Autologous fat transplantation to the velopharynx for treating mild velopharyngeal insufficiency: A 10-year experience.

BACKGROUND: For the last two decades, autologous fat transplantation has been used to treat mild velopharyngeal insufficiency (VPI); however, there is still disagreement about its effectiveness. The aim of the study was to evaluate the procedure by using speech analysis and magnetic resonance imaging (MRI). PATIENTS AND METHODS: This is a prospective study of 47 non-syndromic patients with mild VPI who underwent autologous fat transplantation to the velopharynx between 2006 and 2015. Thirty-two patients had a cleft palate, all of which had been repaired before fat transplantation. Eight patients developed VPI after adenotonsillectomy, one after uvulo-palatoplasty and six had VPI of unknown etiology. Twelve patients underwent two procedures of fat transplantation. Preoperative and 1-year postoperative audio recordings were blinded for scoring independently by three senior speech therapists on a five-point scale. Preoperative and 1-year postoperative MRIs were obtained during phonation, measuring the velopharyngeal distance and the velopharyngeal gap area. Correlations between the speech outcomes and MRI were calculated. RESULTS: Audible nasal emission was the only speech parameter that improved significantly postoperatively (p = 0.005). A significant reduction in both velopharyngeal distance (p < 0.005) and the gap area (p < 0.005) was found after treatment. A significant improvement in the mobility of the velum was observed after treatment (p = 0.03). There was no significant correlation between speech outcomes and MRI. CONCLUSIONS: Autologous fat transplantation for the treatment of mild VPI, although significantly reducing audible nasal emission, made no significant improvement in hypernasality or nasal turbulence. No complications were observed.

Impact of orthognathic surgery on velopharyngeal function by evaluating speech and cephalometric radiographs.

BACKGROUND: Maxillary retrognathia is a well-known consequence of abnormal facial growth in patients with cleft lip and palate. Orthognathic surgery improves facial appearance and occlusion but may induce velopharyngeal insufficiency. The aim of this study was to evaluate the effect of orthognathic surgery on velopharyngeal function by using speech analysis and lateral cephalometric radiographs. PATIENTS AND METHODS: We conducted a retrospective study of 47 patients who underwent maxillary advancement ±â€¯mandibular setback between 2006 and 2016. Preoperative and 1 year postoperative audio recordings were blinded for scoring by three trained speech therapists. Preoperative and 1 year postoperative lateral cephalometric radiographs were used to obtain information about skeletal movement and its relationship with the velopharyngeal area. Correlations between speech outcomes and cephalometric radiographs were determined. RESULTS: Hyponasality improved significantly after surgery (p < 0.05), whereas hypernasality deteriorated significantly only in patients who underwent maxillary advancement alone (p < 0.05). No difference in speech parameters was found between patients with hypernasality or patients who had a pharyngoplasty preoperatively and the rest of the group. No correlation was found between the amount of maxillary advancement and hypernasality. A significant correlation (r < -0.49, p < 0.05) was found between the preoperative velar length and hypernasality postoperatively. CONCLUSIONS: Maxillary advancement has a negative impact on velopharyngeal function, whereas bimaxillary surgery seems to protect from deterioration. No difference was found in the amount of maxillary advancement or in velopharyngeal measurements between the Le Fort I group and the bimaxillary group. A short soft palate is a predictor of hypernasality after orthognathic surgery.

Midface distraction osteogenesis: internal vs. external devices.

This study compares internal and external distraction devices in the treatment of midface retrusion. 20 patients were treated with midface distraction (12 Crouzon, 4 Apert, 4 others); 12 with internal distraction (MID device), 8 with external distraction (Red or Blue device). The two groups were compared regarding operation time, peroperative blood loss and complications. The groups were comparable regarding patient age, sex, weight and diagnosis. In the MID-group, 7 of 12 patients (58%) underwent Le Fort III, 5 underwent 12 monobloc (32%). In the Blue device group, three of eight patients underwent Le Fort II (38%), three of eight underwent Le Fort III (38%), and two of eight underwent monobloc (25%). Operation time was shorter in the Blue device (mean 298 min) than in the MID group (mean 354 min). Peroperative blood loss and complication rates were similar. The internal distraction device is the 'gold standard' for treating midface retrusion. The use of an external distraction device in midface distraction osteogenesis is associated with a shorter operation time; peroperative blood loss and complications were similar. An external device affords better 3-dimensional control during the distraction process, so external distraction is preferable in patients who will tolerate this treatment.

