Pressure-Specified Sensory Device Research Articles

6. Breast Flap Neurotization After Autologous Free Flap Breast Reconstruction: A Prospective Trial

Purpose: Restoration of breast sensation is an important factor to consider following autologous breast reconstruction (ABR). Flap neurotization may result in improved sensation after ABR, but current literature regarding both patient-reported outcomes and quantitative sensation after neurotization is inadequate and heterogenous. We present a prospective trial investigating the long-term outcomes of flap neurotization regarding breast sensation. Methods: 98 patients (n = 166 flaps) were prospectively evaluated for breast sensation and quality-of-life 1-5 years after ABR. This included 55 neurotized patients (n=97 neurotized breast flaps) and 44 non-neurotized patients (n=71 non-neurotized breast flaps). Evaluation consisted of the validated patient-reported questionnaire (BREAST-Q), a sensation-specific patient-reported questionnaire, and pressure-specified sensation testing at 9 locations on the breast using the AcroVal pressure-specified sensory device. Continuous variables were compared using independent t-tests. Categorical variables were compared using chi-squared analyses. Results: Non-neurotized patients were significantly more likely to report breast sensation was affecting their daily lives due to pain or discomfort, while neurotized patients were more likely to report they did not notice a difference in breast sensation after ABR or that the change in sensation was not affecting their daily lives (p= 0.035). While there was no significant difference in quantitative sensation between neurotized and non-neurotized patients at 1 year after ABR, neurotized patients were significantly more sensate at 4 of 9 testing locations on the breast (0.011<p<0.039) when evaluated 2-5 years after ABR. Conclusion: Breast sensation affects the daily lives of breast reconstruction patients and is an important long-term outcome to consider following ABR. Neurotization is associated with improved protective sensation as well as reduced pain and discomfort in the long-term after ABR.

Comparing Autologous to Device-Based Breast Reconstruction: A Pilot Study of Return in Breast Sensation.

Poor breast sensation is common after mastectomy and reconstruction. In this study, we aim to define the temporal pattern of sensory changes after reconstruction and to compare the return in sensation between autologous and device-based reconstruction. Women undergoing mastectomy with immediate reconstruction, with either tissue expander (TE) or neurotized deep inferior epigastric perforator (DIEP) flap, were prospectively identified at their preoperative or postoperative visit at defined time points. Neurosensory testing was performed in 9 breast regions using the AcroVal pressure-specified sensory device to determine 1 point-static cutaneous thresholds. Sensitivity data were averaged between patients at each time point and plotted over time. Eighty-seven patients (153 breasts) were included in this study, including 41 women (75 breasts) with DIEP flap and 46 women (78 breasts) with TE. The groups were comparable in age, body mass index, breast size, chemotherapy, radiotherapy, and number of revisional breast surgeries (P > 0.05). Compared with preoperative baseline, mean cutaneous thresholds in DIEP flap patients were comparable in most outer breast regions at 18 months postoperatively and in the entire breast, except the inner inferior region, at 3 years (P > 0.05). In contrast, mean cutaneous thresholds in TE patients continued to be significantly worse in the entire breast at 5 years postoperatively compared with baseline (P < 0.05). Autologous breast reconstruction is superior in sensory recovery. Patients undergoing DIEP flap can expect sensory return to preoperative levels by 3 years, with sensation returning by 18 months in some areas of the breast. Patients undergoing device reconstruction should expect a slower and more unpredictable return in breast sensation.

