100 anastomoses: a two-year single-center experience with robotic-assisted micro- and supermicrosurgery for lymphatic reconstruction

Robotic-assisted microsurgery has gained significant attention in recent years following the introduction of two dedicated microsurgical robotic systems specifically designed for this purpose. These feature higher degrees of movement and motion scaling which are useful tools, especially when performing surgery in areas of the body which are difficult to access. Robotic-assisted microsurgery has been implemented in lymphatic surgery as well as soft tissue reconstructive surgery at our institution over the past 2.5 years. Our study gives an insight into the details and outcomes of the first 100 consecutive (super-) microsurgical anastomoses in peripheral and central lymphatic reconstruction performed with the Symani® Surgical System between 2021 and 2024. In total, 67 patients were treated, receiving robotic-assisted lymphatic reconstruction with lymphatic tissue transfer (LTT) and/or lymphovenous anastomoses (LVA)/lympholymphatic anastomoses (LLA). No anastomosis-associated complications were recorded postoperatively. The majority of patients reported a postoperative improvement of their lymphedema or central lymphatic disorder. In conclusion, we show the successful implementation of the Symani® Surgical System into our clinical practice of lymphatic reconstruction. Although the necessary intraoperative setup and the use of intrinsic motion scaling lead to a slight increase in operating time, the presented study demonstrates the advantages of robotic assistance which becomes particularly evident in lymphatic surgery due to the involved deep surgical sites and the need for supermicrosurgical techniques.

Transdisciplinary sarcoma care: a model for sustainable healthcare transformation

No abstract available.

Thromboembolic events in burn patients: An analysis of risk factors and different anticoagulants

BACKGROUND

Burn patients are in a state of activated coagulation, putting them at risk for thromboembolic events. Additionally, certain patient-related factors are associated with an increased risk of thrombus formation. This study aimed to evaluate the incidence of thromboembolic events and identify potential risk factors, including patient characteristics, surgical treatment, anticoagulation strategies, and laboratory parameters.

METHODS

A single-centre retrospective cohort study was conducted on all patients with burns treated between 2002 and 2020. Medical reports of patients with and without thromboembolic events were descriptively analysed. The association of time to thromboembolic events with total body surface area (TBSA) was assessed by cause-specific Cox models adjusted for different covariates. The association of time to thromboembolic events with type and dosage of anticoagulants was assessed using a cause-specific Cox proportional hazards model with time-dependent covariates, applied to a matched subset of patients.

RESULTS

The incidence of thromboembolic events was 8.1% in a cohort of 642 patients. We found a statistically significant increase in the hazard for thromboembolic events by a factor of 1.02 (95% CI 1.00 to 1.03; P ≤ 0.05) per percent increase in TBSA. We identified former alcohol abuse (HR=2.54, CI 1.33 to 4.84, P = 0.005) and higher body mass index (HR=1.06, 95% CI 1.00 to 1.12, P = 0.046) as potential risk factors for the development of thromboembolic events. We further noted inadequate median anti-Factor-X activity levels and elevated C-reactive protein and procalcitonin levels at the time of the event.

CONCLUSION

Our results showed a moderate risk of thromboembolic events among burn patients, underlining the importance of close monitoring with regard to thrombus formation. In particular, patients with higher TBSA, alcohol abuse and BMI may be evaluated more regularly for thromboembolic events. Anti-Factor-X activity levels should be determined regularly and therapy should be adjusted if necessary.

In Vitro Assessment of Bacterial Adhesion and Biofilm Formation on Novel Bioactive, Biodegradable Electrospun Fiber Meshes Intended to Support Tendon Rupture Repair

The surgical repair of a ruptured tendon faces two major problems: specifically increased fibrous adhesion to the surrounding tissue and inferior mechanical properties of the scar tissue compared to the native tissue. Bacterial attachment to implant materials is an additional problem as it might lead to severe infections and impaired recovery. To counteract adhesion formation, two novel implant materials were fabricated by electrospinning, namely, a random fiber mesh containing hyaluronic acid (HA) and poly(ethylene oxide) (PEO) in a ratio of 1:1 (HA/PEO 1:1) and 1:4 (HA/PEO 1:4), respectively. Electrospun DegraPol (DP) treated with silver nanoparticles (DP-Ag) was developed to counteract the bacterial attachment. The three novel materials were compared to the previously described DP and DP with incorporated insulin-like growth factor-1 (DP-IGF-1), two implant materials that were also designed to improve tendon repair. To test whether the materials are prone to bacterial adhesion and biofilm formation, we assessed 10 strains of Staphylococcus aureus, Staphylococcus epidermidis, Pseudomonas aeruginosa, and Enterococcus faecalis, known for causing nosocomial infections. Fiber diameter, pore size, and water contact angle, reflecting different degrees of hydrophobicity, were used to characterize all materials. Generally, we observed higher biofilm formation on the more hydrophobic DP as compared to the more hydrophilic DP-IGF-1 and a trend toward reduced biofilm formation for DP treated with silver nanoparticles. For the two HA/PEO implants, a similar biofilm formation was observed. All tested materials were highly prone to bacterial adherence and biofilm formation, pointing toward the need of further material development, including the optimized incorporation of antibacterial agents such as silver nanoparticles or antibiotics.

Delineation of the healthy rabbit duodenum by immunohistochemistry - A short communication

The duodenum acts as a vital organ that performs fundamental physiological functions like digestion and nutrient absorption. Situated in the lower abdomen, the duodenum is located between the stomach and the jejunum. Usually, the duodenum is divided into four anatomical portions. We here compare paraffin embedded and cryosections of the healthy rabbit duodenum for research purposes. This analysis evaluates the differential outcomes resulting from the application of these fixation methodologies in conjunction with immunohistochemical assays targeting extracellular matrix markers collagen I, collagen III, fibronectin, α-smooth muscle actin (α-SMA), and proliferation marker ki67 as well as inflammatory marker PAR-2. Subsequent recommendations are provided based on our findings. Furthermore, the advantage of an antigen retrieval step in immunohistochemical labelling of paraffin sections was demonstrated and confirmed with an isotype negative control. Basic classical histological stainings as HE, GT and elastin were also performed. Comparison of different stainings and labellings was performed in serial sections, showing that adjacent to the circular muscle of the duodenum, the connective tissue was composed of collagen I and fibronectin, while the artery and vein walls were predominantly α-SMA positive. Moreover, PAR-2 immunohistochemical staining was performed, where particularly a type of gland adjacent to Brunner's glands showed prominent PAR-2 positive areas, while the Brunner's glands themselves were PAR-2 negative. Proliferating ki67 positive cells facing the lumen were highly abundant in all kinds of glands except for the Brunner's glands. This effort serves to furnish the research community with reference imagery pertinent to scientists opting for the rabbit duodenum model. The diversity of staining techniques employed herein establishes a foundational repository of images, primed for comparative analysis against pathological conditions. Furthermore, these images hold the potential to illustrate inter-species variations. For instance, they can be juxtaposed against murine or rat intestinal tracts, or even offer insights into the human context.

Robotic Microsurgery in Extremity Reconstruction - Experience With a Novel Robotic System

Background: Robotic systems have successfully been introduced into other surgical fields in the past. First attempts with different setups are made in the field of microsurgery. The Symani® Surgical System, a flexible platform consisting of two robotic arms, features motion scaling with tremor filtration to address the demands and complexity of microsurgery. Symani's NanoWrist Instruments are the world's smallest, wristed surgical instruments, intended to improve a surgeon's range of motion beyond the capability of the human hand. This combination allows surgeons to scale their hand movements while seamlessly articulating the robotic micro instruments. Purpose: We report on our experience in extremity reconstruction with this novel system.Research Design: The Symani Surgical System® was used for 6 cases of extremity reconstruction. The surgeon controlled the manipulators along with the footswitch while either sitting away from the operating table relying on 3D visualization with an exoscope or sitting at the operating table using a standard microscope.Data Collection: Microsurgical anastomoses were performed in 4 patients (3 end-to-end arterial anastomoses and one end-to-side arterial anastomosis) and nerve grafting was performed in 2 patients.Results: Microvascular anastomoses were slower vs conventional microsurgery, but all anastomoses were patent. Epineural coaptation showed proper fascicle alignment and tissue manipulation could be kept to a minimum. The platform's motion scaling allows the surgeon to perform precise micro-movements with only minimal tissue manipulation and hard-to-reach anatomy becomes accessible more easily.Conclusions: Robotic microsurgery might gain importance in the nearer future but more data will need to be collected.