Plate fixation of extra-oral subcondylar ramus osteotomy for correction of mandibular prognathism: clinical aspects and short term stability.

AIM: The present study describes an extra-oral approach for subcondylar oblique ramus osteotomy using stable fixation for setback of the mandible. The aim was to investigate the incidence of neurosensory disturbances of the mandibular nerve, evaluate facial scar appearance, and assess skeletal stability following the procedure. METHODS: Forty-two consecutive patients with mandibular prognathism were operated upon using the subcondylar oblique ramus osteotomy and plate fixation. The patients were followed up for 6 months following surgery. Intra-operative and postoperative complications, neurosensory function, and facial scar characteristics were recorded. Lateral cephalograms were available immediately before operation, and immediately after operation and 6 months postoperatively. Skeletal stability was based on cephalometric assessment. RESULTS: Among the 19 patients operated earliest, neurosensory disturbances were recorded in five individuals at the 6 month follow-up. In the subsequent group of 23 patients, no disturbances were reported. All but two patients were not concerned about the facial scar 6 months postoperatively. Mean anterior relapse at the 6 month follow-up was 0.5 mm, representing 9% of the surgical setback. CONCLUSION: Extra-oral subcondylar oblique ramus osteotomy with plate fixation is a stable procedure with a low incidence of neurosensory disturbances if the osteotomy is placed well behind the mandibular foramen. Facial scar appearance was rarely a matter of concern to the patients.

Changes in plasma IL-1beta, TNF-alpha and IL-6 after total hip replacement surgery in general or regional anaesthesia.

Different anaesthetic methods influence the neuro-immuno-endocrine biologic responses to surgery and may thus possibly interfere with the postoperative course and development of complications. The neuroendocrine system is closely related to the cytokine network. In this study, the effects of general anaesthesia (n=6) and regional spinal/epidural anaesthesia (n=6) on the cytokine response (IL-1beta, TNFalpha, IL-6) to uncemented total hip replacement surgery were evaluated. The postoperative clinical course was uneventful in every case. In both groups, only very low values of plasma IL-beta were measured perioperatively, whereas plasma IL-6 increased postoperatively with peak values 4 h after surgery. The changes in plasma TNF-alpha were not significant. No significant differences in plasma TNF-alpha or IL-6 were found between patients operated in general or in regional anaesthesia. This suggests minor influence of plasma cytokines on the possible beneficial effects of regional anaesthesia on the clinical course after surgery in low risk patients. There were slightly higher TNF-alpha and IL-6 levels after the operation and significantly lower cortisol levels during the operation in the regional anaesthesia group compared to the general anaesthesia group, giving rise to a significant inverse correlation between peak values of IL-6 and peak values of cortisol. This supports the theory that after surgery the inhibitory effect of cortisol on monocyte cytokine production overrides adrenergic stimulation.

Standard preoperative assessment can improve outcome after cholecystectomy.

OBJECTIVE: To assess the outcome of cholecystectomy after standard preoperative handling and selection of patients, focusing on the potential of the operation to eliminate biliary colic. DESIGN: Prospective study. SETTING: University Hospital, Norway. PATIENTS: 806 patients (median age 56, range 18-91 years, male:female ratio 1:2.7), were referred to our clinic for cholecystectomy between 1992 and 1996. INTERVENTIONS: Unless there was a clear indication for cholecystectomy (frequent attacks of biliary colic/or recent complications of gallstones or both), patients were investigated in a standard way to find out what else was causing the abdominal pain. MAIN OUTCOME MEASURES: Residual pain was assessed at a clinical examination three months postoperatively, and clinical condition a median of three years later was assessed by a questionnaire. RESULTS: 465 (58%) patients were operated on primarily, and an additional 29 patients were operated on after further evaluation. Three months after cholecystectomy, 35 (7%) had persistent pain, mostly caused by other specific diseases and relieved after specific treatment. A median 3 years postoperatively, only 21 (4%) reported that they still had abdominal pain. CONCLUSION: Standard selection of patient improved the outcome of cholecystectomy. Compared with a historical control group, residual pain after three months was reduced from 20% to 7%. After three years, 96% of the patients no longer had their main clinical problem.

