Background:. Vascularized lymph node transfer (VLNT) involves the autologous transplantation of functioning lymph nodes to a lymphedematous region. Despite various donor and recipient sites, comparative effectiveness and complication rates remain understudied. This study aims to develop an evidence-based algorithm for donor- and recipient-site selection in VLNT. Methods:. A prospectively maintained database was reviewed for patients who underwent unilateral VLNT for chronic extremity lymphedema between January 1, 2016, and December 31, 2023. Surgical effectiveness was assessed using circumferential limb measurements over time. Complications were graded according to the Clavien-Dindo classification. Results:. Among 161 patients, donor sites included groin (n = 129, 80.1%), lateral thoracic (n = 16, 9.9%), mesenteric (n = 13, 8.1%), and omental (n = 3, 1.9%) flaps, all of which demonstrated comparable long-term effectiveness. For upper extremity lymphedema, axillary placement (n = 125, 94.7%) resulted in faster and greater volume reductions than distal forearm placement (n = 6, 4.5%). For lower extremity lymphedema, lower leg placement (n = 18, 62.1%) was more effective than the groin (n = 10, 31.0%). Waterjet-assisted liposuction provided transient improvements only, without long-term benefits. Complications occurred in 14 (8.7%) patients and were exclusively observed after groin-based (n = 12, 9.1%) or thoracic-based VLNTs (n = 2, 6.9%). Conclusions:. Donor-site selection should prioritize minimizing morbidity, given their comparable long-term effectiveness. In contrast, recipient-site selection significantly impacts outcomes, with axillary and lower leg placements demonstrating greater effectiveness. Scar tissue release may have a more influential role in VLNT outcomes than previously recognized.

Background:Upper and lower extremity lymphedema is a chronic, progressive condition that significantly impairs the quality of life of affected patients. Despite the recently established effectiveness of physical therapy and supermicrosurgical interventions, current guidelines frequently lag behind emerging evidence and commonly do not offer stage-specific treatment algorithms. This gap in evidence-based guidance may prompt clinicians with limited experience to seek support from large language models such as ChatGPT. Objective:Given the potential of artificial intelligence to rapidly integrate emerging research, this study evaluated how clinicians from different professional backgrounds rate the quality and reliability of personalized lymphedema management recommendations generated by ChatGPT. Methods:In this exploratory cross-sectional study, ChatGPT generated treatment recommendations for 6 standardized lymphedema case scenarios. An international panel of 67 participants (resident doctors, board-certified specialists, physiotherapists, and advanced practice nurses) from 34 institutions across 11 countries assessed the recommendations using a modified DISCERN questionnaire with a 9-point agreement scale ranging from 1 (completely disagree) to 9 (completely agree). Ratings were summarized as pooled means with variability measures and compared across clinician groups (residents vs board-certified physicians vs physiotherapists or advanced practice nurses) using group comparison testing. Results:ChatGPT was rated most favorably for diagnostic accuracy and treatment relevance, with higher ratings among residents than board-certified physicians. Residents assigned significantly lower scores for source indication, source currency, and communication of uncertainty. Between-group differences were observed across multiple DISCERN items, consistent with systematically more critical appraisal by experienced specialists. Participants reported moderate to high trust and willingness to consider ChatGPT as a supplementary resource, with more favorable perceptions among younger respondents. Conclusions:Clinicians perceived ChatGPT as potentially useful for preliminary orientation and educational support in lymphedema management, especially for less experienced users. Despite not being blinded, lower ratings in evidence transparency and uncertainty communication, particularly among experienced specialists, suggest that current artificial intelligence outputs should not be used as stand-alone guidance. Future work should test clinically integrated, citation-grounded workflows in prospective settings and evaluate whether they improve decision quality and efficiency.