QS4: Genital Neurosensory Outcomes After Innervated Radial Forearm Phalloplasty

Purpose:Radial free forearm flap (RFFF) phalloplasty is the most commonly-used technique for gender-affirming phalloplasty procedures. Microsurgical coaptation of the free flap nerves to branches of the genital nerves aims to provide patients with a sensate neophallus. Return of sensation in the neophallus is poorly understood and has yet to be well characterized in the literature. This study serves to describe sensation in the neophallus, which will assist in setting patient expectations for recovery and improving operative technique and planning, especially in selection of nerves for coaptation.Methods:A total of 14 patients undergoing RFFF were tested for pressure sensation in the neophallus postoperatively. Testing was conducted via 1-point static (1PS) testing using the Pressure Specified Sensory Device (PSSD). A 100g monofilament was used to screen the neophallus for sensation beginning at 3 cm distal to the base and advancing distally by 1 cm until the patient reported no sensation; the PSSD was then applied at the last point the patient reported sensation for precise pressure measurements. These measurements were taken on the right and left ventral and dorsal shaft 1 cm from the ventral and dorsal midlines, respectively. The right and left urethral meatus was also measured for sensation (representing the ulnar-most skin of the RFFF). Measurements were taken at intervals beginning as early as 1 week postoperatively; the longest patient follow-up thus far has been 17 months.Results:Of the 14 patients, 13 had tactile pressure sensation at their most recent measurement (range 1-17mos). The remaining patient did not have a measurement beyond one month postoperatively. Of the 14 patients, consistent long-term follow-up measurements were currently available for 7. Among these patients, return of any sensation was measured at an average of 69 days (12-160 days) postoperatively. The earliest time point at which a patient had any sensation was two weeks postoperatively while another patient had sensation through the full length of the neophallus measured at 2.5 months postoperatively; subsequent measurements of this patient showed a decreased threshold (increased sensitivity) for pressure sensation over time.Conclusions:Preliminary data suggests that innervation of the RFFF neophallus can be accomplished via microsurgical nerve coaptation and that recovery of sensation may occur much faster in some patients than previously thought possible. Further follow-up and a larger patient cohort is necessary to fully characterize nerve recovery and regeneration in gender-affirming phalloplasty patients.

Tactile Hand Sensation Following Split Thickness Radial Forearm Free Flap Phalloplasty

PURPOSE: Radial forearm free flap (RFFF) phalloplasty is often referred to as the gold standard for gender-affirming phalloplasty procedures.1 Forearm neuropathy, a frequently listed complication of RFFF phalloplasty, has yet to be quantified in patients who undergo this procedure with a device as precise as the Pressure Specified Sensory Device (PSSD). The purpose of this study was to determine whether there is a change in tactile hand sensation following RFFF phalloplasty, and whether these changes vary by cutaneous region of the hand. The results of this study will help counsel patients who may view potential neuropathy as a barrier to pursuing this procedure. METHODS: A total of 9 patients undergoing split thickness RFFF phalloplasty were tested preoperatively and 1-week postoperatively for tactile hand sensation. Testing was conducted using a 2-point static (2 PS) test with a Disk-Criminator and PSSD. The testing sites included the cutaneous regions of the dorsal first webspace and the first phalanx of the index finger and pollex of the RFFF donor arm. The 2 PSSD prongs were set at a distance determined by initial testing with the Disk-Criminator. The PSSD measured the threshold of pressure necessary for the patient to discriminate 2 points. Two-sided paired t tests compared the pre- and postoperative pressure values on each of the 3 hand locations. The numerical differences in pre- and postoperative pressures were then compared between each of the 3 locations to determine whether or not there was a difference in postoperative sensation based on hand region. The PSSD pressure values were standardized based on the prong distance determined by the Disk-Criminator, and percent change in standardized PSSD score differences for each cutaneous region was calculated. All tests were considered significant at P < 0.05. RESULTS: There were no significant differences between pre- and postoperative PSSD pressures for all cutaneous regions tested (P > 0.05). However, on average, patients required 8.04% more pressure applied in the dorsal first webspace in order to discriminate 2 points, 8.43% more in the first phalanx of the index finger, and 16.7% more in the first phalanx of the pollex postphalloplasty (all n.s.). Furthermore, when comparing each of the three cutaneous regions to each other, there was no difference in the change in pressures between each region (P > 0.05). In other words, each of the three regions of the hand was similarly impacted by the operation. CONCLUSIONS: The results of this study suggest that while past literature reports cases of numbness and/or tingling post-RFFF phalloplasty,1 immediate postoperative sensation is not significantly different than preoperative sensation. The fear of donor arm neuropathy is a potential barrier for patients seeking this life-changing procedure, yet this study quantifies the degree of neuronal damage and may encourage patients to undergo the procedure. These results will help guide patient-physician conversations regarding RFFF phalloplasty in order to create realistic patient expectations for postoperative outcomes. REFERENCE: 1. Kovar A, Choi S, Iorio ML. Donor site morbidity in phalloplasty reconstructions: outcomes of the radial forearm free flap. Plast Reconstr Surg Glob Open. 2019;7:e2442.