[Treatment of recurrent mandibular dislocation]. / Behandling av residiverende kjeveleddsluksasjon.

Recurrent mandibular dislocation is an uncommon human disorder. It is found most frequently in people with neurologic diseases, patients with symptomatic temporomandibular joint diseases and in patients treated with neuroleptics. Numerous techniques have been developed for the surgical treatment of recurrent mandibular dislocation. Leclerc blocking procedure and other techniques are designed to limit the forward displacement of the condylar head. An alternative procedure is eminectomy where the articular eminence is removed in order to allow the condyle to move more freely. In the period 1990 to 1997, 23 patients (38 joints) were subjected to either Leclerc blocking procedure or eminectomy for recurrent mandibular dislocation at the Ullevål University Hospital. Treatment results were good, but some cases of recurrence were observed after the Leclerc blocking procedure.

Effects of heparin coating on the expression of CD11b, CD11c and CD62L by leucocytes in extracorporeal circulation in vitro.

Leucocyte adhesion molecules are involved in the leucocyte-endothelial interaction and in the activation of coagulation and binding of complement and endotoxin. Thus, they are important in inflammation, systemic acute phase reaction, ischaemia reperfusion injury and resistance against infections. The expression of the adhesion molecules CD11b, CD11c and CD62L on leucocytes and changes in plasma products of neutrophil activation (myeloperoxidase, lactoferrin) and complement activation (C3bc, SC5b-9 (TCC)) were examined in an extracorporeal circulation (ECC) model and the effects of Carmeda bioactive surface (CBAS) heparin coating (n = 7) of the circuits were compared to uncoated control circuits (n = 5). In this model, new 'unactivated' cells mobilized from the bone marrow could not interfere with descriptive measures of cell activation as seen in in vivo studies. In the control group, CD11b and CD11c were upregulated on monocytes and granulocytes during ECC, whereas CD62L was downregulated. Heparin coating reduced the increase in CD11b and CD11c on granulocytes (p < 0.02 at 2 h), but the delayed increase in CD11c on monocytes and the delayed downregulation of CD62L on granulocytes and monocytes did not reach statistical significance. Further, heparin coating also reduced the initial decrease in the absolute cell counts of monocytes and granulocytes (p = 0.01 at 2 h), reflecting reduced adhesion to the oxygenator/tubing. The increases in plasma myeloperoxidase, lactoferrin, C3bc and TCC were lower in the heparin-coated group compared to the control group. The increases in plasma myeloperoxidase and lactoferrin correlated significantly to the increase in CD11b (r = 0.71, p = 0.02 and r = 0.64, p = 0.05, respectively) and CD11c (r = 0.72, p = 0.008 and r = 0.72, p = 0.008, respectively) on granulocytes, suggesting interacting regulatory pathways in the process of neutrophil adhesion, activation and degranulation. Thus, in this in vitro ECC model, heparin coating of oxygenator/tubing sets reduced leucocyte activation and leucocyte adhesion-related phenomena.

[Treatment of facial gunshot injuries]. / Behandling av skuddskader i ansiktet.