Developmental tissue engineering (TE) strategies recapitulating endochondral ossification (ECO)-the major ossification pathway in bone development and repair- are a promising avenue for the treatment of critical size and congenital bone defects. In this work, we develop a customizable approach using adipose stromal cells (ASC)-derived cartilage organoids as building blocks to generate clinically relevant grafts. Our hypothesis is that progenitor cells rather than mature chondrocytes would enable robust cartilage organoids fusion allowing graft tunability and scaling up. Using a cyclic approach alternating chondrogenic and proliferative cues we produce cartilage organoids surrounded by stromal chondrogenic progenitors. When re-exposed to chondrogenic medium, this perichondrial layer forms new cartilage tissue and acts as a biological cement in between cartilage organoids. A key feature of our approach is the iterative aspect of the protocol, where scaled up cartilage tissues obtained can themselves be used as building blocks to create larger tissue. Finally, in vivo, these grafts remodel efficiently into functional and mechanically apt bone organs mirroring ECO during skeletal development over the course of 24 weeks. Collectively, our findings provide a strong proof of concept of the envisioned TE strategy paving the way for a clinical application in the near future.

The lateral cutaneous nerve of the calf (LCNC), a purely sensory branch of the common peroneal nerve, is frequently overlooked or misidentified in anatomic and clinical literature. Due to its small caliber, variable origin, and overlapping sensory distribution, the LCNC is often mistaken for the lateral sural nerve or disregarded as clinically insignificant. For patients with either misdiagnosed or undiagnosed pain in the lateral knee or calf, microsurgical decompression or nerve relocation of the LCNC can result in symptom improvement or complete resolution. The purpose of this paper is to underscore the importance of considering the LCNC in patients with posterolateral calf pain of unclear etiology.

BackgroundPerineal reconstruction remains challenging due to complex anatomy, high bacterial load, and frequent postoperative complications. Extensive tissue defects after oncologic resection or severe infection commonly necessitate reconstructive procedures. Although myocutaneous flaps are widely used, perforator flaps offer advantages such as muscle preservation and reduced donor-site morbidity. Given the perineal region's critical role in defecation, urination, and sexual function, evaluating patients' quality of life (QoL) after reconstructive surgery is essential.MethodsThis single-center cohort study evaluated postoperative complication rates and QoL after perineal reconstruction with perforator versus non-perforator flaps from 2013 to 2023. All participants were invited to complete a postoperative QoL survey.ResultsOf all the patients, 58 % received a perforator-based and 40 % a non-perforator-based reconstruction. One patient (2.3 %) underwent a combined approach. The primary indication for perineal reconstruction (68.9 %) was defect coverage after oncologic resection. Both groups had a 50 % complication rate. Donor-site morbidity was higher in the non-perforator flap group, with all complications classified as Clavien-Dindo grade III. Additional findings were exploratory: patient satisfaction was higher in the non-perforator flap group (100 % vs 66 %), although this group had a substantially longer follow-up period (4.14 vs 1.74 years). Conversely, numerically higher QoL scores were observed in the perforator flap group.ConclusionPerforator flaps demonstrated a more favorable donor-site profile, representing the most robust finding of this cohort. Observed differences in complications and patient-reported outcome measures are exploratory, and QoL continues to be insufficiently addressed in oncologic perineal reconstruction, underscoring the need for enhanced interdisciplinary collaboration.

BACKGROUND:Demand for aesthetic surgery has risen rapidly, and the parallel growth in cross-border medical travel is increasingly burdening European health systems with imported complications. The perspective of board-certified plastic surgeons themselves-as both providers of cross-border care and managers of its complications-has not been systematically captured at a European level. METHODS:An anonymous online questionnaire (43 items across three thematic sections) was distributed by the European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS) to its member national societies between December 2025 and February 2026. The instrument addressed (A) the practice of surgeons treating international patients, (B) the management of complications from procedures performed abroad, and (C) safeguards and policy reform. Quantitative data were summarised descriptively; free-text responses were analysed thematically. RESULTS:Two hundred and fifty board-certified plastic surgeons from 36 countries responded; 230/250 (92.0%) held national or international board certification. The most common procedures performed for international patients were breast augmentation (n=86), breast reduction/mastopexy (n=82), and abdominoplasty (n=80). Eighty-nine per cent of respondents had managed complications of procedures performed abroad in the preceding five years; abdominoplasty (n=144), breast augmentation (n=106), and liposuction (n=76) predominated, with wound dehiscence/necrosis (n=156) and infection (n=131) the most frequent patterns. Cost was the most often cited primary motivation for patients (49.8%); 79.2% of respondents identified board certification as the single most important verification criterion, and 77.2% identified profit prioritisation over patient safety as the principal facilitator-related risk. Mandatory international qualification standards (35.6%) and stricter facilitator regulation (23.6%) were the most frequently endorsed policy priorities. CONCLUSIONS:European plastic surgeons describe a fragmented landscape in which a regulated core coexists with an unregulated commercial periphery. ESPRAS proposes a four-pillar framework-public surgeon registries, facility and facilitator accreditation, mandatory complication insurance, and harmonised European patient- and surgeon-facing guidelines-as the basis of a coordinated European response.