Delineation of the healthy rabbit tongue by immunohistochemistry - A technical note

In the oral cavity the tongue is an important muscular organ that supports the swallowing of food and liquids. It is responsible for the sense of taste, based on the many different taste buds it contains. Research in the field of tongue diseases demands for suitable preclinical models. The healthy rabbit tongue may therefore serve as baseline and reference for the pathological situation. With this consideration, we covered the fixation and histological stainings as well as the immunohistochemical labelling of the healthy rabbit tongue. In this technical note, initial choice of the fixative is discussed, with a comparison of formalin fixation and subsequent paraffin embedding versus cryopreservation. Moreover, we delineate the effect of an antigen retrieval step for formalin fixation by several examples. Finally, we provide ECM markers collagen I, collagen III, fibronectin, α-SMA and elastin staining as well as ki67 for proliferative status and PAR-2 protein expression as a marker for inflammatory status and nociception in tongue sections, mainly from the tongue body. Technically, we found superiority of paraffin sections for collagen I, collagen III, fibronectin, ki67 and α-SMA labelling, for selected detections systems. As for ECM components, the lamina propria was very rich in collagen and fibronectin, while the muscular body of the tongue showed only collagen and fibronectin positive areas between the muscle fibers. Moreover, α-SMA was clearly expressed in the walls of arteries and veins. The inflammatory marker PAR-2 on the other hand was prominently expressed in the salivary glands and to some extent in the walls of the vessels. Particular PAR-2 expression was found in the excretory ducts of the tongue. This technical note has the aim to provide baseline images that can be used to compare the pathological state of the diseased rabbit tongue as well as for inter-species comparison, such as mouse or rat tongue. Finally, it can be used for the comparison with the human situation.

Measuring quality of care in autologous breast reconstruction: a Delphi consensus

Measuring and benchmarking quality of care in surgical oncology has been gaining popularity. In autologous breast reconstruction (ABR), a standardized set of indicators to assess quality of care is lacking. In this study, we defined a set of evidence-based quality indicators for autologous breast reconstruction. First, we performed a systematic review to identify factors related to quality of care in ABR. Variables were categorized depending on their function: indicators related to outcome, indicators related to process and case-mix variables. The review was followed by a 3-round Delphi Consensus to determine which indicators and case-mix-variables were considered relevant and feasible for inclusion in an ABR standard set of indicators. 932 unique articles were identified, of which 110 papers were included in the study. Indicators were categorized by function: outcome, process and case-mix variables. In total, 8 process indicators and 41 outcome indicators were extracted. 30 case-mix-variables were included. Following 3 rounds of questioning in the Delphi Consensus, all respondents agreed on type of ABR, oncological outcomes and patient satisfaction for the standard set. Indicators related to complications were consistently ranked highly. Most process indicators were not chosen after 3 rounds of questioning. 11 case-mix-variables were included in the final set. Following the Delphi Consensus, it was possible to identify 33 process and outcome indicators and 11 case-mix-variables for inclusion for a standard set of quality indicators. With the inclusion of both objective and patient-reported outcome measures, this set of indicators provides a multidimensional measurement tool for quality assessment for ABR.

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

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

First-in-human Use of a Microsurgical Robotic System for Central Lymphatic Reconstruction

Advances in the development of robotic systems have recently enabled the use of robotic technology in reconstructive lymphatic surgery. Although the advantages of microsurgical robots must be weighed carefully against the costs, their use may allow for smaller surgical approaches and easier access to anatomically deeper structures or even smaller vessels. We report on a case of a patient with central lymphatic dilation causing abdominal pain and severely reduced physical capacity. Sonography-assisted intranodal injection of indocyanine green allowed for localization of the lymphatic cyst and anastomosis with the left ovarian vein, applying robotic-assisted microsurgery for the first time on the central lymphatic system. Following the successful reconstruction of lymphatic drainage and decompression of the cyst, the patient reported a complete regression of her preoperative symptoms. From a surgical point of view, the Symani Surgical System improved precision and allowed significantly smaller surgical access. Considering the high morbidity and rarity of pathologies of the central lymphatic system, central lymphatic surgery is to date rarely performed. With improved precision and significantly smaller surgical access, robotic-assisted microsurgery has great potential to expand the treatment options for central lymphatic lesions.

Delineation of the healthy rabbit tonsil by immunohistochemistry - A short communication

Situated in the oral cavity, the rabbit palatine tonsils are part of the mucosal immune system and help to defend the body against foreign pathogens. Expressed as two oval protrusions in the wall of the oropharynx, the rabbit palatine tonsils are characterized by excretory ducts and trabeculae. We here compare paraffin embedded and cryosections of the healthy rabbit tonsils. This analysis centers on evaluating the differential outcomes resulting from the application of these fixation methodologies in conjunction with immunohistochemical assays targeting collagen I, collagen III, fibronectin, α-smooth muscle actin (α-SMA), and ki67. Subsequent recommendations are provided based on our findings. Furthermore, we demonstrate the advantage of an antigen retrieval step in immunohistochemical labeling of paraffin sections. Basic classical histological stainings as HE, GT and elastin were also performed. Comparison of different stainings and labelings was furthermore performed in serial sections, showing that adjacent to the excretory ducts, the tonsillar tissue was particularly composed of collagen I and fibronectin, while the vessel walls were predominantly α-SMA positive. Moreover, PAR-2 immunohistochemical staining was performed, where a small fraction of the cells found in the tonsillar connective tissue were PAR-2 positive (probably a subpopulation of mast cells), as well as the lumen of some excretory ducts and trabeculae. Collagen III on the other hand was only weakly expressed in the tonsils. Proliferating ki67 positive cells were rare. This endeavor serves to furnish the scientific community with reference imagery pertinent to researchers opting for the rabbit palatine tonsil model. The diversity of staining techniques employed herein establishes a foundational repository of images, primed for comparative analysis against pathological conditions. Furthermore, these images hold the potential to illustrate inter-species variations. For instance, they can be juxtaposed against murine or rodent tonsils, or even offer insights into the human context.

Unlocking the Power of Benchmarking: Real-World-Time Data Analysis for Enhanced Sarcoma Patient Outcomes

Benchmarking is crucial for healthcare providers to enhance quality and efficiency, notably for complex conditions like sarcomas. Multidisciplinary teams/sarcoma boards (MDT/SBs) are vital in sarcoma management, but differences in their processes can affect patient outcomes and treatment costs, despite adherence to international guidelines. To address this issue, this study aimed to compare two MDT/SBs and establish an interoperable digital platform, Sarconnector®, for real-time-world data assessment and automated analysis. The study included 983 patients, 46.0% of whom female, with a median age of 58 years, and 4.5% of patients presented with metastasis at diagnosis. Differences were observed in the number of first-time presentations, follow-up presentations, primary sarcomas, biopsies and chemotherapy indications between the two MDT/SB. The results highlight the importance of benchmarking and utilizing a harmonized data approach, such as the RWT approach provided by the Sarconnector®, to standardize and evaluate quality and cost metrics. By identifying areas of improvement and making data-driven decisions on the meta-level, healthcare providers can optimize resources and improve patient outcomes. In conclusion, benchmarking with the RWT harmonized data approach provided by the Sarconnector® can help healthcare providers improve the overall effectiveness of the healthcare system and achieve better outcomes for their patients in terms of both outcomes and costs.