Neurotization of the Nipple-Areola Complex during Implant-Based Reconstruction: Evaluation of Early Sensation Recovery.

The concept of sensate autologous breast reconstruction is not novel, and prior literature has focused mainly on sensate abdominally based breast reconstruction. The goal of this article is to present the authors' results with a novel technique performing sensate implant-based reconstruction. A database was prospectively maintained for patients who underwent implant-based sensate breast reconstruction. The anterior branch of the lateral fourth intercostal is identified and preserved during the mastectomy by the breast surgeon. A processed nerve allograft is used as an interpositional graft connecting the donor nerve to the targeted nipple-areola complex. The sensory recovery process was objectively monitored using a pressure-specified sensory device. Thirteen patients underwent the proposed technique. Eight patients with 15 breasts were monitored for sensory recovery. For sensory measurement, the nipple had a mean threshold of 67.33 ± 34.48 g/nm. The upper inner (29 ± 26.75 g/nm) and upper outer (46.82 ± 32.72 g/nm) nipple-areola complex quadrants demonstrated better scores during the moving test compared with the static test. Mean time between the test and surgery was 4.18 ± 2.3 months, and mean time between the second test and surgery was 10.59 ± 3.57 months. Threshold improvements were documented after the second test for all nipple-areola complex areas evaluated. This is the first study to report on early results obtained after performing sensate implant-based breast reconstruction. More studies are required to determine the long-term outcomes and impact on quality of life and to assess whether patient or breast characteristics impact the success of this procedure.

Comparison of neurosensory devices in detecting cutaneous thresholds related to protective sensibility: A cross-sectional study in São Paulo, Brazil

AimsTo quantify the static and moving cutaneous sensibility threshold of diabetic patients using a neurosensory device for quantitative pressure detection. MethodsThree hundred thirty-four (n = 334) patients with type 2 diabetes and no previous history of wounds on the feet were studied using the one- and two-point static (1SP;2 SP) and one- and two-point moving (1MP;2 MP) tests through the pressure-specified sensory device (PSSD) on the cutaneous territory of the dorsal first web, hallux pulp, and medial calcaneal. In addition, patients were evaluated using the Semmes-Weinstein monofilament (SWM) No. 5.07 and tuning fork (128 Hz), which were used as normality parameters to detect the loss of protective sensibility. The same examinations were used to assess the control group (228 nondiabetic). ResultsAltered values were observed for the static and moving tests over the three studied nerve territories. In comparing the sensibility threshold between diabetic patients who were sensitive and nonsensitive to SWM 5.07, we observed that this filament is not the most indicated for identifying the loss of sensibility in these patients. The prevalence of patients at risk varied between 85 and 89%. The biochemical marker associated with these high rates was HbA1c (p = 0.02). ConclusionsNumeric quantification of the pressure threshold allowed us to determine the functional deficit of nerve fibers. Our findings suggest that the neurosensory device should be used as an adjuvant tool to evaluate the degree of loss of sensation on the skin.