Evaluating the complex, three-dimensional (3D) architecture of de novo angiogenesis in artificially engineered tissue remains a significant challenge, as conventional methods like 2D histology and microimaging techniques are limited. For axial vascularization techniques, a reproducible method for complete visualization of the microcirculatory system is needed. We present an integrated workflow for high-resolution 3D visualization of neovascularization within arteriovenous (AV) loop-based tissue constructs in a rat model. An intravascular perfusion with a cationic near-infrared fluorescent dye, MHI148-polyethylenimine, was used to 3D label the patent vasculature. Following perfusion-fixation and explantation, the construct was rendered optically transparent using an ethyl cinnamate-based clearing protocol. The fluorescent signal was then imaged using confocal and light-sheet fluorescence microscopy at 7 and 28 days postimplantation. Our workflow successfully achieved high-contrast, 3D visualization of the microvascular network, allowing for whole-mount and segmental analysis of the vascular tree. At day 7, imaging delineated solely the AV loop axis while by day 28, a dense and complex, interconnected capillary plexus from the central axis demonstrated a progressive neovascularization. Downstream processing compatibility was confirmed through successful rehydration and 3D nuclear counterstaining. This workflow offers a powerful and reproducible method for detailed structural assessment of microvascular networks in large engineered constructs, overcoming key limitations of existing techniques.

OBJECTIVES:Fracture-related infection (FRI) is a feared complication in orthopaedic trauma surgery. They are associated with multiple surgical interventions and prolonged antibiotic treatment duration, and hence, increased costs. The objective of this study was to assess the costs of FRI treatment in a Tertiary Swiss Trauma Center and to identify the variables associated with increased costs. PATIENTS AND METHODS:In this retrospective cohort study, 116 patients with an FRI treated in a Swiss tertiary center between 01/2012 and 12/2019 were included. Clinical data and the costs of each hospital stay were evaluated. Predefined variables were categorized as modifiable and non-modifiable factors and examined for their influence on costs and hospital length of stay (LOS) in univariable and multivariable analyses. RESULTS:The median cost per patient was 39,219 [interquartile range (IQR) 22,657 to 68,588] CHF. The median LOS was 21 [IQR 14 to 36] days. Most patients were male (67%) with a median age of 58 years [40-70]. The median duration of IV antibiotic use was 16 [9-27] days. Costs related to hospitalization (nursing and physiotherapy) accounted for the highest expenses with a relative share of 49%, whereas surgical procedures had a minor impact on the total cost with a relative share of 19%. In the univariable analysis, significant drivers of both costs and LOS were the number of FRI surgeries, the use of negative pressure wound therapy, duration of IV antibiotic treatment, and cases with a change of surgical strategy. After adjustment for patient and treatment factors, duration of IV antibiotics and change of surgical strategy were associated with higher costs. CONCLUSIONS:This study illustrates the financial burden of FRI in a DRG system and identifies potential drivers for these costs. Since repeated surgeries or unplanned surgical revisions are drivers of costs, optimal pre-operative planning and coordination between the involved disciplines is key to minimize costs. Management in multidisciplinary teams that are specialized in the treatment of these complex and cost-intensive patients may therefore reduce the financial burden.