Benefits of robotic-assisted lymphatic microsurgery in deep anatomical planes

Micro- and supermicrosurgeries have become standard techniques for lymphatic reconstruction. As increasingly smaller vessels are being targeted, robotic-assisted surgery has emerged as a new approach to push reconstructive limits owing to its ability of motion scaling and providing better accessibility of deep anatomical regions. The precision of the robot is achieved at the expense of operating speed among other variables; therefore, the surgeon must weigh the enhanced dexterity against the additional operating time and cost required for the robotic surgical system itself to ensure optimal resource utilization. Here we present a case series of 8 patients who underwent robot-assisted lymphatic microsurgery for omental flap transfer to the axilla and lympho-venous anastomosis. The Symani® Surgical System was used with a conventional microscope or 3D exoscope. The use of 3D exoscope provided clear benefits in terms of surgeon positioning. Moreover, access to the recipient vessels near the thoracic wall was significantly improved with the robotic setup. In addition, suture precision was excellent, resulting in patent anastomoses. Operating time for anastomosis was comparable to that for manual anastomosis and demonstrated a steep learning curve. The benefits of robotic systems in operating fields with good exposure require further evaluation. However, owing to longer instruments, additional stability, dexterity, and motion precision, robotic systems offer a marked advantage for operating in deep anatomical planes and on small structures. A potentially new field for the implementation of robotic surgery is central lymphatic reconstruction. Progress in terms of operating time and cost is crucial, and future research should validate the effectiveness of robotic-assisted surgery in larger clinical studies.

Basic Principles in the Management of Acute Burn Injuries in Adults

INTRODUCTION

This review outlines an overview of up-to-date, stage-appropriate treatment methods for burn injuries as practiced at the National Burn Center of the University Hospital Zurich. It intends to provide practitioners with recommendations for the management of acute minor to severe burn injuries based on scientific evidence as well as the long-term experience of the Burn Center. The focus is on a practical guideline and various options including novel, innovative conceptual approaches.

PROMs after Lymphatic Reconstructive Surgery: Is There a Correlation between Volume Reduction and Quality of Life?

Patients with upper limb lymphedema and lower limb lymphedema experience a wide range of physical and psychological symptoms that affect quality of life. The benefits of lymphatic reconstructive surgery for patients with lymphedema are undisputed. However, recording volume reduction alone may be insufficient with regard to postoperative outcome because measurements are often inadequate, depend on many factors, and do not reflect improvement in quality of life.

Methods

We conducted a prospective single center study patients receiving lymphatic reconstructive surgery. Patients received volume measurements preoperatively and at standardized postoperative intervals. To evaluate patient-reported outcomes, patients completed the following questionnaires: LYMPH-Q Upper Extremity Module, quickDASH, SF 36, Lymphoedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphoedema, and Lower Extremity Functional Scale at the aforementioned intervals.

Results

We included 55 patients with upper limb lymphedema (24%) and lower limb lymphedema (73%) of lymphedema grades I-III. Patients received lymphovenous anastomosis only (23%), free vascularized lymph node transfer (35%) or a combination of both (42%). Analysis of patient-reported outcome measurements revealed improvements with respect to a broad range of complaints, particularly physical function, symptoms, and psychological well-being. There was no correlation between the extent of volume reduction and improvement in quality of life (Pearson correlation coefficient below ±0.7; P > 0.05).

Conclusions

Based on a broad range of outcome measurements, we observed an improved quality of life in almost all patients, even in those without measurable volume loss of the extremity operated on, which emphasizes the need for a standardized use of patient-reported outcome measures to evaluate the benefits of lymphatic reconstructive surgery.

A Comparative Analysis to Dissect the Histological and Molecular Differences among Lipedema, Lipohypertrophy and Secondary Lymphedema

Lipedema, lipohypertrophy and secondary lymphedema are three conditions characterized by disproportionate subcutaneous fat accumulation affecting the extremities. Despite the apparent similarities and differences among their phenotypes, a comprehensive histological and molecular comparison does not yet exist, supporting the idea that there is an insufficient understanding of the conditions and particularly of lipohypertrophy. In our study, we performed histological and molecular analysis in anatomically-, BMI- and gender-matched samples of lipedema, lipohypertrophy and secondary lymphedema versus healthy control patients. Hereby, we found a significantly increased epidermal thickness only in patients with lipedema and secondary lymphedema, while significant adipocyte hypertrophy was identified in both lipedema and lipohypertrophy. Interestingly, the assessment of lymphatic vessel morphology showed significantly decreased total area coverage in lipohypertrophy versus the other conditions, while VEGF-D expression was significantly decreased across all conditions. The analysis of junctional genes often associated with permeability indicated a distinct and higher expression only in secondary lymphedema. Finally, the evaluation of the immune cell infiltrate verified the increased CD4+ cell and macrophage infiltration in lymphedema and lipedema respectively, without depicting a distinct immune cell profile in lipohypertrophy. Our study describes the distinct histological and molecular characteristics of lipohypertrophy, clearly distinguishing it from its two most important differential diagnoses.

Complications arising from aesthetic surgery procedures in foreign countries and Switzerland

BACKGROUND

Cosmetic surgery tourism has increased in popularity in recent years, with arising complications and post-operative follow-up care often managed in the client's home country, thereby burdening the Swiss health care system.

METHODS

We retrospectively reviewed patients with complications after cosmetic surgeries abroad and in Switzerland who were treated at the University Hospital Zurich between 2015 and 2019. Data were collected from medical records and reviewed for patient characteristics, procedures, complications, and treatment modalities.

RESULTS

A total of 228 patients (207 females and 21 males) were identified with female mean age of 40.9±12.0 years and male mean age of 34.3±8.9 years. Most complications were observed for procedures performed in Europe (69%) with only thirty-six patients (16%) experiencing complications due to a procedure undertaken in Switzerland. Breast surgery was the most frequently performed procedure (60%), followed by body contouring (17%) and facial surgery (12%). The most common complications occurring after surgeries abroad were pain and discomfort (19%) as well as aesthetic dissatisfaction (18%), followed by wound breakdown (14%) and infection (11%). Most patients (76%) were treated as outpatients and the treatment of all patients over the observed period cost the healthcare system $ 795,574.

CONCLUSIONS

There is an ongoing trend of cosmetic surgery tourism leading to an increasing number of patients with complications requiring aftercare in Switzerland. In contrast to previous research, more men are seeking cosmetic surgery abroad and the most common complications, such as wound healing disorders and infection, descreased in favor of aethetic dissatisfaction, possibly indicating ameliorated patient aftercare abroad.

Enzymatic debridement for circumferential deep burns: the role of surgical escharotomy

INTRODUCTION

Circumferential deep burns carry a high risk for a burn induced compartment syndrome. It was recently shown that an enzymatic bromelain-based debridement with Nexobrid® is a safe and efficient procedure to release pressure in deep circumferential extremity burns reducing the need for surgical escharotomy. We therefore herein aimed to analyze the conceptual relation between Nexobrid® and surgical escharotomy.

PATIENTS AND METHODS

We conducted a retrospective study on all patients with circumferential deep partial-thickness or full-thickness burns requiring immediate escharotomy that was either performed by surgical incision or Nexobrid®. Medical records of 792 patients that were treated at the burn center of the University Hospital Zurich between 2016 and 2021 were analyzed.

RESULTS

Overall, 62 patients with circumferential deep partial-thickness or full-thickness burns who received preventive decompression either by Nexobrid® (N = 29) or surgical escharotomy (N = 33), were included. Whilst distribution of age, sex, BMI and type of injury showed no difference between the groups, the ABSI score, TBSA, percentage of third degree burns and mortality were significantly higher in patients who received a surgical escharotomy.

CONCLUSION

While the use of Nexobrid® to prevent burn induced compartment syndrome has steadily increased, surgical escharotomies were predominantly performed in severely burned patients with a high degree of full-thickness burns. Thus, higher mortality in this patient group needs to be considered with caution and is mainly attributed to the higher TBSA. Although evidence is lacking for the use of Nexobrid® for larger body areas exceeding 15%, escharotomy is also the more reliable and faster approach in such critically burned patients.

Donor Site Defect Coverage of the Forearm with Dermal Substitute After Harvesting Radial Forearm Free Flap for Phalloplasty: Is MatriDerm® Worth the Effort?