Aesthetic improvements of radial forearm flap donor site by autologous fat transplantation

Despite its reliability, radial forearm (RF) flap is still affected by high donor site morbidity with poor cosmetic and functional outcomes after coverage with skin grafts. Having fat grafting demonstrated promising and effective filling and rejuvenating properties, we considered and tested it as a valuable alternative to dermal substitutes for the aesthetic improvement of RF flap donor site. Thirty-three patients with previous RF free flap reconstruction and poor donor site outcomes after full-thickness skin grafting to RF region were evaluated for secondary fat injection to improve outcomes. Objective and subjective assessments of results with standardized ultrasonographic soft tissue thickness measurements, cutaneous sensibility tests with the pressure-specified sensory device and scar assessment scale (POSAS) have been performed. Bivariate statistical analyses were performed comparing outcomes with contralateral healthy forearm. All cases showed significant improvement in soft tissue thickness (p< 0.031), cutaneous sensibility and scar appearance, with improved patient’s and observers’ scar assessment scores (<0.001). In conclusion, fat transplantation is an effective procedure that provided us with an adjunctive autologous layer in-between skin graft and underlying fascia, as well as a rejuvenating effect on skin and scars.

Nipple-Sparing Mastectomy Improves Long-Term Nipple But Not Skin Sensation After Breast Reconstruction: Quantification of Long-Term Sensation in Nipple Sparing Versus Non-nipple Sparing Mastectomy.

Changes in breast sensation after reconstruction are expected. Return of breast sensation after reconstruction and whether nipple-sparing mastectomy offers a substantial benefit in terms of sensation has been inconsistently documented in the literature. We conducted the current study using the pressure-specified sensory device to quantify postoperative breast sensation in patients undergoing nipple-sparing versus non-nipple-sparing mastectomy. Consecutive adult women who underwent nipple-sparing (NSM) and non-NSM (NNSM) and were at least 18 months postreconstruction were included. Breast measurements were taken in 4 quadrants (upper/lower lateral, upper/lower medial) and nipple. Averaged skin cutaneous thresholds [(UL+LL+UM+LM)/4] and nipple sensation between NSM and NNSM were compared as the primary outcome measure. A generalized estimating equations model was used; univariate and multivariate variable analyses were done when appropriate. Forty-four patients (74 breasts) were examined (53 NNSM vs 21 NSM). The groups were further subdivided into autologous versus implant-based reconstruction. Averaged cutaneous skin thresholds for quadrants were better for the NSM, 51.8(±24.5) g/mm versus NNSM, 56.5(±25.7) g/mm, although this difference was not statistically significant. However, NSM breasts measured higher nipple or nipple area sensitivity, 44.5(±30.8) g/mm versus NNSM, 83.8(±27.4) g/mm (P < 0.001). In a multivariate regression analysis, a predictor of decreased sensation was the number of revision surgeries, especially after third revision. Breast sensation is decreased after reconstruction in both NSM and NNSM, but nipple sensation or nipple area is better preserved in NSM breasts. Number of revision surgeries (>3) was a predictor of decreased sensation.

Comparison of Neurosensory Assessment Methods in Plastic Surgery

Sensory assessment of the skin is essential to document the function of the sensory fibers of the tested nerves. The Semmes-Weinstein monofilaments, disk-criminator, electrodiagnostic testing, and Pressure-Specified Sensory Device (PSSD) have been currently used to assess sensory function of peripheral nerves. None of these methods is optimal because of different drawbacks; however, an increasing number of articles, which recognize the reliability of PSSD, have been published during the last decade. In this review, following a short overview on basic physiology and assessment methods of the skin sensory receptors, we compared the sensory assessment methods and summarized the applications of the PSSD in the field of different clinical areas, mainly peripheral neuropathies, breast, and flap surgery.

