Donor Site Scar Research Articles

Use of the superficial circumflex iliac artery perforator flap for urethra and/or shaft reconstruction in gender diverse persons: 10-year single center experience.

Although the free radial forearm flap (FRFF) is the gold standard for phalloplasty, the conspicuous donor-site scar, need for microsurgery and the tendency for the phallus to deflate over time makes both patients and surgeons look for alternatives. We describe our long-term experience with the pedicled superficial circumflex iliac artery (SCIP) flap for urethral and/or penile shaft reconstruction. This flap can be applied for similar indications as FRFF-phalloplasty, but with primary closure of the donor site(s) and without microsurgery. We retrospectively reviewed surgical outcomes of all patients who underwent urethra and/or shaft reconstruction using SCIP-flaps as part of phalloplasty for gender-affirming surgery in our center between 2012 and 2022. Over a 10-year period, 55 SCIP-flaps were performed as part of phalloplasty. This included 47 unilateral SCIP-flaps, of which 10 were used for shaft reconstructions and 37 for urethra reconstructions. Primary closure was achieved in 100% of patients. No failures were observed for shaft reconstructions.For urethra reconstructions, 8 SCIP-urethras (14%) failed completely, and 3 SCIP-flaps were converted to free flaps. In total, 82% of patients with a SCIP-urethra reconstruction were able to stand while voiding.Eight bilateral SCIP-flaps were performed for one-stage shaft and urethra creation, of which 3 patients (38%) experienced urethral fistulas and/or strictures. This study shows that the SCIP-flap is a technically feasible and safe pedicled alternative for urethral and penile shaft reconstruction in gender diverse individuals, with similar urethral complication rates compared to FRFF and ALT-phalloplasty, however, with potentially lower shaft sensation.

Safe and reliable use of supraclavicular flaps for head and neck reconstruction.

The supraclavicular flap is a regional flap in the supraclavicular area nourished by the transverse cervical or supraclavicular arteries. This flap gained popularity in the 2000s as it requires less surgical time than free flap reconstruction and has minimal donor-site morbidity. However, a high rate of postoperative complications has been reported. Moreover, there is ongoing debate regarding the indications and limitations of this flap. In this study, we confined the flap design to the supraclavicular fossa, considering flap vascularity and in an effort to minimize donor site morbidity. Between 2014 and 2023, we performed supraclavicular flap reconstruction in 3 cases of cervical skin defects and 1 case of a pharyngeal mucosal defect. The average defect and flap sizes were 7×3.9cm and 11.5×4.4cm, respectively. The lower border of the flap remained above the clavicle, and the lateral border did not exceed the acromioclavicular joint. When the flaps were transferred using the transposition method, the angle of transposition was limited to <90 degrees. When the VY advancement or turnover method was selected, we paid attention to the tension-free flap inset. We successfully reconstructed the defects without flap-related complications, and donor site scars were inconspicuous in all patients. In conclusion, we believe that confining the flap design to the supraclavicular fossa, limiting the indications of this flap to the reconstruction of medium-sized defects, and using tension-free flap insets are important for the successful application of this flap.

Utilizing Endoscopy to Assist in Harvesting the Pedicled Pectoralis Major Muscle Flap for Axillary Defect Repair: Case Report

Background: The pedicle pectoralis major muscle flap is the primary workhorse flap used in head, neck, and large axillary reconstruction; however, traditional harvesting techniques may leave significant donor site scarring. Case Report: Endoscopy-assisted harvesting of a pedicled pectoralis major muscle flap, or muscle flap and musculocutaneous flap, was performed in two patients, after which axillary defects were closed with a 4 cm incision at the 5th intercostal space using the harvested flap matching the size of the defect. The harvesting process took 40 and 32 minutes, respectively, and patients were able to return home at 5 to 7 days post-surgery. No postoperative complications were observed in either patient. Conclusion: Endoscopic harvesting of the pedicled pectoralis major flap helps to reduce the extent of skin incisions because it gathers the pedicle vessel under the skin. Furthermore, it minimizes postoperative complications such as long hypertrophic scars.

Graftless Syndactyly Release.

