements (9.0-15.0mm), which might have been due to an inadequate amount and/or positioning of the graft, or to poor dimensional stability. This may be resolved by improved graft positioning or by using a different kind of (xeno)graft.

Processing of Targets and Non-targets in Verbal Working Memory.

In this study we used functional MRI (fMRI) to examine whether defining a stimulus as a target affects brain activation associated with a verbal working memory (WM) task. Seventeen healthy right-handed volunteers performed a Sternberg task with three consonants as memory set. We performed a region of interest based fMRI analysis to examine differences in brain activity patterns between targets and non-targets. Non-target brain activity was subtracted from target activity and hemispheric and fronto-parietal differences were tested by conducting a MANOVA. Participants responded correctly to 97.5% of the stimuli. The fMRI results showed a hemisphere by fronto-parietal location interaction, where targets evoked increased activity in the right frontal regions compared to non-targets, whereas the left frontal task activation did not differ between targets and non-targets. In the parietal regions, targets evoked increased activity compared to non-targets in the lateral anterior, but not the medial posterior part. Our study revealed that defining a stimulus as a target within a verbal WM task evokes an increase in brain activity in right frontal brain regions, compared to non-targets. Our results suggest an important hemispheric differentiation in target processing, in which the right frontal cortex is predominantly involved in processes associated with target stimuli. The left frontal cortex does not differentiate between processing target and non-target stimuli, suggesting involvement in WM processes that are independent of stimulus type. Parietal, the lateral anterior part is predominantly involved in target processing, while the medial posterior part does not differentiate between target and non-target processing.

Splintless surgery using patient-specific osteosynthesis in Le Fort I osteotomies: a randomized controlled multi-centre trial.

The accuracy of orthognathic surgery has improved with three-dimensional virtual planning. The translation of the planning to the surgical result is reported to vary by >2mm. The aim of this randomized controlled multi-centre trial was to determine whether the use of splintless patient-specific osteosynthesis can improve the accuracy of maxillary translation. Patients requiring a Le Fort I osteotomy were included in the trial. The intervention group was treated using patient-specific osteosynthesis and the control group with conventional osteosynthesis and splint-based positioning. Fifty-eight patients completed the study protocol, 27 in the patient-specific osteosynthesis group and 31 in the control group. The per protocol median anteroposterior deviation was found to be 1.05mm (interquartile range (IQR) 0.45-2.72mm) in the patient-specific osteosynthesis group and 1.74mm (IQR 1.02-3.02mm) in the control group. The cranial-caudal deviation was 0.87mm (IQR 0.49-1.44mm) and 0.98mm (IQR 0.28-2.10mm), respectively, whereas the left-right translation deviation was 0.46mm (IQR 0.19-0.96mm) in the patient-specific osteosynthesis group and 1.07mm (IQR 0.62-1.55mm) in the control group. The splintless patient-specific osteosynthesis method improves the accuracy of maxillary translations in orthognathic surgery and is clinically relevant for planned anteroposterior translations of more than 3.70mm.

Aesthetic outcomes of upper eyelid blepharoplasty: a systematic review.

Although upper blepharoplasty is a common cosmetic surgical intervention, a better scientific understanding of the aesthetic results and the preferred surgical technique to achieve the best aesthetic results is still needed. A systematic search using four search engines (PubMed, Embase, CINAHL, and Cochrane) was performed to identify any study on the aesthetic outcome of a solitary upper blepharoplasty; these were subjected to quality assessment for possible inclusion. Eligible studies were randomized controlled trials, controlled trials, cohort studies, and case series (n ≥ 10). A total of 4043 studies were assessed, of which 26 were included. Aesthetic outcomes included patient-reported outcome measures, scarring, eyebrow height, tarsal platform show, and panel or expert evaluation. Meta-analysis was not possible. Patients were generally satisfied with the aesthetic result and scar formation after an upper blepharoplasty. The amount of tarsal platform show increases, which positively affects the aesthetics. The eyebrow seems to move down slightly. The surgical technique used (skin only or skin/muscle removal) did not influence patient satisfaction or the physician-assessed aesthetic outcomes. Patients are generally satisfied after an upper blepharoplasty. The optimal design of the skin excision is still a matter of debate, especially when addressing lateral hooding. Further objective research is advised.

