Translation of SCAR-Q into Finnish and psychometric validation of the Finnish version.

BACKGROUND: An effective patient-reported outcome measure for scars is needed to assess scar treatments and thus improve scar management. The recently developed SCAR-Q questionnaire for all scar types, which consists of the Appearance, Symptom, and Psychosocial impact scales, has been developed with patients' input. The aim of this study was to translate the SCAR-Q into Finnish and to assess its psychometric properties in burn patients. METHODS: The translation protocol followed the International Society for Pharmacoeconomics and Outcomes Research guidelines. Participants for the psychometric validation of the Finnish SCAR-Q were adults with deep second or third degree burns treated with skin grafting in the Helsinki Burn Centre between 2006 and 2017. Internal consistency was assessed by using Crohnbach's alpha and reliability by using ICC, SEM, R values, and Mann-Whitney U-test. The internal structure of each SCAR-Q subscale was investigated by using exploratory factor analysis. RESULTS: 190 burn patients participated in the psychometric validation of the Finnish SCAR-Q. 135 (71.1 %) of the participants were male. Ceiling effect was present in all subscales. Internal consistency was excellent with all subscales, Crohnbach's alpha 0.97, 0.91, and 0.94. Reliability was good in all subscales, ICC 0.84, 0.88, and 0.91. The parallel analysis suggested inclusion of one factor into factor analysis for the Appearance scale and the Psychosocial impact scale, whereas two factors for the Symptom scale. CONCLUSION: The Finnish version of the SCAR-Q is equivalent with the original scale, showed excellent internal consistency, factor analysis confirmed it for the Appearance and Psychosocial impact scale, and demonstrated good reliability with all subscales when used in assessing burn scars.

International consensus recommendations on face transplantation: A 2-step Delphi study.

Face transplantation is a viable reconstructive approach for severe craniofacial defects. Despite the evolution witnessed in the field, ethical aspects, clinical and psychosocial implications, public perception, and economic sustainability remain the subject of debate and unanswered questions. Furthermore, poor data reporting and sharing, the absence of standardized metrics for outcome evaluation, and the lack of consensus definitions of success and failure have hampered the development of a "transplantation culture" on a global scale. We completed a 2-round online modified Delphi process with 35 international face transplant stakeholders, including surgeons, clinicians, psychologists, psychiatrists, ethicists, policymakers, and researchers, with a representation of 10 of the 19 face transplant teams that had already performed the procedure and 73% of face transplants. Themes addressed included patient assessment and selection, indications, social support networks, clinical framework, surgical considerations, data on patient progress and outcomes, definitions of success and failure, public image and perception, and financial sustainability. The presented recommendations are the product of a shared commitment of face transplant teams to foster the development of face transplantation and are aimed at providing a gold standard of practice and policy.

Enhanced recovery after surgery (ERAS) protocol improves patient outcomes in free flap surgery for head and neck cancer.

BACKGROUND: In recent years, enhanced recovery after surgery (ERAS) guidelines have been developed to optimize pre-, intra-, and postoperative care of surgical oncology patients. The aim of this study was to compare management outcome of patients undergoing head and neck cancer (HNC) surgery with free flap reconstruction at our institution before and after the implementation of the ERAS guidelines. METHODS: This retrospective study comprised 283 patients undergoing HNC surgery with free flap reconstruction between 2013 and 2020. Patients operated before and after the implementation of the ERAS protocol in October 2017 formed the pre-ERAS group (n = 169), and ERAS group (n = 114), respectively. RESULTS: In the pre-ERAS group the mean length of stay (LOS) and intensive care unit length of the stay (ICU-LOS) were 20 days (range 7-79) and 6 days (range 1-32), and in the ERAS group 13 days (range 3-70) and 5 days (range 1-24), respectively. Both LOS (p < 0.001) and ICU-LOS (p = 0.042) were significantly reduced in the ERAS group compared to the pre-ERAS group. There were significantly fewer medical complications in the ERAS group (p < 0.003). No difference was found between the study groups in the surgical complication rate or in the 30-day or 6-month mortality rate after surgery. CONCLUSIONS: We found reduced LOS, ICU-LOS, and medical complication rate, but no effect on the surgical complication rate after implementation of the ERAS guidelines, which supports their use in major HNC surgery.