Syndactyly release aims to address skin deficits by resurfacing web spaces and sides of digits to allow independent digital motion while minimizing the risk of web creep and scar contractures. Conventional methods include the use of a dorsal and interdigitating flaps with full-thickness skin grafts. More recently, there have been several descriptions of "graftless" syndactyly release without skin grafts, thus avoiding a further (usually distant) donor site. However, the indications of when and when not to use these techniques remain unclear. In addition, the inevitable scarring from extra recruitment of local adjacent skin is perhaps underemphasized. In this article, we revisit the trilobed flap technique which serves to balance the amount of skin needed for resurfacing digits while minimizing local donor site scarring. The geometry and nuances of the flap inset are illustrated in detail to guide those embarking on this technique. The trilobed syndactyly release technique is a reproducible, safe, and reliable method for the release of simple syndactyly.

88 Lessons Learned Evaluating Ablative Fractional CO2 Laser for Burn-Related Donor Site Scars

88 Lessons Learned Evaluating Ablative Fractional CO2 Laser for Burn-Related Donor Site Scars

Usage of Dermal Regeneration Templates (Pelnac) for Coverage of Exposed Hand Tendons in Acute Setting.

The loss of soft tissue coverage of tendons is a challenging reconstructive problem after acute hand trauma. Subsequent tendon adhesions and the loss of range of movement in addition to the poor aesthetic outcome and donor site scarring should be avoided when deciding the plan of management. Pelnac is one of the commonly used skin substitutes in reconstructive surgery that can be used for coverage of exposed tendons, but the postoperative functional outcome needs to be addressed in detail. Twenty-six patients with acute isolated tendon injuries distal to the wrist joint were included. Two-stage reconstructive procedures were performed; the first one was the application of Pelnac. The second stage was carried out after the complete integration of Pelnac via the application of a split-thickness graft. The function outcome assesses the return of the normal range of motion to the affected hand and the QuickDASH score questionnaire. The aesthetic outcome was assessed using the Vancouver scar scale. The Pelnac was integrated in 100% of cases, with complete grafts taken in 22 of 26 patients. The mean QuickDASH score was 20.5 ± 15.7, and mean Vancouver scar scale was 3.53 ± 3.2. The full range of motion returned in 22 of 26 patients. Using Pelnac to cover the exposed hand tendons in an acute setting is a convenient and efficient procedure with minimal morbidity. It can offer a good option for their coverage with preservation of hand function and acceptable aesthetic outcome.

Effectiveness of a Regenerative Epithelial Suspension (RES), on the pigmentation of split-thickness skin graft donor sites in children: the dRESsing pilot randomised controlled trial protocol

BackgroundPaediatric donor site wounds are often complicated by dyspigmentation following a split-thickness skin graft. These easily identifiable scars can potentially never return to normal pigmentation. A Regenerative Epidermal Suspension (RES)...

A cadaveric study and clinical application of the free superficial circumflex iliac artery perforator flap reconstruction of limb soft tissue defects

Introduction In recent decades the superficial circumflex iliac artery perforator (SCIP) flap technique has gradually overcome the previous disadvantages of its pedicle and donor site to be widely applied in treating tissue's defects. This article investigates the vascular anatomy of the SCIP flap and evaluates the result of using the flap to reconstruct limb defects. Materials and Methods The study was performed in two parts. Firstly a cross-sectional descriptive anatomical study comprising 49 groin dissections in 25 cadavers, with contrast radiographic demonstration of the vascular anatomy. Secondly a retrospective case series of 51 free SCIP flaps in 49 patients. Surgical outcomes were evaluated using the Vancouver Scar Scale on the regional function and the aesthetics of implanted flap and donor sites. Results The results of anatomical analysis on cadavers showed the superficial circumflex iliac arteries were detected in all specimens with an average diameter of 1.4 ± 0.3 mm. The superficial subcutaneous venous systems were also recorded, including two veins (superficial circumflex vein and superficial epigastric vein) in 79.5% with an average diameter of 2.3 ± 0.6 mm. The flap results showed the alive flap rate was 90.2%, partial-necrosis flap was 3.9% and total necrosis of the flap in 5.9%. In the aesthetic evaluation, fine line scars were seen in 13/51 cases (25.5%), stretch scars in 33/51 cases (64.7%) and hypertrophic scars in 5/51 patients (9.8%), with no cases of keloid scars. Conclusion The SCIP flap is a reliable free-tissue transfer for reconstructing limb soft tissue defects. Moreover, the SCIP flap is an ideal flap with pleasing aesthetics because the donor-site scar is situated in a well-hidden site. Care must be taken when vein grafts are used to lengthen the flap as flap necrosis rates increase.