Patients with gunshot injuries in the maxillofacial region should be resuscitated and subjected to a general examination in the emergency room. Chest X-rays and head CT scans should be performed on a routine basis, and in selected cases angiography and plain X-ray films of the cervical columns are also recommended. Treatment of the facial defects depends to some degree on the type of firearm involved, i.e. high velocity rifle, low velocity weapon or shotgun. The traditional treatment for war and civilian gunshot injuries to the face has been debridement, soft tissue closure and conservative treatment of fractures, with closed reduction and external fixation. This treatment may leave inadequate stabilization of remaining bone fragments, with collapse and later contraction of soft tissue. It fails to take advantage of the modern craniofacial and microsurgical techniques used in a more recent approach that can be termed initial final treatment of gunshot wounds. This treatment modality is recommended for civilian low velocity gunshot injuries and, after repeated debridements, also for injuries caused by shotguns and high velocity weapons.

Expression of beta-2-integrins and L-selectin by leukocytes and changes in acute-phase reactants in total hip replacement surgery.

The aim of this study was to characterize the changes in the quantitative expression of beta 2-integrins and L-selectin detected by means of fluorochrome-conjugated monoclonal antibodies and flow cytometry on leukocytes in the systemic circulation after a major musculoskeletal trauma, i.e. hip replacement surgery, and to relate these changes to parameters of the acute-phase response [plasma acute-phase reactants (C-reactive protein, CRP, and interleukin-6, IL-6) and parameters of coagulation activation (thrombin-antithrombin III complexes, TAT)]. Eight patients with either primary or secondary osteoarthritis of the hip received uncemented total hip prostheses. LFA-1 (CD11a/CD18) was upregulated on granulocytes during the operation. MAC-1 (CD11b/CD18) expression on monocytes increased to peak levels 20 h after surgery, whereas the L-selectin (CD62L) expression on monocytes and granulocytes reached peak values at the end of surgery. The changes in expression of LFA-1 on monocytes, MAC-1 on granulocytes and p150,95 (CD11c/CD18) on monocytes and granulocytes during and after the operation did not reach statistical significance. TAT and IL-6 increased during surgery and reached peak values at the end of the operation and 20 h after surgery, respectively. In contrast, CPR concentrations increased after surgery with peak levels 44 h postoperatively. Significant upregulation of LFA-1 on granulocytes and L-selectin on monocytes and granulocytes preceded the increase in IL-6 which again preceded the increase in CRP. However, the up- or downregulation of leukocyte beta 2-integrins and L-selectin during and after surgery was not significantly correlated with the increase in IL-6. The increases in TAT correlated well with the upregulation of L-selectin on monocytes, but not with the beta 2-integrins known to participate in the coagulation process in vitro. The rise in CRP was inversely correlated with the maximal increase in expression of MAC-1 on monocytes. In conclusion, the changes in leukocyte adhesion molecules during and after surgery indicate changes in critical leukocyte functions. The lack of correlation between quantitative up- and downregulation of leukocyte beta 2-integrins and parameters of the acute phase response suggests that these processes are regulated through independent pathways or that functional up- and downregulation of adhesion molecules, shedding, leukocyte-endothelial adhesion and mobilization of new unactivated cells may result in a net estimate of leukocyte activation not suspected to be positively correlated to acute-phase reactants.

[Prospective comparative studies as tools for quality assurance. Important when laparoscopic techniques are introduced]. / Prospektive sammenliknende studier som kvalitetssikringsredskap. Viktig ved innføring av laparoskopiske teknikker.

During the first two years of laparoscopic surgery altogether 200 cholecystectomy and 40 appendectomy patients were included in prospective, comparative studies. The stay in hospital averaged two days after laparoscopic versus seven days after open cholecystectomy. Days away from work postoperatively averaged nine days after laparoscopic, versus 28 days after open cholecystectomy. After appendectomy, the stay in hospital was reduced from three to one day and absence from work from 14 days in the open surgery group to seven days in the laparoscopic group. Clear advantages have thus been documented in the groups with mini-invasive treatment, since only 5% experienced postoperative complications after laparoscopic treatment, as against 11% after open cholecystectomy (p < 0.02).

Effects of short-term treatment with corticosteroids and indomethacin on bone healing. A mechanical study of osteotomies in rats.