Acute effects of ∆9-tetrahydrocannabinol (THC) on resting state brain function and their modulation by COMT genotype.

Cannabis produces a broad range of acute, dose-dependent psychotropic effects. Only a limited number of neuroimaging studies have mapped these effects by examining the impact of cannabis on resting state brain neurophysiology. Moreover, how genetic variation influences the acute effects of cannabis on resting state brain function is unknown. Here we investigated the acute effects of ∆9-tetrahydrocannabinol (THC), the main psychoactive constituent of cannabis, on resting state brain neurophysiology, and their modulation by catechol-methyl-transferase (COMT) Val158Met genotype. Thirty-nine healthy volunteers participated in a pharmacological MRI study, where we applied Arterial Spin Labelling (ASL) to measure perfusion and functional MRI to assess resting state connectivity. THC increased perfusion in bilateral insula, medial superior frontal cortex, and left middle orbital frontal gyrus. This latter brain area showed significantly decreased connectivity with the precuneus after THC administration. THC effects on perfusion in the left insula were significantly related to subjective changes in perception and relaxation. These findings indicate that THC enhances metabolism and thus neural activity in the salience network. Furthermore, results suggest that recruitment of brain areas within this network is involved in the acute effects of THC. Resting state perfusion was modulated by COMT genotype, indicated by a significant interaction effect between drug and genotype on perfusion in the executive network, with increased perfusion after THC in Val/Met heterozygotes only. This finding suggests that prefrontal dopamine levels are involved in the susceptibility to acute effects of cannabis.

Functional outcomes of upper eyelid blepharoplasty: A systematic review.

OBJECTIVE: Various functional outcomes after upper blepharoplasty are reported in the literature. We systematically reviewed the literature to assess the objective and subjective functional effects of upper blepharoplasty. METHODS: After a systematic search of four search engines (Pubmed, Embase, Cinahl and Cochraine), any study on objective and subjective (patient reported) functional outcome after upper blepharoplasty was subjected to a quality assessment for possible inclusion in the review. The intervention was defined as a solitary surgical upper blepharoplasty containing the removal of skin, with or without the removal of a strip of orbicularis oculi muscle and/or upper orbital fat. Eligible studies were randomized controlled trials, controlled trials, cohort studies and case series (n ≥ 10). RESULTS: A total of 3525 studies were assessed, of which 28 studies were included in this systematic review. Favorable outcomes after an upper blepharoplasty were reported and included enlarged visual field, enhanced quality of life related to fewer headaches and improved vision. Furthermore, sensitivity of the eyelids decreased, with differences in recovery. Outcomes for eyebrow height, astigmatism, contrast sensitivity and eyelid kinematics were not consistent between the studies. No meta-analysis could be performed due to the limited scope of included studies and the great variety in outcomes and blepharoplasty techniques. CONCLUSIONS: Upper blepharoplasty is accompanied by a great variety of beneficial functional outcomes including an increased visual field and improvement in headache- and vision-related quality of life. Further research is needed, especially where results are conflicting (effects on eye dryness and eyebrow height) and/or the data are limited (contrast sensitivity, astigmatism).

[Perioral treatment options in cosmetic facial surgery]. / Periorale behandelingsmogelijkheden in de cosmetische aangezichtschirurgie.

The perioral region is unique and important in the face, both from a functional and an aesthetic point of view. There is a strong relationship between the perioral soft tissues, such as the lips and the corners of the mouth, and the underlying dentition and the jaws. Perioral ageing phenomena, such as depressed corners of the mouth, volume loss and wrinkles, can be improved, however, to a limited extent with intraoral treatment. These ageing phenomena can usually be treated more effectively with several extraoral treatment modalities that also enhance perioral aesthetics. The perioral cosmetic treatment options can be divided into various lifting procedures and volumising techniques. Considering that the dentist has to deal regularly with patients with perioral aesthetic wishes and also functional problems, it is important that one has knowledge of the different perioral treatment options, for both cosmetic and functional options.

Comparison of the long-term clinical performance of a biodegradable and a titanium fixation system in maxillofacial surgery: A multicenter randomized controlled trial.