Breast augmentation is a popular cosmetic procedure that is generally considered safe. However, the rising trend of nonspecialists performing these procedures has increased the risk of complications, including rare but serious acute bleeding. We present a case of a healthy 22-year-old patient who experienced acute bleeding after bilateral breast augmentation by a nonplastic surgeon, resulting in massive hypovolemic shock that required 27 packed red blood cell (PRBC) transfusions and led to acute cardiopulmonary failure. The patient had 2 cardiac arrests, necessitating resuscitation and extracorporeal membrane oxygenation, which was removed after 6 days. An emergency surgical revision was performed to remove the breast implants for effective hemostasis. This case highlights the significant risks associated with cosmetic breast procedures and emphasizes the importance of early surgical intervention in cases of acute bleeding. Patients should be made aware of these risks, and cosmetic surgery should only be performed by trained specialists.

Introduction Up to one-fifth of breast cancer survivors will develop chronic breast cancer-related lymphoedema (BCRL). To date, complex physical decongestion therapy (CDT) is the gold standard of treatment. However, it is mainly symptomatic and often ineffective in preventing BCRL progression. Lymphovenous anastomosis (LVA) and vascularised lymph node transfer (VLNT) are microsurgical techniques that aim to restore lymphatic drainage. This international randomised trial aims to evaluate advantages of microsurgical interventions plus CDT versus CDT alone for BCRL treatment.Methods and analysis The effectiveness of LVA and/or VLNT in combination with CDT, which may be combined with liposuction, versus CDT alone will be evaluated in routine practice across the globe. Patients with BCRL will be randomly allocated to either surgical or conservative therapy. The primary end point of this trial is the patient-reported quality of life (QoL) outcome ‘lymphoedema-specific QoL’, which will be assessed 15 months after randomisation. Secondary end points are further patient-reported outcomes (PROs), arm volume measurements, economic evaluations and imaging at different time points. A long-term follow-up will be conducted up to 10 years after randomisation. A total of 280 patients will be recruited in over 20 sites worldwide.Ethics and dissemination This study will be conducted in compliance with the Declaration of Helsinki and the International Council for Harmonisation-Good Clinical Practice (ICH-GCP) E6 guideline. Ethical approval has been obtained by the lead ethics committee ‘Ethikkommission Nordwest- und Zentralschweiz’ (2023-00733, 22 May 2023). Ethical approval from local authorities will be sought for all participating sites. Regardless of outcomes, the findings will be published in a peer-reviewed medical journal. Metadata detailing the dataset’s type, size and content will be made available, along with the full study protocol and case report forms, in public repositories in compliance with the Findability, Accessibility, Interoperability and Reuse principles.Trial registration number NCT05890677.

BACKGROUND:Approximately 20% of flap surgeries in people with spinal cord injury/disorder and stage III and IV pressure injury result in a major complication requiring re-surgery. Although several factors are associated with postoperative complications according to the literature, there is no risk prediction model for major postoperative complications in the treatment of stage III and IV pressure injuries in people with spinal cord injury/disorder. STUDY AIM:The study aims to predict the risk of major postoperative complications in people with spinal cord injury/disorder and stage III and IV pressure injury at hospital admission. SETTING:The study was conducted in a Swiss acute and rehabilitation hospital for people with spinal cord injury/disorder that specialises in the treatment of people with spinal cord injury/disorder using the Basel Decubitus Approach. METHODS:We performed a retrospective cohort study based on routinely collected clinical data in a Swiss hospital. Risk predictors for major postoperative complications during hospitalisation in pressure injuries over the sacrum/coccyx, ischium or trochanter between 01/2016 and 12/2022 were identified using a mixed effects logistic Bayesian LASSO analysis. RESULTS:We included 252 treatment procedures in 167 individuals. Major complications occurred in 48 (19%) treatment procedures. Estimated glomerular filtration rate (eGFR) according to the cystatin formula (odds ratio [OR] 0.91, confidence interval [CI] 0.62-1.02), vitamin D (25-hydroxy vitamin D; OR 1.05, CI 0.98-1.23), vitamin B12 (OR 0.91, CI 0.74-1.05), sodium (OR 0.75, CI 0.16-1.05) and C-reactive protein (CRP; OR 0.98, CI 0.79-1.07) were found to be predictive of major complications at hospital admission. CONCLUSION:For the Basel Decubitus Approach, high levels of eGFR, vitamin B12 and sodium negatively affected major postoperative complications and should, therefore, be assessed during hospital stay. Further investigation is needed to determine the positive effect of high vitamin D and low CRP levels on major postoperative complications.