Translation and validation of a Finnish version of the Facial Clinimetric Evaluation (FaCE) Scale.

BACKGROUND: The Facial Clinimetric Evaluation (FaCE) scale is a patient-reported health status instrument developed for assessing the health-related quality of life (HRQoL) in patients with facial nerve paralysis. The aim of this study was to translate and validate the FaCE scale for the Finnish-speaking population. METHODS: The FaCE scale was translated according to international guidelines. Sixty patients in an outpatient clinic prospectively completed the translated FaCE scale and generic HRQoL instrument (15D). The objective facial paralysis grading was made using the Sunnybrook and House-Brackmann scales. Repeated FaCE and 15D instruments were mailed to patients 2 weeks later. Total scores of the FaCE instrument and subscales were calculated, and floor and ceiling effects were examined. Exploratory factor analysis was made. Internal consistency, reliability, and repeatability were assessed. Convergence with 15D instrument, Sunnybrook, and House-Brackmann scales was examined. RESULTS: The total internal consistency of the FaCE scale was high (Cronbach's alpha 0.83). There were no statistically significant differences found between mean scores of the subscales in test-retest analysis (p > 0.05). Intra-class correlations coefficients were high, ranging between 0.78 and 0.92, and the correlations were statistically significant (p < 0.001). There were statistically significant correlations observed between the FaCE scale and the 15D, Sunnybrook, and House-Brackmann scores. CONCLUSION: The FaCE scale was successfully translated and validated in Finnish with good validity and reliability. We also demonstrated statistically significant correlations between the generic HRQoL15D instrument and both the Sunnybrook and House-Brackmann physician-based grading scales. The FaCE scale is now ready for use in Finnish facial paralysis patients.

Sauna contact burns in adults in the Helsinki Burn Centre during 2006-2018.

INTRODUCTION: Within Finish culture is a strong tradition of sauna bathing. This special environment predisposes the persons refreshing in the sauna to different kind of burns with varying etiologies. Despite the high prevalence of sauna related burns in Finland, there is paucity on the sauna related burns literature. METHODS: In this 13-year retrospective study, all sauna-related contact burns in the adult population treated at the Helsinki Burn Centre were analyzed. Altogether 216 patients were included in this study. RESULTS: The incidence of sauna-related contact burns was significantly higher in males; they accounted for 71.8% of patients. In addition to male gender, another risk factor was high age, with the elderly also being more prone to have a longer length of stay in hospital and more often receiving operative treatment. Despite most burns being relatively small, they were deep and more than one-third (36.6%) of patients underwent surgery. A strong seasonal variation in the injuries was recorded; over 40% of the burns took place during the summer months. CONCLUSION: Sauna contact burns are common, and despite their small size, they frequently cause deep injuries indicating operative treatment. There is a clear male predominance in the patient population. Most probably the cultural aspects of sauna bathing at summer cottages explain the strong seasonal variation in the incidence of these burns. The long latency between initial injury and presentation at the Helsinki Burn Centre should be highlighted to health care centres and central hospitals.

Comprehensive outcome analysis in two composite face transplants in Helsinki: Have we succeeded?

INTRODUCTION: There is a need to define what is success after face transplantation (FT). We have previously created a four-component criteria tool to define indications for FT. In this study, we used the same criteria to evaluate the overall outcome of our first two patients after FT. PATIENTS AND METHODS: Preoperative analysis of our two bimaxillary FT patients was compared to the results at four and six years post-transplantation. The facial deficiency impact was divided into four categories: (1) anatomical regions, (2) facial functions (mimic muscles, sensation, oral functions, speech, breathing, periorbital functions), (3) esthetics, and (4) impact on health-related quality of life (HRQoL). Immunological status and complications were also evaluated. RESULTS: For both patients, near-normal anatomical restoration of almost all the facial regions (except the periorbital and intraoral regions) was achieved. The majority of the facial function parameters improved in both patients (patient 2 to a near-normal level). The esthetic score improved from severely disfigured to impaired (patient 1) and to near to normal (patient 2). Quality of life was severely lowered prior to FT and improved after FT but was still affected. Neither patient has experienced acute rejection episodes during follow-up. CONCLUSIONS: We conclude that our patients have benefitted from FT, and we have succeeded. Time will reveal whether we have achieved long-term success.