Fasciocutaneous Free Tissue Transfer in Limb Salvage: Prior Flap as a Split-thickness Skin Graft Donor Site.

Free flap surgery for limb salvage has become the surgical standard for reconstruction of bone and soft tissue with success rates and flap survivals of 94%-95%. The soft tissue defect dictates the technique of coverage. In many cases, multiple techniques of soft tissue coverage are necessary, ranging from myocutaneous and fasciocutaneous free flaps to split-thickness skin grafts (STSGs). It has been shown that fasciocutaneous free flaps are not inferior to muscle flaps in treatment of lower leg limb salvage. Although a complete flap loss is rare, it is not uncommon to have partial flap necrosis, wound dehiscence, or secondary soft tissue defects, necessitating further minor reconstruction, which we call "touch up" skin grafts. In many of these secondary procedures, split thickness skin grafts are sufficient. We have been using the skin portion of the fasciocutaneous free flap as a donor site for harvesting STSGs for quite some time without disadvantages. We believe that minimizing additional donor site morbidity is of great importance. The free tissue transfer is insensate and readily available at the site of injury, making prepping and draping simple as well as cosmetically acceptable, as the transferred free tissue, unfortunately, is rarely a perfect fit. The associated pain, discomfort, and scar of an additional donor site can be avoided. In our case series, we did not experience any flap loss, infections, or complications. Thus, harvesting an STSG from a fasciocutaneous free flap seems to be a feasible option to be considered in limb salvage.

Scarless Donor Site for Breast Reconstruction by Endoscopically Assisted Extended Latissimus Dorsi Flap plus Lipofilling.

Breast reconstruction using endoscopically assisted latissimus dorsi (LD) flap leaves no scar on the back; however, the small amount of tissue obtained makes this procedure less practical. This study aimed to propose a new technique of endoscopically assisted extended LD (eeLD) flap plus lipofilling, which could secure a large breast volume. Lateral thoracic adipose tissues supplied by the thoracodorsal artery branches and the LD muscle were elevated as a single unit only through the mastectomy scar and three ports through the lateral chest. Furthermore, fat was simultaneously injected to support the volume and shape of the breast. Changes in the volume of the reconstructed breast over time were measured using three-dimensional stereophotogrammetry. Overall, 15 breasts of 14 patients who underwent breast reconstruction using an eeLD flap exhibited no serious complications. On average, 281.9 ± 32.4 g of flap and 74.7 ± 19.4 mL of lipofilling were used. Within 8 weeks after the procedure, the volume of the reconstructed breast decreased to 69.5 ± 7.5% and then plateaued. Seven patients needed a subsequent session of lipofilling to acquire adequate breast volume and projection. Notably, according to the BREAST-Q back scores, patients who underwent eeLD flap surgery were significantly more satisfied than those who underwent conventional LD musculocutaneous flap surgery using a skin paddle on the back at the same institution (82.8 ± 9.2 versus 62.6 ± 6.3; P < 0.0001). Despite the limitations in volume, eeLD flap plus lipofilling is advantageous because it does not leave a noticeable donor-site scar. Therapeutic, IV.

The Nasolabial Flap in Nose Reconstruction: Tips and Tricks Towards Expanded Usage and Optimized Cosmesis.

Background: The nose is the most critical aesthetic element of the face and even the smallest loss of substance can create a deformity of concern. The forehead flap has been the workhorse for nasal reconstruction for centuries but requires multiple surgical steps and leads to prominent donor-site scarring. The nasolabial flap allows a single-step reconstruction with a donor-site scar concealed in the nasolabial crease but is conventionally designated for small defects involving the ala. Methods: The authors analysed all surgical records of patients undergone nasal reconstruction by nasolabial flap between May 2005 and December 2021 by the Plastic Surgery Unit of a major regional hospital in Lombardy. Defects were classified according to Burget's subunit principle and the 3-component approach. Reconstruction features and finesses were reported and analysed. Results: In the 16-year period under analysis, 378 patients with nasal defects of various aetiologies received nose reconstruction by nasolabial flap. All nasal subunits were involved; 20 patients had multisubunit defects. In all the cases the reconstruction with nasolabial flap, alone or combined with other solutions, was intended to be one-stage. Conclusions: The authors present several tips and tricks about preoperative planning and design, choice of the pedicle, flap harvesting and sculpting with preservation/restoration of grooves and convexities, conjoining multiple flaps, downsizing extensive defects by a rhinoplasty-like framework reduction. With a careful planning and refined technique, the range of application of the nasolabial flap can include defects involving any nasal subunit and larger and/or multisubunit defects.