An aesthetically and functionally pleasing phalloplasty is most commonly performed by a free radial forearm flap. However, the problem with donor site morbidity on the forearm remains unsolved. The aim of this study was to evaluate if the use of a dermal template such as MatriDerm® on the donor site significantly decreases the incidence of complications based on the Clavien–Dindo classification, such as wound healing disorders and reoperation rate, and if it could shortens the duration of hospital stay. A case series analysis was conducted at our institution. A total of 21 patients divided into two groups undergoing the phallic construction after the Gottlieb and Levine design in a single center underwent the donor site defect coverage either by MatriDerm® and split-thickness skin graft from the thigh or by full-thickness skin graft from the groin area. The use of MatriDerm® and split-thickness skin graft showed to have a statistically significant impact on the rate of complications (p = 0.008). Complications that were treated conservatively as well as that require surgical revision were significantly lower in the MatriDerm® group than in the full-thickness skin graft group (p = 0.002). Complications occurred not only at the forearm but also at the groin, where the full-thickness skin graft was harvested. The large dimension of the free radial forearm flap used for phalloplasty resulted in a significant donor site morbidity, leading to wound healing disorders, reoperations, and extended length of hospital stay. Therefore, we consider the use of dermal templates such as MatriDerm® as worth the additional effort and costs in this patient collective.

How to measure success in lower extremity reconstruction, which outcome measurements do we use a systematic review and metanalysis

Different factors have to be considered and weighted in the treatment algorithm of lower extremity reconstruction. A combination of both clinicians' and patients' perspectives is necessary to provide a conclusive picture. Currently, there aren't any standardized and validated measurement data sets for lower extremity reconstructions. This makes it necessary to identify the relevant domains. We, therefore, performed a systematic review and metanalysis of outcome measurements and evaluated their ability to measure outcomes after lower extremity reconstruction. A systematic review and metanalysis according to the 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses' protocol were performed for studies reporting at least one structured outcome measurement of lower extremity reconstruction. Both Patient (PROMs)- and Clinician reported outcome measurements (CROMs)were analyzed. Of the 2827 identified articles, 102 were included in the final analysis. In total 86 outcome measurements were identified, 34 CROMs, 44 PROMs and 8 (9.3%) outcome measurements that have elements of both. Twenty-four measure functional outcome, 3 pain, 10 sensations and proprioception, 9 quality of life, 8 satisfaction with the result, 5 measure the aesthetic outcome, 6 contours and flap stability and 21 contain multidomain elements. A multitude of different outcome measurements is currently used in lower extremity reconstruction So far, no consensus has been reached on what to measure and how. Validation and standardization of both PROMs and CROMs in plastic surgery is needed to improve the outcome of our patients, better meet their needs and expectations and eventually optimize extremity reconstruction by enabling a direct comparison of studies' results.

Botulinum toxin to improve facial expression in a patient with Urofacial (Ochoa) Syndrome

The Urofacial or Ochoa Syndrome is a very rare congenital disorder that includes vesical bladder dysfunction and a peculiar inverse facial expression, which brings patients to express a sad-crying face while they intend to laugh. Up-to-date treatments have addressed only the urological side of this disease. However, also the impaired facial mimicry has a strong impact on patients' quality of life. We treated a young patient with Botulinum toxin to address this impairment and obtained pleasing results, including a harmonic smile and a very satisfied patient. To the best of our knowledge, this is the first time that the use of Botulinum toxin is reported in literature to address the facial expression component of this disease.

Scar versus shape: patient-reported outcome after different surgical approaches to gynecomastia measured by modified BREAST Q®

OBJECTIVES

The challenge in the operative therapy for enlargement of the male breast is to deal with the skin excess. Shape and scars are the major parameters after which patients assess their operative result. Therefore, we assessed the satisfaction rate among patients undergoing subcutaneous mastectomy at our institution with special regard to scar tissue formation and the postoperative appearance of the chest wall in dependence of the surgical approach (periarolar versus inframammary fold).

METHODS

The study includes n = 36 male patients who underwent subcutaneous mastectomy at AGAPLESION Markus Hospital Frankfurt/Main. Patient's satisfaction dependent with the appearance of the chest wall and scar formation was evaluated by a modified BREAST Q® questionnaire plus two male-based additional questions.

RESULTS

There is no statistically significant difference in satisfaction with the operative result depending on the pattern of incision (periareolar versus submammary periareolar; 81.9% versus 75.5%) with the operative result. Evaluation of additional questions of the modified BREAST Q® questionnaire showed that 86% of the patients (n = 31) would rather have more scars and a flatter chest wall. A BMI >25 kg/m² is accompanied by a higher risk for complications (p = 0.04).

CONCLUSIONS

Periareolar incision is still the method of choice, if promising an aesthetic appealing result. When reaching its limits though, we showed that a flat and male-shaped appearance of the chest wall is priority for the patients and should therefore be for the surgeon as well.

10-Year single center experience in lower limb reconstruction with free muscle flaps - factors influencing complications in 266 consecutive cases

The anatomy and technique of free muscle flaps - in particular gracilis flap and latissimus dorsi flap - in lower extremity reconstruction have been well described. There is a paucity of data on potential risk factors in larger patient series that affect the outcome. The objective of this study was to address this lack of knowledge by reporting outcomes and complications of free muscle flaps as a primary option in lower extremity reconstruction. From 2009 to 2020, a total of 253 consecutive patients with soft tissue defects of the lower limb from trauma, infection or malignancies underwent lower extremity reconstructive surgery with 266 free muscle flaps. Complications requiring revision surgery were noted in 36.1% of cases. Total flap loss occurred in 10.5% of cases. Patients requiring revision surgery were older, more likely to be female, more likely to be active smokers, and more likely to have a higher ASA score. Lower extremity reconstruction with free muscle flaps has a relevant complication rate that both patient and reconstructive surgeon need to be aware of. Prospective studies should try to further assess the factors affecting the outcome.

[Robotics in plastic surgery]

In recent years surgical robotic systems which were specifically developed for microsurgery have expanded the application of robotic-assisted surgery to plastic reconstructive surgery. Currently, there are two microsurgical robotic systems available for reconstructive plastic surgery. Both systems feature tremor reduction and motion scaling technologies, which are intended to optimize the surgeon's precision and dexterity. In the Department of Plastic Surgery and Hand Surgery at the University Hospital Zurich, the Symani Surgical System® has already been used for many microsurgical and supermicrosurgical operations, including autologous breast reconstruction, nerve transfer and, in particular, reconstructive lymphatic surgery. Despite special technical challenges, such as a lack of haptic feedback, the advantages outweigh the disadvantages for an appropriately trained and skilled microsurgeon, including smaller surgical access incisions for anatomically deep structures and an improvement in surgical precision.

Delineation of the healthy rabbit heart by immunohistochemistry - A technical note

Heart failure poses a big health problem and may result from obesity, smoking, alcohol and/or growing age. Studying pathological heart tissue demands accurate histological and immunohistochemical stainings in animal models, including chromogenic and fluorescent approaches. Moreover, a reliable set of healthy heart stainings and labeling are required, in order to provide a reference for the pathological situation. Heart and brain tissue of a healthy rabbit were collected, and different histological key steps were compared, such as paraffin embedding after formalin fixation versus cryopreservation; an antigen retrieval (AR) step in processing paraffin sections versus the same procedure without AR; or a chromogenic with a fluorescent detection system, respectively. Using serial sections, we stained the same morphological structure with classic approaches (HE, Masson Goldner Trichrome (GT) and Elastica van Gieson (EL)) and with different markers, including collagen I, collagen III, fibronectin, α-SMA, protease-activated receptor-2 (PAR-2) which is an inflammation-related marker, and ki67 for proliferating cells. Differences between conditions were quantitatively assessed by measuring the color intensity. Generally, cryosections exhibited a more prominent signal intensity in immunohistochemically labeled sections than in paraffin sections, but the strong staining was slurry, which sometimes impeded proper identification of morphological structures, particularly at higher magnifications. In addition, the advantage of an AR step was observed when compared to the condition without AR, where signal intensities were significantly lower. Different stainings of the heart arteries and the myocardium revealed a clear distribution of extracellular matrix components, with prominent collagen III in the artery wall, but an absence of collagen III in the myocardium. Moreover, paraffin-embedded sections provided more distinct structures compared to cryosections after collagen III, ki67, fibronectin, and α-SMA labeling. As for the Purkinje cells that were depicted in the heart and the cerebellum (Purkinje neurons), we found GT staining most suitable to depict them in the heart, while HE as well as EL staining was ideal to depict Purkinje neurons in the cerebellum. In sum, we provide useful reference images with different stainings for researchers using the rabbit heart or brain model. Such images can help to decide which of the immunohistochemical protocols are valuable to reach a specific aim. Recommendations are given for the best visualization of the target structures and specific (immunohistochemical) staining.