Facial Expression after Face Transplant: An International Face Transplant Cohort Comparison.

BACKGROUND: Assessment of motor function restoration following face transplant (FT) is difficult, as standardized, bilateral tests are lacking. This study aims to bolster support for software-based analysis through international collaboration. METHODS: FaceReader (Noldus, Wageningen, The Netherlands), a facial expression analysis software, was used to analyze posttransplant videos of eight FT patients from Boston, Massachusetts (range, 1 to 9 years after transplant), two FT patients from Helsinki, Finland (range, 3 to 4 years after transplant), and three FT patients from Antalya, Turkey (range, 6.5 to 8.5 years after transplant). Age-matched healthy controls from respective countries had no history of prior facial procedures. Videos contained patients and controls performing facial expressions evaluated by software analysis using the Facial Action Coding System. Facial movements were assigned intensity score values between 0 (absent) and 1 (fully present). Maximum values were compared with respective healthy controls to calculate percentage restoration. RESULTS: Of 13 FT patients, eight patients were full FT, five patients were partial FT, and two patients were female patients. Compared with healthy controls, the median restoration of motor function was 36.9% (interquartile range, 28.8% to 52.9%) for all patients with FT ( P = 0.151). The median restoration of smile was 37.2% (interquartile range, 31.5% to 52.7%) for all patients with FT ( P = 0.065). When facial nerve coaptation was performed at the distal branch level, average motor function restoration was 42.7% ± 3.61% compared with 27.9% ± 6.71% at the proximal trunk coaptation level ( P = 0.032). Use of interpositional nerve grafts had no influence on motor outcomes. CONCLUSIONS: Software-based analysis is suitable to assess motor function after FT. International collaboration strengthens outcome data for FT. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Translation and psychometric validation of the Finnish version of the Patient Scar Assessment Scale for use in patients with burn scars.

BACKGROUND: The aim of this study was to create a Finnish scar assessment scale by translating and evaluating the psychometric properties of the Patient Scar Assessment Scale (PSAS), a part of the Patient and Observer Scar Assessment Scale (POSAS), with burn patients to enable its use in burn care. METHODS: The translation process followed international guidelines with forward and backward translations and cognitive debriefing with patients. Psychometric validation was performed with adult patients with burns who had been treated at the Helsinki Burn Centre between 2006 and 2017 with skin grafting following the excision of deep second- or third-degree burns. To ensure reproducibility, the PSAS was sent to the study participants twice. The correlation between the PSAS and health-related quality of life (HRQL) was also tested. RESULTS: In total, 192 patients, of whom 71 % were male, participated in this study. The mean (SD) age of the participants was 57 (17) years. The internal consistency of the PSAS was good, Cronbach's α 0.89 (95 % CI: 0.86-0.91). The reproducibility was also good concerning all items and the total score, ICC from 0.77 to 0.89. As expected, the total PSAS score correlated negatively with HRQL. CONCLUSION: The PSAS was successfully translated and culturally adapted into Finnish and the newly translated version has good validity and reproducibility for assessing mature burn scars.

A prospective dual-centre intra-individual controlled study for the treatment of burns comparing dermis graft with split-thickness skin auto-graft.