Nipple–areola complex cutaneous sensitivity: A systematic approach to classification and breast volume

The aim of our study was to develop a systematic approach to provide a data bank on normative cutaneous pressure thresholds of the nipple-areola complex (NAC) in different breast volumes and a classification of the NAC sensitivity function. A population of 150 Caucasian women stratified in five groups of 30 subjects according to the Lalardie-Jouglard classification of breast volume was enrolled in our study. A single evaluator (B.L.) performed breast volume assessments using the BREAST-V and sensory testing on NACs with Pressure-Specified Sensory Device; static and moving one- and two-point discriminations of nipple and areola were collected from each group. Statistical analysis using mixed effects model was performed with significant p-values <0.05. Nipple was found to be more sensitive than areola for both static and moving one-point tests. From our analyses emerged an inverse relationship between skin pressure thresholds and breast volume, with NACs from small breasts (group A) statistically more sensitive than NACs from macromastia women (group E). Properly, the group A women were found to be 0.42, 1.89, 4.98, and 9.55 times progressively more sensitive (p < 0.001) than groups B, C, D, and E, respectively, for quickly adapting fibers of nipple, and 0.58, 1.97, 4.97, and 8.67 times more sensitive (p < 0.001) than groups B, C, D, and E, respectively, for quickly adapting fibers of areola. The sensitivity function of the nipple and areola was classified as high (first degree), medium (second degree), and low (third degree) according to mean ± standard deviation of the overall values. Our study first provides a complete data bank of normative NAC sensitivity in a wide range of breast volumes, and gives three degrees of classification of NAC sensitivity function.

Sensory Testing in Patients With Hemodialysis-Associated Carpal Tunnel Syndrome Submitted to Surgical Decompression

Carpal tunnel syndrome (CTS) is the most common compression neuropathy of the upper limb. Close to 5% of patients with chronic renal failure who need hemodialysis present CTS. Clinical history and physical examination remain the most adequate tools for diagnosis, and there is still controversy regarding the most reliable test to complement it. Evaluation of sensory thresholds using Pressure-Specified Sensory Device (PSSD) has become an important instrumental test. This study aimed to determine the values of pressure sensory thresholds using the PSSD before and after treatment of CTS in a special group of patients who underwent chronic hemodialysis. The PSSD incorporates a pressure transducer linked to a computer capable of measuring the cutaneous pressure thresholds referred by the patient. Two groups were compared as follows: group 1, patients with hemodialysis-related CTS; and group 2, CTS in non-hemodialysis patients. The following measurements were assessed: static one point, moving one point, static two points, and moving two points. There was improvement (lower thresholds) in the postoperative measurements in all parameters assessed in group 1, and improvements in all parameters except the moving one point test in group 2. Nerve decompression, as expected, can be considered a good treatment of CTS even in more severe cases as in those patients under hemodialysis. The PSSD tests were reliable to confirm the diagnosis and thus to indicate the decompression. It is even more beneficial to provide a comparison between preoperative and postoperative data and different causes of CTS.

The construct validity and responsiveness of sensory tests in patients with carpal tunnel syndrome.

Background and Purpose :Sensory evaluation is fundamental to evaluation of patients with Carpal Tunnel Syndrome (CTS). The purpose of this study was to determine the construct validity and responsiveness for sensory threshold tests in patients with CTS.Methods :Sixty-three patients diagnosed with CTS were evaluated prior to orthotic intervention and again at follow up at 6 and 12 weeks. Sensory tests included touch threshold PSSD (Pressure Specified Sensory Device) and vibration threshold (Vibrometer). Construct validity was assessed by comparing sensory tests to hand function, and dexterity testing using Spearman rho (rs). Patients were classified as either responders or non-responders to orthotic intervention based on the change score of the Symptom Severity Scale (SSS) of 0.5. Responsiveness of the sensory tools was measured using ROC (receiver operating characteristic) curves, SRM (Standardized Response Mean), and ES (Effect Sizes).Results :The PSSD had low to moderate correlations (rs ≤ 0.32) while Vibrometer scores had moderate correlations (rs = 0.36 - 0.41) with dexterity scores. The Clinically Important Difference (CID) for the PSSD was estimated at 0.15 g/mm2 but was not discriminative. The Vibrometer demonstrated moderate responsiveness, with a SRM = 0.61 and an ES = 0.46 among responders. The PSSD had a SRM = 0.09 and an ES = 0.08 and showed low responsiveness for patients with a clinically important improvement in symptoms.Conclusion :Measurement properties suggest that the Vibrometer was preferable to the PSSD because it was more correlated to hand function, and was more responsive. Clinicians may choose use the Vibrometer opposed to the PSSD for determining important change in sensation after orthotic intervention.