A distinct M2 macrophage infiltrate and transcriptomic profile decisively influence adipocyte differentiation in lipedema

Lipedema is a chronic and progressive adipose tissue disorder, characterized by the painful and disproportionate increase of the subcutaneous fat in the lower and/or upper extremities. While distinct immune cell infiltration is a known hallmark of the disease, its role in the onset and development of lipedema remains unclear. To analyze the macrophage composition and involved signaling pathways, anatomically matched lipedema and control tissue samples were collected intra-operatively from gender- and BMI-matched patients, and the Stromal Vascular Fraction (SVF) was used for Cytometry by Time-of-Flight (CyTOF) and RNA sequencing. The phenotypic characterization of the immune component of lipedema versus control SVF using CyTOF revealed significantly increased numbers of CD163 macrophages. To gain further insight into this macrophage composition and molecular pathways, RNA sequencing of isolated CD11b+ cells was performed. The analysis suggested a significant modification of distinct gene ontology clusters in lipedema, including cytokine-mediated signaling activity, interleukin-1 receptor activity, extracellular matrix organization, and regulation of androgen receptor signaling. As distinct macrophage populations are known to affect adipose tissue differentiation and metabolism, we evaluated the effect of M2 to M1 macrophage polarization in lipedema using the selective PI3Kγ inhibitor IPI-549. Surprisingly, the differentiation of adipose tissue-derived stem cells with conditioned medium from IPI-549 treated SVF resulted in a significant decreased accumulation of lipids in lipedema versus control SVF. In conclusion, our results indicate that CD163+ macrophages are a critical component in lipedema and re-polarization of lipedema macrophages can normalize the differentiation of adipose-derived stem cells in vitro evaluated by the cellular lipid accumulation. These data open a new chapter in understanding lipedema pathophysiology and may indicate potential treatment options.

A cohort study on neuropathic pain of the saphenous nerve—factors influencing surgical outcome

Background

Due to its partially superficial course, the saphenous nerve is vulnerable to injury by trauma or surgery potentially leading to painful neuroma formation. Different surgical techniques to treat neuroma have been described, but so far, no one has proven to be superior to the others. The aim of this study was therefore to identify factors influencing the outcome of revision surgery in saphenous nerve neuropathic pain in our department.

Methods

From 2010 to 2020, a total of 29 consecutive patients with neuropathic pain and suspected neuroma of the saphenous nerve underwent revision surgery. A medical chart review was performed to collect patient-, pain-, and treatment-specific factors. Outcomes were registered.

Results

Post revision surgery in neuropathic pain of the saphenous nerve, 16 (55.2%) patients suffered from persisting pain. In multivariable logistic regression models evaluating the risk of persisting pain post saphenous nerve revision surgery, both smoking and preoperative opiate consumption represented independent predictors of higher risk for persisting pain.

Conclusions

Patients with injury to the saphenous nerve should be coached toward smoking cessation. Whenever possible, forgoing opiate treatment might be beneficial.

Level of evidence: Level IV, Risk/Prognostic.

Targeted therapies and checkpoint inhibitors in sarcoma

Sarcomas are defined as a group of mesenchymal malignancies with over 100 heterogeneous subtypes. As a rare and difficult to diagnose entity, micrometastasis is already present at the time of diagnosis in many cases. Current treatment practice of sarcomas consists mainly of surgery, (neo)adjuvant chemo- and/or radiotherapy. Although the past decade has shown that particular genetic abnormalities can promote the development of sarcomas, such as translocations, gain-of-function mutations, amplifications or tumor suppressor gene losses, these insights have not led to established alternative treatment strategies so far. Novel therapeutic concepts with immunotherapy at its forefront have experienced some remarkable success in different solid tumors while their impact in sarcoma remains limited. In this review, the most common immunotherapy strategies in sarcomas, such as immune checkpoint inhibitors, targeted therapy and cytokine therapy are concisely discussed. The programmed cell death (PD)-1/PD-1L axis and apoptosis-inducing cytokines, such as TNF-related apoptosis-inducing ligand (TRAIL), have not yielded the same success like in other solid tumors. However, in certain sarcoma subtypes, e.g. liposarcoma or undifferentiated pleomorphic sarcoma, encouraging results in some cases when employing immune checkpoint inhibitors in combination with other treatment options were found. Moreover, newer strategies such as the targeted therapy against the ancient cytokine macrophage migration inhibitory factor (MIF) may represent an interesting approach worth investigation in the future.

Preoperative Mapping of Lymphatic Vessels by Multispectral Optoacoustic Tomography

Background: In lymphatic reconstructive surgery, visualization of lymph vessels is of paramount importance. Indocyanine green (ICG) lymphography is the current gold standard in preoperative lymphatic imaging. However, visualization of lymph vessels is often limited by an overlying dermal backflow of ICG, becoming particularly prominent in advanced lymphedema stages. Multispectral optoacoustic tomography (MSOT) has recently been introduced as a promising noninvasive tool for lymphatic imaging. Methods and Results: A single-center proof-of-concept study with a prospective observational design was conducted at the Department of Plastic Surgery and Hand Surgery of the University Hospital Zurich. Between February 2021 and August 2021, seven patients with different grades of lymphedema were analyzed by the MSOT Acuity system before undergoing lymphovenous anastomosis (LVA). Conventional ICG lymphography served as comparison. MSOT succeeded to accurately depict blood and lymphatic vessels at different locations in six patients, including areas of dermal backflow. The MSOT signal of lymph vessels further correlated well with their macroscopic appearance. Conclusion: We could successfully visualize lymphatic vessels in patients with lymphedema by MSOT and establish the new method for preoperative mapping and selection of incision sites for LVA. Regardless of dermal backflow patterns, MSOT proved to be a valuable approach for identifying and clearly discerning between lymphatic and blood vessels.

Is Lymphedema a Systemic Disease? A Paired Molecular and Histological Analysis of the Affected and Unaffected Tissue in Lymphedema Patients

Secondary lymphedema is a chronic, debilitating disease and one of the most common side effects of oncologic surgery, substantially decreasing quality of life. Despite the progress conducted in lymphedema research, the underlying pathomechanisms remain elusive. Lymphedema is considered to be a disease affecting an isolated extremity, yet imaging studies suggest systemic changes of the lymphatic system in the affected patients. To evaluate potential systemic manifestations in lymphedema, we collected matched fat and skin tissue from the edematous and non-edematous side of the same 10 lymphedema patients as well as anatomically matched probes from control patients to evaluate whether known lymphedema manifestations are present systemically and in comparison to health controls. The lymphedematous tissue displayed various known hallmarks of lymphedema compared to the healthy controls, such as increased epidermis thickness, collagen deposition in the periadipocyte space and the distinct infiltration of CD4+ cells. Furthermore, morphological changes in the lymphatic vasculature between the affected and unaffected limb in the same lymphedema patient were visible. Surprisingly, an increased collagen deposition as well as CD4 expression were also detectable in the non-lymphedematous tissue of lymphedema patients, suggesting that lymphedema may trigger systemic changes beyond the affected extremity.

Impact of High-Molecular-Weight Hyaluronic Acid on Gene Expression in Rabbit Achilles Tenocytes In Vitro

(1) Background: Surgical tendon repair often leads to adhesion formation, leading to joint stiffness and a reduced range of motion. Tubular implants set around sutured tendons might help to reduce peritendinous adhesions. The lubricant hyaluronic acid (HA) is a viable option for optimizing such tubes with the goal of further enhancing the anti-adhesive effect. As the implant degrades over time and diffusion is presumed, the impact of HA on tendon cells is important to know. (2) Methods: A culture medium of rabbit Achilles tenocytes was supplemented with high-molecular-weight (HMW) HA and the growth curves of the cells were assessed. Additionally, after 3, 7 and 14 days, the gene expression of several markers was analyzed for matrix assembly, tendon differentiation, fibrosis, proliferation, matrix remodeling, pro-inflammation and resolution. (3) Results: The addition of HA decreased matrix marker genes, downregulated the fibrosis marker α-SMA for a short time and slightly increased the matrix-remodeling gene MMP-2. Of the pro-inflammatory marker genes, only IL-6 was significantly upregulated. IL-6 has to be kept in check, although IL-6 is also needed for a proper initial inflammation and efficient resolution. (4) Conclusions: The observed effects in vitro support the intended anti-adhesion effect and therefore, the use of HMW HA is promising as a biodegradable implant for tendon repair.