To investigate if donor and recipient site morbidity (healing time and cosmesis) could be reduced by a novel, modified split-thickness skin grafting (STSG) technique using a dermal component in the STSG procedure (DG). The STSG technique has been used for 150 years in surgery with limited improvements. Its drawbacks are well known and relate to donor site morbidity and recipient site cosmetic shortcomings (especially mesh patterns, wound contracture, and scarring). The Dermal graft technique (DG) has emerged as an interesting alternative, which reduces donor site morbidity, increases graft yield, and has the potential to avoid the mesh procedure in the STSG procedure due to its elastic properties. A prospective, dual-centre, intra-individual controlled comparison study. Twenty-one patients received both an unmeshed dermis graft and a regular 1:1.5 meshed STSG. Aesthetic and scar assessments were done using The Patient and Observer Scar Assessment Scale (POSAS) and a Cutometer Dual MPA 580 on both donor and recipient sites. These were also examined histologically for remodelling and scar formation. Dermal graft donor sites and the STSG donor sites healed in 8 and 14 days, respectively (p < 0.005). Patient-reported POSAS showed better values for colour for all three measurements, i.e., 3, 6, and 12 months, and the observers rated both vascularity and pigmentation better on these occasions (p < 0.01). At the recipient site, (n = 21) the mesh patterns were avoided as the DG covered the donor site due to its elastic properties and rendered the meshing procedure unnecessary. Scar formation was seen at the dermal donor and recipient sites after 6 months as in the standard scar healing process. The dermis graft technique, besides potentially rendering a larger graft yield, reduced donor site morbidity, as it healed faster than the standard STSG. Due to its elastic properties, the DG procedure eliminated the meshing requirement (when compared to a 1:1.5 meshed STSG). This promising outcome presented for the DG technique needs to be further explored, especially regarding the elasticity of the dermal graft and its ability to reduce mesh patterns.Trial registration: ClinicalTrials.gov Identifier (NCT05189743) 12/01/2022.

Validation of the Finnish FACE-Q for use in patients undergoing surgery for functional problems or malignancy.

The aim of this study was to produce a Finnish version of the FACE-Q scales Satisfaction with Forehead and Eyebrows, Adverse effects: Forehead, Eyebrows and Scalp, and Adverse effects: Cheeks, Lower face and Neck, and assess the performance of these scales and the Satisfaction with Facial Appearance, Satisfaction with Outcome and Appearance-related Psychosocial Distress in patients who had undergone surgery for functional problems or malignancy affecting the forehead or cheeks. The general health-related outcomes instrument 15 D was used as a reference. Patients who had undergone a frontal lift, a direct brow lift, a facelift or an excision of a facial tumor in Helsinki University Hospital plastic surgery department in 2009-2019 were identified. A postal survey study was conducted with 305 patients, of whom 135 (44%) responded. Diagnoses included facial nerve dysfunction (53%), brow ptosis (21%) and skin, mucosal or salivary gland tumor (20%). The FACE-Q scales displayed high internal consistency (Cronbach's alphas ≥0.80) and good reliability on repeat administration. The exploratory factor analysis revealed unifactorial influences for all scales except the Adverse effects: Forehead, Eyebrows and Scalp. Weak correlations with 15 D dimensions were detected. The FACE-Q scales evaluated here are suitable for use in patients with functional problems or malignancy.

The four category systematic approach for selecting patients for face transplantation.

There is a need for a systematic approach to evaluate patients for potential face transplantation (FT). Ten patients with severe facial defects treated between 1995 and 2017 formed the study group. Data was collected from patient charts and clinical, radiological and laboratory examinations. Facial deficiencies were subdivided into four different categories: anatomical region (10 facial subunits), facial function, aesthetic defect (range 0-9-worst), and impact on health-related quality of life (HRQoL) (15D questionnaire, range 0-1). Immunological status and possible contraindications were also evaluated. Defect aetiology consisted of burns (4), ballistic injury (3), blunt injury (1), blast injury (1), and neurofibromatosis type I (1). All patients had central facial deficiencies and 6 patients had 8 to 10 injured facial subunits. All patients had at least partial loss of facial function. The mean aesthetic disfigurement score was 6.4. The median lowering of 15D score was -0.107. None were significantly sensitized although four patients had relative contraindications and one patient had an absolute contraindication for FT. Three patients with a severe overall facial deficiency were considered as potential FT candidates. We herein propose a comprehensive and systematic tool to evaluate potential candidates for FT. This approach includes assessment of 4 key categories: anatomical regions affected, facial function, aesthetics, and HRQoL.

The Second Helsinki Face Transplantation and the World Experience of Revision Surgery During the First Posttransplantation Year.