Test–retest reliability and validity of normative cut-offs of the two devices measuring touch threshold: Weinstein Enhanced Sensory Test and Pressure-Specified Sensory Device

Introduction Touch threshold screening instruments must accurately distinguish normal versus abnormal sensation to screen nerve pathology. This study was conducted to find out whether two touch threshold measuring devices (i.e. Weinstein Enhanced Sensory Test (WEST) and Pressure-Specified Sensory Device (PSSD) provide consistent results and indicators of “normal” sensation, and secondarily what rules best define normality. Methods The study design was a cross-sectional reliability and validity assessment with 23 healthy participants. Instruments were applied in random order on the pulp of the middle and little fingers of both hands; with five applications on each digit. Cut-offs of 3, 4, and 5 correct responses were used to classify the response as being normal. Weighted kappa and percent agreement were used to indicate test–retest reliability of the WEST, and validity was determined by calculating the percentage of normal controls that achieved a normal score. The Bland–Altman method was used to characterize the retest reliability of PSSD, and validity was determined by whether the mean of the score is different from the normative scores. Results The agreement between test and retest of WEST (detection level = 3/5) was almost perfect ( k = 1). The average percentages of normal detection of the WEST on two test/retest were 93% and 97% (detection level = 4/5) and 82% and 85% (detection level = 5/5). All mean PSSD tests values were found within the predetermined normal range. The Bland–Altman plot demonstrated a minimal mean difference between test occasions and similar limits of agreement across the four test locations. Discussion The study found that more than 90% of the tests with healthy young participants were reliable and valid in relation to their ability to detect a normal WEST filament or PSSD within a normal force range. Our study was limited by a small sample with healthy participants.

Long-Term Sensory Recovery of Nipple-Areola Complex following Superolateral Pedicled Reduction Mammaplasty

The aim of this study was to investigate nipple-areola complex sensation at 48-month follow-up following superolateral pedicled reduction mammaplasty using the pressure-specified sensory device. Data regarding nipple-areola complex sensation for static and moving one- and two-point discrimination were collected from 30 active group hypertrophic-breasted patients undergoing superolateral pedicled reduction mammaplasty preoperatively, at 6 months, and at 48 months, and from a control group of 30 unoperated women with normal-sized breasts. Breast volume was assessed using the BREAST-V instrument. For the nipple, static one-point discrimination showed that mean pressure thresholds for the active group at 48 months were 4.10 and 4.19 times higher than preoperatively and in the control group (p<0.001), respectively; moving one-point discrimination showed that mean pressure thresholds for the active group at 48 months were 4.08 and 3.23 times higher than preoperatively and in the control group (p<0.001), respectively. For the areola, static one-point discrimination showed that mean pressure thresholds in the active group at 48 months were 4.12 and 4.83 times higher than preoperatively and in the control group (p<0.001), respectively; moving one-point discrimination showed that mean pressure thresholds from the active group at 48 months were 4.56 and 4.46 times higher than preoperatively and in the control group (p<0.001), respectively. Despite a slight worsening at 6 months after surgery, patients who had undergone superolateral pedicled reduction mammaplasty showed significant nipple-areola complex sensibility reduction at 48-month follow-up. Although the nipple-areola complex of hypertrophic-breasted patients was seen to be nonsignificantly less sensitive than normal-sized breasts, a significant decrease of sensation was observed following reduction mammaplasty. Therapeutic, II.