BACKGROUND:Artificial intelligence (AI) is rapidly advancing and increasingly applied in facial palsy research. However, there is no comprehensive review to guide surgeons on AI-based facial assessment tools. Although photographic standards exist, videographic standards for emotions have not been proposed. Implementing these standards is essential for improving information exchange and data comparison with the new AI tools. METHODS:The authors conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, by analyzing databases including MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials. The authors' focus was on the use of AI-based facial assessment tools in patients with facial palsy who subsequently received intervention or surgery for their facial palsy. Data were evaluated descriptively, and recommendations, including videographic standards, were developed in collaboration with experts from multiple centers. RESULTS:The authors identified 3222 articles, 35 of which met the inclusion criteria. Five AI applications analyzed static, dynamic, and chemodenervation procedures in unilateral or bilateral facial palsy. These focused on specific facial landmarks or emotion recognition from photographs and videos, but varied in the expressions and emotions analyzed. Five studies provided validation data with either healthy subjects or other outcome measurements. The authors recommend a minimum videographic assessment including the validated emotions neutral and happy. CONCLUSIONS:AI-related publications on facial palsy have significantly increased, but no consensus exists on the optimal AI-assessment software. The proposed flowchart from the authors' systematic review can guide clinicians in decision-making. The authors recommend using the proposed videographic emotions to improve study consistency and comparability, and also encouraging further validation studies.

Background:Breast reduction surgery has been recognized for its potential to improve quality of life in patients with macromastia or after unilateral oncological treatment. However, comparative analysis of different surgical techniques remains sparse. Patient-reported outcome measures have emerged as indispensable tools in assessing patient satisfaction and postoperative outcomes. Driven by the hypothesis of substantial differences between self-reported patient outcomes and professional assessments, this study aimed to compare different technical approaches, integrating both the patients' and plastic surgeons' perspectives. Methods:A 10-year retrospective single-center cohort study was conducted to compare patient- and surgeon-reported outcomes using pre- and postoperative BREAST-Q questionnaires and aesthetic self-assessments. Outcomes and postoperative complication rates of different technical approaches were analyzed using photographic documentation. Results:A total of 170 patients met the inclusion criteria, of which 92 agreed to further photographic documentation for aesthetic evaluation. The median follow-up duration was 4.9 years. BREAST-Q scores significantly improved across all surgical techniques, with comparable scores in both oncoplastic and nononcoplastic patients. Notably, patients reported greater satisfaction with the postoperative aesthetic outcomes than surgeons. Multivariable analysis confirmed body mass index as a significant risk factor for postoperative complications. Conclusions:Breast reduction surgery improves both aesthetic outcomes and long-term quality of life, regardless of surgical technique or the use of oncoplastic methods. The discrepancy between patient and surgeon satisfaction highlights the need for a patient-centered approach, such as incorporating patient-reported outcome measures to evaluate postoperative results.

OBJECTIVES:This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effects of microsurgery versus complex physical decongestive therapy in people with chronic breast cancer-related lymphoedema.

IntroductionCostochondral grafting is well-known reconstructive option for the temporomandibular joint. In the upper extremity, non-vascularized costochondral grafts have been used for radial head reconstruction, for osteoarthritis of the trapeziometacarpal joint and proximal pole reconstruction of the scaphoid. Evidence suggests that vascularization of bone grafts lead to a higher union rate and a faster time to union. To avoid other donor sites and improve healing times we endeavored using vascularized costochondral grafts for skeletal reconstruction of the hand.MethodsIn this report, we present the operative technique and three cases of reconstructions. They comprise one case of a third metacarpal head defect including cartilaginous tissue due to avascular necrosis (Mauclair's or Dieterich's disease), one case of scaphoid proximal pole reconstruction due to necrosis and one case of a third metacarpal head reconstruction after direct trauma. Patients’ complaints included pain and clicking of the joint upon movement of the joint. There were also concerns about osteoarthritis and joint destruction on the future. Medium-term outcome showed good results concerning pain as well as normal range of motion without clicking of the joint.ConclusionOsseocartilaginous grafts are not readily available as a reconstructive option. Donor sites at the knee, metatarsophalangeal and the hamate risk a permanent damage and functional deficit. Furthermore, these grafts are not easily vascularized. Costochondral grafts present a viable option with a challenging dissection, but no mid- to long-term functional loss at the donor site.