INTRODUCTION: We conducted a review of all surgical interventions performed during the first postoperative year in published face transplantation (FT) cases. In addition, we herein present our second FT patient, a full-face composite FT with an emphasis on surgical revisions after transplantation. MATERIALS AND METHODS: A literature review was conducted and resulted in 376 publications of which 33 included reference to surgical interventions during the first post-FT year. For our second FT patient, a thorough review of all medical records was performed. RESULTS: Among the first 41 FTs, 32 FT patients had reports with reference to corrective surgery during the first year (22 composite and 10 soft-tissue FTs). Soft-tissue FTs had a median of 2 procedures (range, 1-8 procedures), and composite FTs, 3 procedures per patient (range, 1-9 procedures). Nearly all early interventions (<1 month) were performed in composite FT patients (anastomotic occlusion, hematoma, sialocele, palatinal dehiscence). The most common late interventions were scar corrections, tissue suspensions, periorbital corrections, osseal and dental procedures, and interventions for palatinal dehiscence and sialocele. Our second FT patient has recovered well and has undergone 3 surgical interventions during the first year. CONCLUSIONS: Surgical interventions are very common during the first postoperative year after FT, and composite FTs are more prone to complications necessitating surgical intervention than soft-tissue FTs. There is a wide variety of complications reflecting the heterogeneity of FT allografts. Corrective surgery in FT patients appears safe with only a few reported complications.

Virtual 3D planning and prediction accuracy in two bimaxillary face transplantations in Helsinki.

BACKGROUND: The aim of this study was to describe the 3D planning process used in our two composite face transplantations and to analyze the accuracy of a virtual transplantation in predicting the end-result of face transplantation. METHODS: The study material consists of two bimaxillary composite face transplantations performed in the Helsinki University Hospital in 2016 and 2018. Computed tomography (CT) scans of the recipient and donor were used to define the osteotomy lines and perform the virtual face transplantation and to 3D print customized osteotomy guides for recipient and donor. Differences between cephalometric linear and angular measurements of the virtually simulated and the actual postoperative face transplantation were calculated. RESULTS: No changes to the planned osteotomy lines were needed during surgery. The differences in skeletal linear and angular measurements of the virtually simulated predictions and the actual postoperative face transplantations of the two patients varied between 0.1-5.6 mm and 0.7°-4°. The postoperative skeletal relationship between maxilla and mandible in both patients were almost identical in comparison to the predictions. CONCLUSIONS: 3D planning is feasible and provides close to accurate bone reconstruction in face transplantation. Preoperative virtual transplantation assists planning and improves the outcome in bimaxillary face transplantation.

Case Report: Unravelling the Mysterious Lichtenberg Figure Skin Response in a Patient With a High-Voltage Electrical Injury.

We describe a case of Lichtenberg Figures (LFs) following an electrical injury from a high-voltage switchgear in a 47 year-old electrician. LFs, also known as ferning pattern or keraunographic markings, are a pathognomonic skin sign for lightning strike injuries. Their true pathophysiology has remained a mystery and only once before described following an electical injury. The aim was to characterise the tissue response of LFs by performing untargeted non-labelled proteomics and immunohistochemistry on paraffin-embedded sections of skin biopsies taken from the area of LFs at presentation and at 3 months follow-up. Our results demonstrated an increase in dermal T-cells and greatly increased expression of the iron-binding glycoprotein lactoferrin by keratinocytes and lymphocytes. These changes in the LF-affected skin were associated with extravasation of red blood cells from dermal vessels. Our results provide an initial molecular and cellular insight into the tissue response associated with LFs.

Speech Characteristics and Oromyofunctional Outcomes in Two Bimaxillary Face Transplantation Patients in Helsinki.