Human Bites Over Nose: Management and Reconstruction.

Background Human bite wounds in emergency department need evaluation in regard of reconstruction. These are due to occlusive bite injuries over face. Most commonly, human bites over face involve ear and nose, and may lead to avulsion injury. Defects over nose can be reconstructed immediately after debridement or delayed till the wound heals and scar becomes supple. Thorough wash and lavage with broad- spectrum antibiotic cover has utmost importance in preventing cartilage infection. Methods We report 20 cases of human bite injuries over nose who presented to us in emergency department between 2018 and 2020. At the time of presentation the wound was assessed for closure. If not possible, patient was planned for delayed reconstruction after 3 months. In case delayed reconstruction was planned, the skin and nasal mucosa were approximated at first presentation. The patients underwent paramedian forehead flap after recreation of defect with conchal cartilage graft. Second stage of flap detachment and insetting was done after 3 weeks. After three weeks of second stage, third stage of flap thinning was done. Patients were followed for 3-6 months and subjective satisfaction was noted. Results Nineteen patients underwent delayed staged reconstruction with paramedian forehead flap and one underwent primary wound closure. The flap survival was 100%. The patient satisfaction was excellent in most cases. Conclusion We recommend delayed reconstruction for human bite nasal injuries. For reconstruction, paramedian forehead flap with conchal cartilage graft, if required, provides excellent reconstructive option with good contour and color match and minimal donor site scar.

Topical Application of Purified Amniotic Fluid Accelerated Healing of Full-Thickness Burns, Negating the Need for Skin Grafts: A Case Report

Full-thickness burns almost always require skin grafting because the severity prevents the natural regenerative process. Here, we illustrate the potential to promote natural skin regeneration utilizing growth factors and regenerative proteins in purified amniotic fluid (PAF). A 24-year-old female suffered from full-thickness burns to her legs resulting from a rogue firework. This initiated a treatment plan involving extensive rehabilitation and skin grafting. Instead, the patient was treated with PAF (4 mL) administered topically over 2 days. Forty-five minutes following application, her pain decreased from 10/10 to 2/10. After two treatments her overall recovery time decreased by 75%–leaving her physicians surprised at the obviated need for skin grafting. Topical PAF relieved pain within minutes, making it easier to clean the affected area, enhancing sleep, and allowing more range of motion and autonomy. The efficiency of PAF to reduce pain allowed the patient to discontinue the use of prescribed hydrocodone, an opioid that is fueling an epidemic of abuse and addiction. Accelerated recovery time allowed the patient to return to work sooner, having broader economic implications on medical costs and personal time off. Finally, PAF enhanced the body’s own capacity to heal itself, avoiding painful and costly grafting and decreasing additional donor site scarring.

Interpolation sural flap in acute trauma patients

Objectives: Distal lower leg wounds, regardless of cause, and acute trauma wounds, regardless of site, are difficult. Reconstruction of both situations are much more challenging. Interpolation sural flap is a good alternative for this type of reconstruction. Methods: Fourteen interpolation sural flap were harvested to reconstruct for distal leg region wounds due to acute trauma. Ten male and four female patients aged from 10 to 59 years old were included this study. Results: All flaps survived. No venous congestion and total flap necrosis was seen. There were 4 complications, and all of them were corrected with short interventions. After second stage, no complication was seen. Conclusions: Interpolation sural flap modification has many advantages including reliability, no venous congestion, immediate reconstruction without a surgical team. However, it is a two-staged reconstruction and its donor site scarring can be serious.