We studied the effects of short-term therapy with methylprednisolone and indomethacin on healing of intramedullary pinned osteotomies of the femur in rats. When the osteotomy was complete and healing occurred under unstable conditions with callus formation, indomethacin inhibited healing when estimated by mechanical tests of bending moment, energy expenditure before refracture, and bending rigidity 6 weeks after surgery. No inhibitory effects were seen following corticosteroid treatment. When the osteotomy was incomplete and healing occurred under stable conditions, similar tendencies were observed. Thus, short-term medication with indomethacin inhibits fracture healing. This was not the case with short-term methylprednisolone.

Acute phase reactants and interleukin 6 after total hip replacement. Effects of high dose corticosteroids.

A randomised study was performed to evaluate the association between some commonly measured acute phase proteins and interleukin-6 after a standard musculoskeletal operation, and to investigate the effect of high doses of corticosteroids on these proteins. Eight men and four women with osteoarthrosis but who were otherwise healthy and who were each to have an uncemented hip prosthesis inserted by the porous coated anatomical technique, were included. Patients were randomised to receive methylprednisolone 30 mg/kg body weight 1 1/2 hours before, and four and 12 hours after, operation (n = 6) and compared to a control group (n = 6). Plasma concentrations of C reactive protein, haptoglobin, orosomucoid and alpha 1-antitrypsin; serum concentration of albumin; packed cell volume; white cell count; and plasma concentration of interleukin-6 were measured. The increases in concentrations of acute phase proteins in plasma were significantly less in the group given steroids, but this did not have any obvious clinical consequences. Increase in the concentration of interleukin-6 preceded the increases in acute phase proteins in both groups, reflecting the role of interleukin-6 in the regulation of expression of acute phase protein genes in hepatic cells. The increase of interleukin-6 in the group receiving steroids was less pronounced than that in the control group, indicating that corticosteroids inhibit the generation of interleukin-6 in vivo.

Comparison of functional bracing and locked intramedullary nailing in the treatment of displaced tibial shaft fractures.

Thirty-five displaced tibial shaft fractures, treated with functional bracing were compared with 43 similar fractures, treated with locked intramedullary nailing. There were 22 excellent/good results in the brace group and 38 in the nail group. There was one infection in the brace group and three in the nailed group. There were five delayed unions and two nonunions in the brace group and one delayed union in the nail group. The functional results in the nailed group were better than the braced group but locked intramedullary nailing of tibial shaft fractures require special resources and training. Locked intramedullary nailing fullfils all the functional criteria for acceptable fracture care.

Extraoral subcondylar ramus osteotomy for correction of mandibular prognathism. The surgical technique and complications.

1178 patients with mandibular prognathism and/or asymmetry, in some cases combined with maxillary retrognathism, were treated by extraoral horizontal or oblique ramus osteotomy during the period from 1939 to 1989. The described percutaneous retromandibular approach is a simple, rapid and reliable technique which can usually be performed under local anaesthesia. Very few complications, particularly neurological, were observed. These aspects justify consideration of this technique when indications for a simple, straight set-back procedure of the mandible exist, and there is no tendency to bite-opening. However, the method demands intermaxillary fixation for 6-9 weeks postoperatively.

Changes in leukocyte subpopulations following total hip replacement surgery. Effects of high doses of corticosteroids.

Changes in leukocyte subpopulations and the effects of high-dose corticosteroids (HDC) on these changes were studied in patients undergoing total hip replacement surgery. Twelve patients were randomly divided into a non-steroid (n = 6) and a steroid group (n = 6). The steroid patient group was treated with HDC. In the non-steroid group, we found a leukocytosis, monocytosis, lymphocytopenia and granulocytosis after surgery in local anaesthesia. Only the changes in granulocyte counts were significant. Furthermore, the relative proportion of pan T-cells, helper/inducer T-cells, suppressor/cytotoxic T-cells, B-cells, activated T-cells and natural killer-cell subset did not change significantly during the post-operative course. Thus, lymphocytopenia was caused by reduced absolute counts of all these subsets. However, there was a tendency for decreased relative proportions of pan T-cells, inducer/helper T-cells, activated T-cells and natural killer (NK) cell subset in the early postoperative phase. Treatment with HDC significantly raised the numbers of leukocytes and granulocytes and decreased the lymphocyte and monocyte counts in the first 2 days after surgery, accounting for significant differences between the two patients groups. The percentage of pan T-lymphocytes was significantly lower in the steroid patient group on days 1 and 2 after the operation. There was no significant difference between the two patient groups with regard to the percentages of B-lymphocytes, T-lymphocyte subsets, NK cell subset, leu M3 cells and helper:suppressor ratio.(ABSTRACT TRUNCATED AT 250 WORDS)