OBJECTIVES/HYPOTHESIS: Facial functional restoration is one of the main goals in face transplantation. We report the oromyofacial function outcomes of two bimaxillary face transplantation (FT) patients in Helsinki. STUDY DESIGN: Outcome Study. METHODS: Two male patients, aged 34 and 59, had severe functional facial disabilities following self-inflicted gunshot injuries sustained to their mid and lower faces several years earlier. Both underwent tooth-bearing maxillomandibular face transplantation in 2016 and 2018. We collected data regarding speech, swallowing, sensory recovery, motor recovery, and olfaction prior to transplantation. Patient charts were reviewed from the follow-up period of 4 and 2 years, respectively. RESULTS: Speech intelligibility, acceptability, and articulation continued to improve during follow-up for both patients. Voice quality and resonance were mainly normal at last follow-up. Swallowing improved once lip occlusion was regained, with only minor aspiration evident on videofluorography. Both patients had significant improvement in facial mimic muscle function after FT. The first patient who only had buccal sensory nerves connected has only recovered protective facial sensation, whereas our second patient with buccal, infraorbital, and alveolar nerves connected has almost complete facial two-point discrimination. CONCLUSION: Both patients have regained satisfactory facial sensory and motor function. Sensory recovery seems to be faster and more precise if multiple sensory nerve coaptations are performed. Swallowing and speech have continued to improve over time although not reaching the level of the normal population. We demonstrate how speech-corrective surgery can safely be performed in a FT patient and can improve speech recovery. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2643-E2649, 2021.

The CARe Burn Scale-Adult Form: Translation and linguistic validation into Finnish.

BACKGROUND: Burn injury can dramatically deteriorate health-related quality of life. Effective burn care may minimize the impact of the burn injury and ensure optimal functional outcome. This requires continuous improvement in burn care and assessment of treatment results. The aim of this study was to translate, culturally adapt and linguistically validate the CARe Burn Scale-Adult Form, a burn-specific patient-reported outcome measure, into Finnish. METHODS: The translation process followed the International Society for Pharmacoeconomics and Outcomes Research guidelines consisting of forward and backward translations, pilot-testing and cognitive debriefing interviews of five burn patients, and proofreading before finalizing. The process involved expert panel meetings and continuous discussion between the developers of the Scale and the research group. RESULTS: In the forward translation 10 amendments were required. After the backward translation, 12 items were reworded. Cognitive debriefing interviews led to three alterations enhancing the comprehensiveness and accuracy of the translation. The translation was reviewed by burn occupational therapists for practicality, resulting in 12 modifications. Minor grammatical changes were made after proofreading. CONCLUSION: The Finnish version is the first foreign translation of the CARe Burn Scale. It is equivalent to the original Scale and ready for psychometric validation with burn patients in Finland.

Application of the FACE-Q rhinoplasty module in a mixed reconstructive and corrective rhinoplasty population in Finland.

The FACE-Q Rhinoplasty module is a patient-reported outcome instrument developed for the assessment of primarily aesthetic outcomes of rhinoplasty. The aim of our study was to produce a Finnish version of the instrument and validate it for use in patients undergoing nasal reconstruction as well as those treated with a rhinoplasty. Finnish versions of the FACE-Q scales Satisfaction with Nose, Satisfaction with Nostrils and Adverse Effects: Nose, were translated following established guidelines. Patients undergoing nasal resection, reconstruction or rhinoplasty in Helsinki University Hospital plastic surgery department in 2009-2019 were identified using theatre records. A total of 240 Finnish-speaking patients 18-85 years old were approached with a postal survey questionnaire. The questionnaire included the translated FACE-Q modules and those for Satisfaction with Facial Appearance, Appearance-Related Psychosocial Distress and Satisfaction with Outcome, as well as the general health-related quality of life instrument 15 D. The FACE-Q scales translated readily to Finnish. Eighty-three patients (35%) responded to the survey. Most FACE-Q scales performed well with high internal consistency (Cronbach's alphas 0.87-0.92) and repeatability. Only the Adverse Effects: Nose scale displayed poor consistency and a floor effect with 18% of the patients reporting no adverse outcomes. Answers to the Appearance-Related Psychosocial Distress scale were skewed towards no experienced stress. Answers to the other scales were normally distributed with weak correlation with 15 D dimensions. The Finnish translations of the FACE-Q Rhinoplasty scales perform well at assessing a diverse group of patients including those undergoing nasal reconstruction as well as those undergoing rhinoplasty.