Comparative study of the effects between second toe tibial dorsal artery flap and second toe tibial plantar proper artery flap in repairing finger skin and soft tissue defects

Objective: To compare the effects between second toe tibial dorsal artery flap (2-TDAF) and second toe tibial plantar proper artery flap (2-TPPAF) in repairing finger skin and soft tissue defects. Methods: A retrospective cohort study was conducted. From January 2019 to June 2020, 27 patients with skin and soft tissue defects at the fingertips with area of 1.5 cm×1.2 cm-2.6 cm×1.8 cm after debridement who met the inclusion criteria were admitted to Suzhou Ruihua Orthopaedic Hospital, including 21 males and 6 females, aged 19-59 (37±10) years. According to flap repair methods used in the defective fingers, the patients were divided into 2-TDAF group (12 cases) and 2-TPPAF group (15 cases). The area of 2-TDAF ranged from 1.5 cm×1.2 cm to 2.5 cm×1.6 cm, and the area of 2-TPPAF ranged from 1.7 cm×1.3 cm to 2.6 cm×1.8 cm. Full-thickness skin grafts from the medial side of the ipsilateral leg were grafted to the wounds in donor sites, and the wounds in donor sites of skin grafts were directly sutured. Flap arterial diameter, flap excision time, flap survival situation of patients in 2 weeks after operation, and follow-up time were recorded. At the last follow-up, the two-point discrimination distance of flap graft site, total action motion (TAM) of the finger joints, and wound healing of the flap donor site were recorded; the Vancouver scar scale (VSS) was used to score the scar in donor area of the second toe and the recipient area of fingers; the appearance and self-satisfaction subscales of the Michigan hand outcomes questionnaire (MHQ) were used to evaluate the affected finger. Data were statistically analyzed with independent sample t test or Fisher's exact probability test. Results: The flap artery diameter of patients in 2-TDAF group was 0.35-0.80 (0.56±0.14) mm and the flap cutting time was (14.0±2.7) min, which were significantly shorter than 0.80-1.35 (1.02±0.16) mm and (19.7±3.4) min in 2-TPPAF group (with t values of 7.81 and 4.79, respectively, P<0.01). The flaps of patients in the 2 groups in recipient areas survived well in 2 weeks after operation, and the wounds in donor areas of flaps of patients in the 2 groups healed well at the last follow-up. There was no statistically significant difference in the postoperative follow-up time, and two-point discrimination distance of flap graft site, TAM of the finger joints, VSS score of scar in the second toe donor site and the finger recipient site, and the appearance and self-satisfaction of MHQ scores of the affected finger at the last follow-up (P>0.05). Conclusions: Compared with 2-TPPAF, 2-TDAF has a shallower anatomical layer and shorter time for surgical flap removal, which can preserve the proper arteries and nerves at the base of the toes and reduce the damage to the donor site.

Application of lateral upper arm free flap in the repair of postoperative defects of oral cancer

Objective: To explore the clinical application and efficacy of lateral upper arm free flap (LUAFF) for one-stage repairing of soft tissue defect after oral cancer surgery. Methods: This article was a retrospective analysis of clinical data of 46 patients receiving treatment of one-stage repairing of soft tissue defect with LUAFF after oral cancer surgery in Hunan Cancer Hospital, from June 2019 to June 2021. Among these cases, 40 were males, and 6 were females. The patients' ages were from 23 to 64 years old. The clinical data of patients were reviewed and outcomes were evaluated. SPSS 23.0 software was used for statistical analysis. Results: In the LUAFF of 46 patients, flap area ranged from 5.0 cm×3.5 cm to 15.0 cm×7.0 cm; the mean pedicle length was 8.15±1.42 cm; the mean artery diameter was 1.20±0.41 mm (range, 1.5 to 2.5 mm); the mean diameter of the largest veins was 2.15±0.52 mm; and the median number of perforators was 2.6 (range, 1 to 4). All donor sites were closed primarily. Two cases had arterial anastomosis thrombosis, but their flaps were successfully saved with urgent re-anastomosis of the vessels. The overall flap survival rate was 93.5%(43/46), with flap necroses after operation in three cases. No patient received tracheotomy. The average hospital stay time of patients after operation was 9.4 days. The follow-up time was 6-24 months, elbow and wrist movements on the operative side were normal, and the upper limb muscle strength was not affected. Conclusions: LUAFF is a suitable choice for the repairs of small-moderate tissue defects in oral cancer surgery, with consistent perforators in the flap, simple harvest method, concealed donor-site scar, and high survival rate.