BACKGROUND: Biodegradable fixation systems could reduce or eliminate problems associated with titanium removal of implants in a second operation. AIM: The aim of this study was to compare the long-term (i.e. >5 years postoperatively) clinical performance of a titanium and a biodegradable system in oral and maxillofacial surgery. MATERIALS AND METHODS: The present multicenter Randomized Controlled Trial (RCT) was performed in four hospitals in the Netherlands. Patients treated with a bilateral sagittal split osteotomy (BSSO) and/or a Le Fort-I osteotomy, and those treated for fractures of the mandible, maxilla, or zygoma were included from December 2006 to July 2009. The patients were randomly assigned to either a titanium (KLS Martin) or a biodegradable group (Inion CPS). RESULTS: After >5 years postoperatively, plate removal was performed in 22 of the 134 (16.4%) patients treated with titanium and in 23 of the 87 (26.4%) patients treated with the biodegradable system (P = 0.036, hazard ratio (HR) biodegradable (95% CI) = 2.0 (1.05-3.8), HR titanium = 1). Occlusion, VAS pain scores, and MFIQ showed good and (almost) pain free mandibular function in both groups. CONCLUSION: In conclusion, the performance of the Inion CPS biodegradable system was inferior compared to the KLS Martin titanium system regarding plate/screws removal in the abovementioned surgical procedures. TRIAL REGISTRATION: http://controlled-trials.com ISRCTN44212338.

[Reconstructieve facial surgery in facial defects after the surgical removal of malignant skin tumours]. / Reconstructieve aangezichtschirurgie bij aangezichtsdefecten na chirurgische verwijdering van kwaadaardige huidtumoren.

Because of the enormous and continuing increase in cases of skin cancer in the Netherlands, dentists will increasingly see patients with skin cancer. The most common malignant skin cancers are basal cell carcinoma, squamous cell carcinoma and malignant melanoma. With resection of a skin tumour, the oncological principles should be applied. For the closure of the resulting defect, a choice for the individual patient is made out of numerous techniques. Facial reconstructive surgery aims to restore the face in form and function and to maintain the patient's quality of life. By early recognition of skin tumours of the face, damage to the tissue can be limited. Dentists, who see their patients periodically, can play an important role here.

Splintless surgery: does patient-specific CAD-CAM osteosynthesis improve accuracy of Le Fort I osteotomy?

To analyse the accuracy of maxillary positioning after Le Fort I osteotomy, we retrospectively assessed the outcome in three patients (mean (range) age 40 (21 - 60) years) who had been treated with patient-specific CAD-CAM osteosynthesis plates as part of a bimaxillary osteotomy. Virtual surgical planning in each case was based on cone-beam computed tomography (CT) (Simplant® O&O, Dentsply Implants NV, Kessel-Lo, Belgium), and patient-specific CAD-CAM drilling guides and osteosynthesis plates were produced for maxillary positioning and fixation. We evaluated the accuracy of the placement by virtual comparison of the preoperative and postoperative images. In the upper dentition, postoperative analysis showed a mean (SD) deviation of 1.3 (1.4) mm from the preoperative plan. The method enables accurate placement of the maxilla, independent of the condyle or mandible, without the need for extraoral reference points.

[Cosmetic treatment during orthognathic surgery]. / Cosmetische ingrepen tijdens orthognathische chirurgie.

The goal of a combined orthodontic-surgical treatment is to correct the dysgnathia and malocclusion and thereby achieve an improvement of function. As a supplement to osteotomy, enhancement of facial aesthetics is increasingly being used to gain more harmony in the face and/or to achieve facial rejuvenation. In this regard, one might think of contour- or projection improvement by performing an intra-oral zygoma osteotomy or the placement of an alloplastic implant. By means of lipofilling, changes to the contours of the soft tissue can be realised. A sub mental fat surplus can be corrected by liposuction or lipectomy, resulting in a normalisation of the chin-neck angle. Otoplasty and limited rhinolplasty can also be combined with an osteotomy, while a blepharoplasty and a lip lift for older patients can be applied for facial rejuvenation. These aesthetic corrections can often be performed in the same surgical session as the osteotomy and contribute to significant patient satisfaction.