Facial feminization surgery (FFS) is essential for transgender women seeking alignment between facial appearance and gender identity. Frontal bone and sinus reshaping is a key component of FFS to achieve a more traditionally feminine contour. This retrospective study evaluates the effectiveness of frontal debossing by comparing pre- and postoperative volumetric and morphometric data. Sixteen patients who underwent frontal debossing at the University Hospital Basel between 2020 and 2024 were included. Preoperative and postoperative CT or CBCT scans were used to assess volume changes in the frontal bone, frontal sinus, and bilateral supraorbital rims. Additionally, changes in the nasofrontal angle were measured. Significant volume reductions were observed in all analyzed structures: left supraorbital rim (mean reduction 792.28 mm3), right supraorbital rim (726.19 mm3), frontal bone (2930.81 mm3), frontal sinus (2508.84 mm3), and combined frontal structures (3251.83 mm3). The nasofrontal angle increased by an average of 21.71°, indicating a substantial improvement in upper facial contour. These results support the clinical value of frontal debossing as an effective and safe component of FFS, providing quantifiable improvements in facial morphology and symmetry. This study further underscores the importance of individualized planning and objective outcome assessment in gender-affirming craniofacial surgery.

Purpose Vascularized lymph node transfer (VLNT) entails the autologous relocation of lymph nodes to a lymphedematous region of the body, whereas lymphaticovenous anastomosis (LVA) creates a direct bypass between the lymphatic and venous system. Both techniques are meant to lastingly bolster the local lymphatic drainage capacity. This study compared safety and effectiveness of VLNT and LVA in patients with chronic breast cancer related lymphedema (BCRL).Methods A retrospective cohort study was conducted using data from our encrypted database composed of patients with chronic BCRL who were treated with either VLNT or LVA and had a minimum follow-up of two years. Patient-specific variables analyzed included pre- and postoperative arm circumferences, lymphedema stages and postoperative complications.Results A total of 105 patients met the inclusion criteria, of which 96 patients demonstrated a complete follow-up period of two years. The VLNT group displayed larger preoperative circumferential measurements, evident in both in the isolated examination of the affected arm, as well as when adjusted for the contralateral unaffected arm. Significant reduction in arm volume was achieved by both groups. However, VLNT demonstrated superior relative reduction rates than LVA, neutralizing any significant arm size disparities after 24 months. Surgery duration was slightly longer for VLNT than LVA. Postoperative complications, predominantly minor, were exclusively observed in the VLNT group.Conclusions Both VLNT and LVA offer significant improvement for patients suffering from chronic BCRL. VLNT shows an even greater potential for improvement in more severe cases of BCRL, but involves a higher risk for (mostly minor) complications.

Summary: Lower extremity reconstruction with free flaps in patients with only peroneal artery runoff remains a challenge. Here, we present a novel technique for reconstruction of medial defects in the distal leg using a medial approach to the peroneal artery and a short interposition vein graft anastomosed end to side to the peroneal artery. A retrospective, single-center study was performed including all patients who underwent lower extremity reconstruction with free flaps anastomosed to the peroneal artery using a mini vein graft from November 2020 to March 2022. The primary outcome measure was limb salvage. Secondary endpoints were flap survival and postoperative complications. Seven patients received lower extremity free flap reconstruction with a mini vein graft to the peroneal artery. Flap loss rate was 0%. Limb salvage was achieved in five patients (71%). At 6-month follow-up, all patients were ambulatory. One patient died 1 month after surgery due to heart failure. Mini vein graft to the peroneal artery allows reliable and safe free flap reconstruction of distal leg defects in patients with only peroneal artery runoff.