Tunneled superior naso-labial island flap in post mucor infraorbital defect

&lt;p class="abstract"&gt;Reconstruction of facial infraorbital defects, an untoward sequel of mucormycosis, is an issue confronting the rhinologist.&lt;strong&gt; &lt;/strong&gt;Tunneled island flap was used in a patient with a wide defect involving the infraorbital region. Inspite of intricate pedicle dissection and likelihood of a trapdoor deformity these flaps facilitate repair in a single-staged procedure. The flap is so sited that its vascularity is not compromised neither by stretch tension or overlying tissue compression; while in the tunnel. The occasional, slight bulging is observed which is due to the pedicle; just over the undermined tunnel.&lt;strong&gt; &lt;/strong&gt;This effect settles down with time and doesn’t need corrective intervention&lt;strong&gt;.&lt;/strong&gt; Moreover&lt;strong&gt;,&lt;/strong&gt; the donor site scars are merged in the margins of the aesthetic units thereby retaining central facial symmetry.&lt;/p&gt;

Transposition glabellar flap in post orbital exenteration fistula: case report

&lt;p&gt;Reconstruction of facial orbital region defects, secondary to wound dehiscence following orbital exentration to treat Mucormycosis is an issue confronting the rhinologist. The transposition flaps have a vital role when expected result is unlikely, neither aesthetic nor functional, with a simple primary closure, secondary intention, advancement sliding flap or by free skin grafts. Glabellar transposition flap was used in a patient with a wide defect involving the medial wall of the orbit. Though there is a delicate dissection of pedicel there is likelihood of a trapdoor deformity but the glabellar flap facilitates repair in a single-staged procedure. Moreover, the donor site scars are merged in the margins of the aesthetic units thereby retaining facial cosmesis.&lt;/p&gt;&lt;p class="abstract"&gt; &lt;/p&gt;

Donor-Site Morbidity and Quality of Life after Autologous Breast Reconstruction with PAP versus TMG Flap

The transverse myocutaneous gracilis (TMG) and the profunda artery perforator (PAP) flap are both safe choices for autologous breast reconstruction originating from the same donor region in the upper thigh. We aimed to compare the post-operative outcome regarding donor-site morbidity and quality of life. We included 18 patients who had undergone autologous breast reconstruction with a PAP flap (n = 27 flaps). Prospective evaluation of donor-site morbidity was performed by applying the same questionnaire that had already been established in a previous study evaluating TMG flap (n = 25 flaps) outcome, and results were compared. Comparison of the two patient groups showed equivalent results concerning patient-reported visibility of the donor-site scar and thigh symmetry. Still, the TMG group was significantly more satisfied with the scar (p = 0.015) and its position (p = 0.001). No difference was found regarding the ability to sit for prolonged periods. Donor-site wound complications were seen more frequently in the PAP group (29.6%) than in the TMG group (4.0%). Both groups expressed rather high satisfaction with their quality of life. Both flaps show minimal functional donor-site morbidity and high patient satisfaction. To minimize wound healing problems in PAP patients, thorough planning of the skin paddle is necessary.

Useful vertical latissimus dorsi flap for partial breast reconstruction in every tumor location

BackgroundWe conducted a prospective cohort study to evaluate effective techniques for breast reconstruction after partial mastectomy due to breast cancer. Determining the method of reconstruction is often difficult as it depends on the location of the cancer and the amount of tissue excised.. Here, we present a new technique, using the vertical latissimus dorsi (LD) flap, that can be used in all partial mastectomies and can almost conceal scarring. We also compared these results to those of the mini LD flap.MethodsWe analyzed the data of a total of 50 and 47 patients, who underwent breast reconstruction with the mini LD flap and the vertical LD flap, respectively. Immediately after tumor excision, breast reconstruction was initiated. The skin flap for vertical LD was designed in a planarian shape, such that it may be hidden as much as possible and minimize bulging during closure, and the LD muscle flap was designed with a sufficient distance in the inferior direction.ResultsOur finding showed that the vertical LD flap group required significantly less total operation time than the mini LD flap group. While the mini-LD flap resulted in a scar that was difficult to conceal, the donor site scar of the vertical LD flap could not be seen easily, and no scar was visible on the back.ConclusionsThe vertical LD flap is useful for partial breast reconstruction, in all breast regions requires a rather small volume of the flap. Moreover, recovery was relatively fast with high patient satisfaction.