Long-Term Vascular, Motor, and Sensory Donor Site Outcomes after Ulnar Forearm Flap Harvest

Use of the ulnar forearm flap (UFF) is limited by concerns for ulnar nerve injury and impaired perfusion in the donor extremity. Twenty UFFs were performed over a 6-year period. All patients underwent postoperative bilateral upper extremity arterial duplex studies. A subset of postoperative patients (n = 10) also had bilateral upper extremity sensory and motor evaluations, and functional evaluation via the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH). Motor function was tested by digital and key grip dynamometry. Ulnar nerve sensation was tested by evaluation of one- and two-point perceived pressure thresholds and two-point discrimination using the Pressure-Specified Sensory Device (Sensory Management Services, LLC, Baltimore, MD). All UFFs were viable postoperatively. Mean follow-up was 28.8 months for vascular studies and 45.3 months for motor, sensory, and QuickDASH evaluations. Although mid and distal radial artery flow velocities were significantly higher in donor versus control extremities evaluated at less than 1 year postoperatively, there was no significant difference in extremities evaluated at later time points. Digital pressures, grip strength, key pinch strength, and ulnar sensation were equivalent between donor and control extremities. The mean QuickDASH score was 17.4 ± 23.8. The UFF can be harvested reliably and long-term follow-up shows no evidence of impaired vascular, motor, or sensory function in the donor extremity.

The Mushroom-Shaped Anterolateral Thigh Perforator Flap for Subtotal Tongue Reconstruction

Reconstruction of a functional tongue with proper motility and sensation after subtotal resection is a demanding procedure. The authors describe the reinnervated mushroom-shaped anterolateral thigh perforator flap for subtotal tongue reconstruction. Thirteen patients (mean age, 54.8 years; range, 49 to 71 years) diagnosed with T3 and T4 squamous cell carcinomas were allocated prospectively to anterior total mobile (n = 7) or subtotal tongue resection (n = 6). All patients received the mushroom-shaped anterolateral thigh perforator flap. A Likert scale ranging from 1 to 4 was used to assess speech intelligibility, swallowing function, and cosmetic results. Epicritic and proprioceptive sensitivity testing was performed with the Pressure-Specified Sensory Device on the tip of the tongue preoperatively, on the neotongue at the donor site preoperatively, and at the recipient site 12 months postoperatively; protopathic thermoreceptor and nociceptors were clinically investigated. Outcomes were analyzed, and values of p < 0.05 were considered significant. All flaps healed uneventfully (mean follow-up, 18 months). Six patients (46.2 percent) recovered a nearly natural deglutition, whereas seven (53.8 percent) had mild impairment (p = 0.274). Normal intelligible speech was achieved in seven cases (53.8 percent), and acceptable intelligible speech was achieved in six (46.2 percent) (p = 0.286). Aesthetic results were excellent in eight patients (61.5 percent) and good in five (38.5 percent) (p = 0.592). All patients recovered epicritic, proprioceptive, and protopathic sensitivity; cortical upgrading phenomena of the recipient nerve were observed. The reinnervated mushroom-shaped anterolateral thigh perforator flap was found to be an innovative and effective option for subtotal tongue reconstruction.

Prospective Evaluation of a Single‐sided Innervated Gluteal Artery Perforator Flap for Reconstruction for Extensive and Recurrent Pilonidal Sinus Disease: Functional, Aesthetic, and Patient‐reported Long‐term Outcomes

Treating large and extensive pilonidal sinus disease is a challenging task. Long-term reports on flaps suitable for coverage of large, wide, local-excision defects are sparse. We prospectively evaluated data with a minimum 1-year follow-up of the use of a single-sided, innervated, superior gluteal artery perforator flap. Twenty-one patients (1 woman, 20 men) with a median age of 26 years (min - max = 18 - 46) were included in the study period from September 2005 to April 2010. We recorded flap size, major and minor complications, hospital length of stay, impairment in activities of daily living, pain, aesthetic outcomes, and sensibility in the gluteal region (PSSD, pressure-specified sensory device) at 6 and 12 months postoperatively. The mean defect size (±SD) was 13.0 ± 1.9 × 8.6 ± 1.3 × 5.5 ± 1.2 cm (height × width × depth), and median length of hospital stay was 9 days (range = 7-11). Only two patients developed minor wound-healing complications. Visual analog pain scales significantly improved, with no pain detectable at 12 months postoperatively (p < 0.0001). The aesthetic appearance of the results was good in the majority of patients (61.9-85.7 %). PSSD showed gradual normalization, with retained sensibility in the flap area over 12 months postoperatively (p = 0.0232). During the median 36-month (range = 20-60) follow-up, we have not observed any recurrence in the operated area. The innervated superior gluteal artery perforator flap is a useful technique for covering large and recurrent pilonidal sinus defects following wide local excision and represents an excellent tool in the surgical armamentarium for achieving long-lasting outcomes in this young group of patients.