Burn Scar Ectropion Correction: Surgical Technique for Functional Outcomes

BACKGROUND

Eyelid scarring after severe burn injury of the face is a significant complication endangering vision in addition to the burn scar sequelae. Scar contraction leads to asymmetry and malposition of the eyelid axis, resulting in corneal exposure, eyelid retraction, and incomplete eyelid closure. In consequence, dryness and irritation of the cornea can lead to keratitis, corneal opacity, and vision impairment. In this study, we present our surgical technique for lateral canthopexy in combination with full-thickness skin grafting (FTSGing) in patients with eyelid axis distortion after scar contraction of the periorbital region after severe burn injuries of the face.

METHODS

In this retrospective, single-center case study, we present 5 consecutive patients who experienced severe burn injuries to the face between 2014 and 2019. Patients were suffering from ectropion and malposition of the eyelid axis. In all cases, we performed lateral transosseous canthopexy and FTSGing.

RESULTS

Improved symmetry and complete eyelid closure were restored in all 5 patients. The following ophthalmological examinations showed resolved corneal erosions, as well as reduction of chemosis and epiphora. Further vision impairment was successfully prohibited. Surgical revision with FTSGing was required in 2 patients because of recurrence of unilateral lower eyelid retraction.

CONCLUSIONS

Lateral transosseous canthopexy represents a suitable surgical method to durably correct eyelid malposition, ectropion, and incomplete lid closure in patients with severe scarring of the periorbital region after burns of the face. Early detection of patients at risk and timing of surgical intervention are of great importance.

Outcome Comparison of Different Reconstructive Approaches for Axillary Defects Secondary to Radical Excision of Hidradenitis Suppurativa

BACKGROUND

Radical excision of debilitating hidradenitis suppurativa lesions is the only curative approach in the advanced stages of the disease. Different concepts for axillary reconstruction do exist, but data on their clinical outcome are scarce.

METHODS

This is a retrospective cohort study of two reconstructive methods (posterior arm flap vs. vacuum-assisted closure [VAC] + split-thickness skin graft [STSG]) for axillary defects in patients with severe axillary hidradenitis suppurativa treated at the University Hospital Zurich between 2005 and 2020.

RESULTS

A total of 35 patients (mean age 36 ± 10 years, mean BMI 29 ± 5 kg/m2, Hurley stage II-III) with 67 operated axillae were stratified according to their type of reconstruction. Median operation time in the flap group was 144 min (IQR 114-207) (cumulative 181 min [IQR 124-300]) and 50 min (IQR 40-81) in the VAC + STSG group (cumulative 151 min [IQR 94-194], p < 0.01; p = 0.20 [cumulative time]). The cumulative length of stay was 6 ± 3 days in the flap group and 14 ± 7 days in the VAC + STSG group (p < 0.01). Time to complete wound healing was 27 days (IQR 20-49) in the flap group and 62 days (IQR 41-75) in the VAC + STSG group (p < 0.01). Vancouver Scar Scale score was 6 (IQR 4-9) in the flap group and 11 (IQR 9-12) in the VAC + STSG group (p < 0.01). Protective sensory recovery was most satisfactory in the flap group (p < 0.01). Forty-four percent of patients of the VAC + STSG group demonstrated functional impairment of arm abduction. Time to return to work was less in group A with 42 days (IQR 27-57) needed as compared to group B with 48 days (IQR 34-55) needed (p = 0.32). The average cost saving was 25% higher for the flap group than for the VAC + STSG group.

CONCLUSION

Despite an increased operation time, axillary reconstruction by the posterior arm flap yields a reduced length of stay, less time to complete wound healing along with restoration of a protective sensibility, and less axillary scarring avoiding functional deficits - eventually allowing earlier return to work.

Optimizing large-scale autologous human keratinocyte sheets for major burns-Toward an animal-free production and a more accessible clinical application

Background and Aims

Autologous keratinocyte sheets constitute an important component of the burn wound treatment toolbox available to a surgeon and can be considered a life‐saving procedure for patients with severe burns over 50% of their total body surface area. Large‐scale keratinocyte sheet cultivation still fundamentally relies on the use of animal components such as inactivated murine 3T3 fibroblasts as feeders, animal‐derived enzymes such as trypsin, as well as media components such as fetal bovine serum (FBS). This study was therefore aimed to optimize autologous keratinocyte sheets by comparing various alternatives to critical components in their production.

Methods

Human skin samples were retrieved from remnant operative tissues. Cell isolation efficiency and viability were investigated by comparing the efficacy of porcine‐derived trypsin and animal‐free enzymes (Accutase and TrypLESelect). The subsequent expansion of the cells and the keratinocyte sheet formation was analyzed, comparing various cell culture substrates (inactivated murine 3T3 fibroblasts, inactivated human fibroblasts, Collagen I or plain tissue culture plastic), as well as media containing serum or chemically defined animal‐free media.

Results

The cell isolation step showed clear cell yield advantages when using porcine‐derived trypsin, compared to animal‐free alternatives. The keratinocyte sheets produced using animal‐free serum were similar to those produced using 3T3 feeder layer and FBS‐containing medium, particularly in mechanical integrity as all grafts were liftable. In addition, sheets grown on collagen in an animal‐free medium showed indications of advantages in homogeneity, speed, reduced variability, and differentiation status compared to the other growth conditions investigated. Most importantly, the procedure was compatible with the up‐scaling requirements of major burn wound treatments.

Conclusion

This study demonstrated that animal‐free components could be used successfully to reduce the risk profile of large‐scale autologous keratinocyte sheet production, and thereby increase clinical accessibility.

Evolution of a concept with enzymatic debridement and autologous in situ cell and platelet-rich fibrin therapy (BroKerF)

BACKGROUND

Deep partial-thickness burns are traditionally treated by tangential excision and split thickness skin graft (STSG) coverage. STSGs create donor site morbidity and increase the wound surface in burn patients. Herein, we present a novel concept consisting of enzymatic debridement of deep partial-thickness burns followed by co-delivery of autologous keratinocyte suspension and plated-rich fibrin (PRF) or fibrin glue.

MATERIAL AND METHODS

In a retrospective case study, patients with deep partial-thickness burns treated with enzymatic debridement and autologous cell therapy combined with PRF or fibrin glue (BroKerF) between 2017 and 2018 were analysed. BroKerF was applied to up to 15% total body surface area (TBSA); larger injuries were combined with surgical excision and skin grafting. Exclusion criteria were age <18 or >70 years, I°, IIa°-only, III° burns and loss of follow-up.

RESULTS

A total of 20 patients with burn injuries of 16.8% ± 10.3% TBSA and mean Abbreviated Burn Severity Score 5.45 ± 1.8 were identified. Of the patients, 65% (n = 13) were treated with PRF, while 35% (n = 7) were treated with fibrin glue. The mean area treated with BroKerF was 7.5% ± 0.05% TBSA, mean time to full epithelialization was 21.06 ± 9.2 days and mean hospitalization time was 24.7 ± 14.4 days. Of the patients, 35% (n = 7) needed additional STSG, 43% (n = 3) of whom had biopsy-proven wound infections.

CONCLUSION

BroKerF is an innovative treatment strategy, which, in our opinion, will show its efficacy when higher standardization is achieved. The combination of selective debridement and autologous skin cells in a fibrin matrix combines regenerative measures for burn treatment.

LAY SUMMARY

Patients suffering from large burn wounds often require the use of large skin grafts to bring burned areas to heal. Before the application of skin grafts, the burned skin must be removed either by surgery or using enzymatic agents. In this article, we describe a method where small areas of skin are taken and skin cells are extracted and sprayed on wound areas that were treated with an enzymatic agent. The cells are held in place by a substance extracted from patients' blood (PRF) that is sprayed on the wound together with the skin cells. We believe this technique can be helpful to reduce the need of skin grafts in burned patients and improve the healing process.