Generation of procoagulant (thromboplastin) and plasminogen activator activities in peripheral blood monocytes after total hip replacement surgery. Effects of high doses of corticosteroids.

Development of thromboplastin (tpl) and plasminogen activator (PA) activity in monocytes and the effects of high doses of corticosteroids (HCD) on these activities were studied in patients undergoing a standardized surgical trauma. Twelve patients who received uncemented total hip prostheses were divided into a nonsteroid group (n = 6) and a steroid group (n = 6). We found no significant differences between the two patient groups regarding tpl or PA activities of peripheral blood mononuclear cells (PBM) isolated during the postoperative phase. However, in the nonsteroid group there was a tendency for increased expression of procoagulant activity and decreased fibrinolytic activity on the 1st postoperative day, favoring the formation of fibrin in the monocyte microenvironment. Further, PBM isolated on the 1st and 2nd day after surgery were significantly less capable of generating tpl activity on endotoxin stimulation than cells isolated preoperatively. This was not the case in the steroid group. These patients had also a tendency for decreased fibrinolysis at the end of the 1st postoperative week, indicating increased imbalance towards a more thrombotic stage after surgery.

Effect of high-dose corticosteroids on the incidence of deep vein thrombosis after total hip replacement.

Fifty patients receiving uncemented total hip prostheses were examined by venography of the legs on the 2nd postoperative day. The patients were randomly divided into two groups, a non-steroid group (n = 26) and a steroid group (n = 24). Both groups received dextran thrombo-prophylaxis. The patients in the steroid group were treated with high-dose corticosteroids. The incidence of deep vein thrombosis (DVT) was 38% (19/50). No patients had clinical signs or symptoms of DVT. All thrombi were located distally in the leg. DVT was bilateral in nine patients, in the operated leg in three, and in the non-operated leg in seven. The administration of high-dose corticosteroids did not influence the incidence or pattern of DVT. All patients were followed up clinically and plethysmographically up to 12 months after surgery. Distally located asymptomatic DVT were not given specific treatment. The postoperative course was uneventful except for one patient in each group who developed clinically, apparent DVT more than 3 weeks after operation, although the initial venographic studies were normal.

Deep vein thrombosis after total hip replacement. A venographic study.

The incidence of deep vein thrombosis (DVT) in 62 consecutive patients under dextran thromboprophylaxis after total hip replacement, was examined by venography of the legs on the second postoperative day. The venography was repeated on day 9 after the operation in 43 patients to study the development of thrombi. Twenty-one patients were found to have venographically deep vein thrombosis on the second postoperative day, but had no clinical signs of DVT. All thrombi were located distally in the leg and equally distributed between the operated and the non-operated leg. Distally located asymptomatic DVT were not given specific treatment. Thrombolysis between postoperative day 2 and day 9 seemed to dominate over thrombus formation and propagation. Even large thrombi in the legs may dissolve during the first postoperative week. Thus, the timing is essential for the screening of DVT.

Plethysmographic screening for deep venous thrombosis following total hip replacement.

A series of 97 lower limbs examined with venography and plethysmography after total hip replacement surgery is presented. No patients had clinical signs of deep venous thrombosis (DVT). Venography revealed distal DVT in 26 limbs. Plethysmography was negative in 25 of these cases. A low sensitivity for plethysmographic detection of calf thrombi is described in previous publications. In this study, however, we found a complete lack of correlation between positive plethysmography and venography in limbs with distal, symptomfree thrombosis.