PROSPECTIVE STUDY ON TACTILE SENSITIVITY IN THE HANDS OF A BRAZILIAN POPULATION USING THE PRESSURE-SPECIFIED SENSORY DEVICE

Objective: To evaluate the pressure perception thresholds on the pulp of two fingers (index and little fingers), among a Brazilian population with no nerve injury or neuropathy. Methods: We used the Pressure-Specified Sensory Device (a computerized device) to derive static and dynamic normal pressure perception thresholds and two-point discrimination distances. Results: We tested finger sensitivity on 30 volunteers. Significance analyses were performed using the Student t test. The mean values (g/mm2) for static one and two-point pressure thresholds (s1PD, s2PD) and dynamic one and two-point discrimination (m1PD, m2PD) in the dominant index finger were: s1PD = 0.4, m1PD = 0.4, s2PD = 0.48, m2PD = 0.51. Conclusion: There was no significant difference in sensitivity between the dominant and nondominant hands.

The Impact of Reduction Mammaplasty on Breast Sensation

Our prospective clinical trial collected sensory data using a computerized pressure-specified sensory device comparing 4 procedures for reduction mammaplasty. A total of 48 patients were assessed at baseline, 6 weeks (n = 42), 6 months (n = 15), and 1 year (n = 24) postoperatively. The findings of our study showed pressure sensitivity for women <43 years of age improved by pressure-specified sensory device assessment; whereas, outcome data merely indicated return to baseline in pressure sensitivity for women ≥ 43 years of age. Improved sensitivities for moving and static pressures were found in patients receiving vertical or inferior pedicle reduction mammaplasties. Reductions based on superior pedicles exhibited sensory loss as compared with baseline measurements while those receiving free nipple grafts showed negligible change. Moving and static sensation showed differential return after breast reduction irrespective of the specific surgical approach but sensation was uniquely conserved for the nipple. In the total cohort, the type of breast reduction procedure did not produce significant differences in breast sensation.

Management of intraneural fibro-lipoma of the median nerve and the role of pressure-specified sensory device (pssd) for the patients motor and sensorial evaluations

The intraneural fibro-lipoma is a benign, uncommon tumor which is characterised with infiltration of the epineurium and perineurium by fibrofatty tissue. The preoperative diagnosis is difficult. However, the Pressure-Specified Sensory Device (PSSD) may support identifying the earliest stages of intraneural fibro-lipoma when traditional electrodiagnostic testing will not be able to detect a change in peripheral nerve function. Five patients (3 male, 2 female, age 23-53; mean 41 years) with intraneural fibro-lipoma were operated on. Grip strength, pinch strength and sensorial functions were assessed in all patients before surgery and at the end of the follow-up period by PSSD. The patients were followed-up for 7 to 24 months (mean; 12 month). All patient's condition improved dramatically following the operation and all patients had total relief of pain and paresthesia. The decompression of intraneural fibro-lipoma of the nerve with limited excision and epineurotomy without sacrificing the main nerve and its branches is the ideal surgical procedure. We recommend the use of PSSD in the investigation of patients with peripheral nerve compression, and chronic unusual volar forearm and wrist swelling. PSSD is an important tool for pre-operative evaluation and diagnosis of intraneural fibro-lipoma.