Patient-Reported Outcomes in Free-Flap Breast Reconstructive Surgery over Time (PRO-BREST)

<b><i>Introduction:</i></b> Patient-reported outcomes (PROMs) are increasingly relevant to assess surgical quality and guide decisions in breast reconstruction (BR). Satisfaction with outcomes may change as time progresses. We assessed satisfaction in patients who underwent free-flap BR in the last 12 years. <b><i>Methods:</i></b> All patients who underwent free-flap BR from 2006 to 2018 were invited to complete the validated BREAST-Q for reconstruction. The BREAST-Q comprises 6 domains covering various aspects of satisfaction. Unadjusted linear regression assessed the relationship between different domains of the BREAST-Q and time since BR. Two-sample <i>t</i> tests assessed differences in satisfaction between patients who underwent BR ≥5 years versus &#x3c;5 years prior. <b><i>Results:</i></b> Forty-three women with primary or secondary free-flap BR between 2006 and 2018 were included in the study. Most patients (<i>n</i> = 33, 76.7%) underwent DIEP flap BR. Overall satisfaction with breasts and with outcomes improved as time since BR increased (<i>p</i> = 0.031 and <i>p</i> = 0.017, respectively). Overall satisfaction with outcomes scored higher in patients with BR ≥5 years prior (≥5 years vs. &#x3c;5 years: breast score 88.6 (SD 12.5) versus 66.9 (SD 21.8); <i>p</i> = 0.005). Satisfaction with breasts and psychosocial well-being also scored higher in these patients. There was no difference in results between primary and secondary BR. Patients who underwent additional surgery (refinements) reported higher satisfaction with outcomes and abdominal well-being. <b><i>Conclusions:</i></b> PROMs concerning satisfaction with breast and with outcomes following BR improve as time since treatment progresses. This study demonstrates that time since diagnosis may be an important factor in satisfaction. It underlines the importance of long-term PROMs related to BR, to help provide patients and health care professionals in decision-making and in managing expectations related to BR.

[The use of intraoperative fascicle-topographic electromyography in peripheral nerve surgery: review of the literature and clinical experience]

The intraoperative assessment of a pathological nerve segment is crucial in peripheral nerve surgery. Based on different techniques the function of a peripheral nerve is analyzed and either a neurolysis alone or a resection with subsequent nerve reconstruction is performed. Beside the morphological and histological assessment or the use of a nerve stimulator, intraoperative electrophysiology is highly useful. The aim of this diagnostic tool is the recording of objective parameters, documenting the function of peripheral nerves. Intraoperative electroneurography allows the assessment of a nerve action potential over a pathological nerve segment and has been used for decades. In contrast, additional needle electromyography is rarely used even though this technique is characterized by interesting advantages: It is very helpful for the selection of donor fascicles during neurotization surgeries and for the electrophysiological assessment of neuromata in continuity. In the present review, we discuss the value of intraoperative electromyography in the treatment of peripheral nerve trauma as well as peripheral nerve tumors.

Intraneural fibrosis and loss of microvascular architecture - Key findings investigating failed human nerve allografts

BACKGROUND

Processed nerve allografts are increasingly used in clinical nerve reconstruction with promising results. However, allograft failure has been reported, leading to chronic pain and persistent loss of function. In the present work, we performed a histological and immunohistochemical analysis of two failed allograft reconstructions of a sensory human nerve one year after primary surgery.

METHODS

Two patients with a superficial radial nerve injury underwent nerve reconstruction with processed nerve allografts. The clinical follow-up was complicated by severe neuropathic pain and absent sensory reinnervation. Consequently, the failed allografts were excised with subsequent histological and immunohistochemical examinations. For that purpose, the collagen content and neurofilament network as well as the blood and lymphatic vasculature were analysed in the center of the specimens.

RESULTS

Histology revealed increased fibrosis, fatty degeneration, and disorganised proliferation of nerve fibres. Moreover, the microvascular network within the allografts was characterised by increased numbers of microvessels, whereas no difference was found concerning the lymphatic vasculature.

CONCLUSION

The herein presented histological and immunohistochemical findings indicate that the failure of human allografts is associated with loss of the physiological microvascular architecture. Future studies elucidating the complex interplay of angiogenesis, lymphangiogenesis and axonal regeneration are required to better understand the mechanisms of human allograft failure.

Fluorescence angiography-assisted debridement of critically perfused glabrous skin in degloving foot injuries: Two case reports

RATIONALE

Degloving foot injuries are challenging to treat and associated with life-long sequelae for patients. An appropriate debridement of ischemic soft tissues with maximal preservation of glabrous skin is key during the reconstruction of these injuries. Indocyanine green (ICG) fluorescence angiography is an established technique for the intraoperative evaluation of tissue perfusion.

PATIENT CONCERNS

Two patients sustained complex foot injuries in traffic accidents, including multiple fracture dislocations and extensive degloving of the plantar skin.

DIAGNOSIS

Clinical inspection revealed significant degloving of the glabrous skin in both patients.

INTERVENTIONS

After fracture fixation, ICG fluorescence angiography-assisted debridement with immediate latissimus dorsi free flap reconstruction was performed.

OUTCOMES

In both cases, this technique allowed a precise debridement with maximal preservation of the glabrous skin. The healing of the remaining glabrous skin was uneventful and the 6-month follow-up was characterized by stable soft tissues and satisfying ambulation.

LESSONS

ICG fluorescence angiography is a safe, user-friendly, and quick procedure with minimal risks, expanding the armamentarium of the reconstructive surgeon. It is highly useful for the debridement of extensive plantar degloving injuries and may also help to minimize the number of procedures and the risk of infection.

Insurance coverage policies for reconstructive lymphatic microsurgery procedures in Switzerland

BACKGROUND

Lymphoedema is a progressive and potentially disabling disease. A growing number of studies show promising clinical results after microsurgical reconstruction. However, this treatment is currently not supported by level 1 evidence and insurance coverage is variable.

METHODS

Electronic records of 55 patients with limb lymphoedema, who were eligible for lymphovenous bypass surgery and/or lymphatic tissue transfer in our department from 2017 to 2020, were reviewed. Correspondence between our department and health insurers was analysed. A web-based search and individual telephone interviews were conducted to identify health insurer policies.

RESULTS

We included 42 patients undergoing 46 operations and evaluated the correspondence between our department and nine different health insurers. Overall, reimbursement of costs was approved in 67% (n = 31) of all surgeries and was refused in 33% (n = 15). The mean number of applications for reconsideration sent to insurers was 1.3 &plusmn; 0.7. The time between confirmation of the indication and the final decision ranged from 6 to 300 days (mean 50 days). Reimbursement of cost coverage ranged from 0% to 100% depending on the individual insurance company. No insurance company had policies publicly available online and all stated that they determine coverage only when provided with specific patient details on a case-by-case basis.

CONCLUSION

Insurance companies in Switzerland do not have a uniform policy regarding cost coverage for lymphatic surgery procedures. Moreover, the decision process appeared to be rather uniform within the respective insurance company and independent of the individual case. Standardised evaluation criteria including patient reported outcome measures should be developed to underscore the beneficial effects of lymphatic surgery and facilitate insurance coverage.

Delineation of the healthy rabbit kidney by immunohistochemistry - A technical note

Pre-clinical animal models are needed to investigate and study kidney injuries and diseases. The rabbit kidney model is frequently used because various important parameters can be assessed with it. For example, histology and immunohistochemistry are indispensable as tissue morphology and composition can be investigated qualitatively as well as quantitatively. Here, different histological and immunohistochemical stainings were performed in the rabbit healthy naïve kidney tissue. First, overnight formalin fixation followed by paraffin embedding and cryopreservation with a subsequent 10-minute formalin fixation prior to staining were compared. Cryosections showed a more pronounced staining pattern, with clear borders at low magnifications, but blurred borders at higher magnifications. Then, antigen retrieval (AR) for paraffin embedded sections resulted in more prominent corresponding signals compared to stainings without AR. Moreover, several advantages and disadvantages of chromogenic versus immunofluorescence stainings were considered. Chromogenic staining was advantageous compared to immunofluorescence for collagen I and III, and to a minor degree for fibronectin. Finally, distinct structures, such as the pelvis, the calices, the glomeruli and tubuli, were stained in serial sections with diverse immunohistochemical stainings in order to delineate their composition. The following stainings were performed: standard Haematoxylin&Eosin and Elastica van Gieson staining, collagen I, collagen III, fibronectin, α-SMA, ki-67 and protease-activated receptor-2 (PAR-2). While chromogenic stainings of collagen I and collagen III were particularly useful to depict kidney structures in paraffin sections compared with cryosections, cryosections immunofluorescently stained for α-SMA were superior to paraffin sections, particularly at higher magnifications. With regard to specific structures, we found renal vessel walls positive for fibronectin and α-SMA, while the Bowman's capsule was only positive for fibronectin and α-SMA showed only tiny spots. The mesangial cells of the glomeruli and the distal tubuli were PAR-2 positive, while the proximal tubuli were PAR-2 negative.

Facial Transplantation: Nonimmune-Related Hyperacute Graft Failure-The Role of Perfusion Injury: A Case Report

BACKGROUND

The aim of this study was to report the first case of acute facial allograft transplantation (facial allograft transplantation) failure with allograft removal and autologous free-flap reconstruction.

METHODS

A 49-year-old female patient affected by neurofibromatosis type 1 with a massive neurofibroma infiltrating the whole left hemiface was planned for FAT for the left hemiface including the auricle, all skin and soft tissues from the temporal region, periorbital and nasal region, and up to the perioral area. The maxillary process of the zygomatic bone, left hemimaxilla, and hemimandible from contralateral parasyphysis to the incisura mandibulae were also included.

RESULTS

Total surgical time was 26 hours. There were 2 intraoperative arterial thromboses that were solved with new anastomoses and sufficient flap perfusion. On postoperative day 2, the allograft became pale with suspected arterial occlusion and the patient returned to the operative room for exploration no flow into the FAT was found. The allograft was removed and the recipient site reconstructed with a skin-grafted composite left latissimus dorsi-serratus anterior flap.

CONCLUSIONS

Hyperacute loss of FAT is a very dramatic event, and the activation of a backup surgical plan is crucial to save patient's life, give a reasonable temporary reconstruction, and return on the waiting-list for a second face transplantation.

YouTube as a resource for surgical education with a focus on plastic surgery - a systematic review

Surgery trainees use videos as a means to learn about surgical procedures. YouTube is the biggest online video platform and used for educational content as well but the medical information provided does not undergo peer review or other forms of scientific screening and can thus be of poorer quality. We performed a systematic review that examined the quality of educational videos about surgery and plastic surgery in particular on YouTube. The focus was towards studies on the benefit of YouTube videos for surgical trainees. A literature review was performed to determine the educational quality of plastic surgery videos found on YouTube. Articles reviewing the educational quality of videos about surgical procedures, their accuracy, and their utility for surgical trainees were included. An additional review was performed evaluating the literature about the quality of educational plastic surgery videos. Eleven articles were selected reviewing the educational quality of videos about surgical procedures. Six studies were fully assessed and evaluated concerning the quality of educational plastic surgery videos. There currently seems to be a lack of comprehensive educational surgery and in particular plastic surgery-related information on YouTube. The popularity of YouTube among surgical trainees is high. The quality of available educational surgical video content varies widely. It is in the interest of plastic surgery teaching institutions to provide trainees with high-quality educational video material.

Thermal conditioning improves quality and speed of keratinocyte sheet production for burn wound treatment

BACKGROUND AIMS

Cultured patient-specific keratinocyte sheets have been used clinically since the 1970s for the treatment of large severe burns. However, despite significant developments in recent years, successful and sustainable treatment is still a challenge. Reliable, high-quality grafts with faster availability and a flexible time window for transplantation are required to improve clinical outcomes.

METHODS

Keratinocytes are usually grown in vitro at 37°C. Given the large temperature differences in native skin tissue, the aim of the authors' study was to investigate thermal conditioning of keratinocyte sheet production. Therefore, the influence of 31°C, 33°C and 37°C on cell expansion and differentiation in terms of proliferation and sheet formation efficacy was investigated. In addition, the thermal effect on the biological status and thus the quality of the graft was assessed on the basis of the release of wound healing-related biofactors in various stages of graft development.

RESULTS

The authors demonstrated that temperature is a decisive factor in the production of human keratinocyte sheets. By using specific temperature ranges, the authors have succeeded in optimizing the individual manufacturing steps. During the cell expansion phase, cultivation at 37°C was most effective. After 6 days of culture at 37°C, three times and six times higher numbers of viable cells were obtained compared with 33°C and 31°C. During the cell differentiation and sheet formation phase, however, the cells benefited from a mildly hypothermic temperature of 33°C. Keratinocytes showed increased differentiation potential and formed better epidermal structures, which led to faster biomechanical sheet stability at day 18. In addition, a cultivation temperature of 33°C resulted in a longer lasting and higher secretion of the investigated immunomodulatory, anti-inflammatory, angiogenic and pro-inflammatory biofactors.

CONCLUSIONS

These results show that by using specific temperature ranges, it is possible to accelerate the large-scale production of cultivated keratinocyte sheets while at the same time improving quality. Cultivated keratinocyte sheets are available as early as 18 days post-biopsy and at any time for 7 days thereafter, which increases the flexibility of the process for surgeons and patients alike. These findings will help to provide better clinical outcomes, with an increased take rate in severe burn patients.

Management of posterior interosseous nerve (PIN) palsies after distal biceps tendon repair using a single incision technique- a conclusive approach to diagnostics and therapy

Complete distal ruptures of the biceps brachii tendon are rather rare and surgical reinsertion is the gold standard. Recently, one incision approaches for the refixation of the distal biceps tendon have been popularized with the introduction of a single-incision approach employing a trans-radial cortical button fixation. Since the introduction of this fixation technique we have seen more iatrogenic lesions to the posterior interosseous nerve (PIN) after not having seen any PIN lesions with 2 incision biceps refixation techniques over the last 5 years. Several patients with iatrogenic PIN affections after one incision refixation techniques of the distal biceps tendon were referred to our level 1 department of Plastic surgery and hand surgery from different orthopedic surgeons. Over the course of 6 months we saw 5 patients with a similar history. We decided to analyze this problem and propose a course of action to regain function of the PIN innervated muscles as good and fast as possible. If there is a loss of function in the PIN innervated muscles after distal biceps refixation a neurological evaluation including electrophysiology needs to be conducted. An ultrasound assessment of the nerve itself should guide the clinician in the decision between a conservative and a surgical treatment in the early postoperative phase. If surgical exploration is warranted intraoperative neurography should be the basis on which ground (partial) grafting or solely neurolysis is performed. Postoperatively all patients need to follow a rehabilitation protocol to help with nerve regeneration and regaining of motor function.

'Viewer discretion advised when preparing for surgery' - why YouTube cannot teach you how to do an upper blepharoplasty. An evaluation of the educational potential of surgical videos on blepharoplasty on YouTube

Over the last years, the layout of surgical training has significantly changed. Surgical residents rely on YouTube videos to prepare for upcoming cases. Eyelid surgery including blepharoplasty ranks among the 5 most often performed cosmetic surgeries. It will be one of those surgeries regularly researched by plastic surgery residents. Therefore, the aim of this study was to evaluate the educational value of the most viewed upper lid blepharoplasty videos on the most popular video broadcasting website, YouTube. A video scoring system consisting of 8 items was developed in accordance with the technical details described in the literature. Video scores were categorized into 3 groups, namely as 'poor', 'moderate; or 'good' in terms of their contribution to surgical education. The first 300 videos were evaluated for the search results for 'blepharoplasty'. After exclusion and summarization of video fragments, a total number of 36 videos were included in the study. Multivariable logistic regression models found no correlation between likes, views, comments and the attributed educational score. The quality of available educational surgical video content varies widely, and surgical trainees need to be critically aware of this as view counts as well as the number of likes and comments will not necessarily relate to videos' educational quality. There is a need for high-quality educational videos.