Background: Large segmental bone defects remain a major challenge in reconstructive surgery, particularly in the presence of impaired vascularization. Despite advances in scaffold design and biomaterials, insufficient vascular supply continues to represent the primary limitation in bone tissue engineering, often leading to impaired osteogenesis and graft failure. Objective: This review aims to analyze the role of vascularized flaps as “living bioreactors” in bone tissue engineering, focusing on their capacity to enhance scaffold vascularization, support osteogenesis, and facilitate clinical translation. Methods: A narrative review was conducted through a structured search of PubMed, Scopus, and Web of Science using combinations of the following keywords: “bone tissue engineering”, “vascularized flaps”, “arteriovenous loop”, and “in vivo bioreactor”. Relevant preclinical and clinical studies were selected based on their contribution to vascularization strategies in scaffold-based bone regeneration, with the aim of illustrating the evolution and integration of these approaches. Results: Vascularized flaps provide an established vascular network and a biologically active microenvironment that promote scaffold integration and tissue regeneration. Periosteal flaps demonstrate strong osteogenic potential, whereas muscle and omental flaps primarily act as vascular carriers and adaptable regenerative environments. AV loop-based strategies enable intrinsic axial vascularization, ensuring rapid and homogeneous perfusion of large constructs. Hybrid approaches, including regenerative matching axial vascularization (RMAV), integrate vascularized tissues with advanced biomaterials and show promising translational outcomes. Conclusions: Vascularization-driven strategies represent a paradigm shift in bone tissue engineering, moving from passive scaffold implantation to actively engineered, vascularized constructs. The integration of microsurgical techniques with advanced biomaterials offers significant potential for the development of personalized and clinically applicable bone regeneration strategies.

Background/Objectives: Simulation has become an integral part of contemporary surgical training, allowing safe acquisition of technical skills with objective performance assessment. Microsurgery and robotic surgery share several technical features, including fine bimanual coordination, precise instrument control, and stereoscopic vision. This study aimed to evaluate whether a structured microsurgical course is associated with improved performance on a robotic surgical simulator and to explore its potential role within robotic training pathways. Methods: A prospective study was conducted between October 2022 and November 2025 at a single academic center, including 56 participants divided into three groups. Group A consisted of surgical residents attending a 3-day Basic Microsurgery Course; Group B included residents who did not undergo training during the same period; and Group C comprised experienced microsurgeons. Groups A and B performed two robotic simulation tasks at baseline (T0) and after three days (T1). Group C was assessed at T1 only as a reference benchmark. Performance was evaluated using simulator-derived metrics. Statistical analysis was performed using paired and unpaired t-tests. Results: Group A showed significant improvement across several performance parameters following training, whereas no comparable changes were observed in Group B. At T1, Group A demonstrated better performance than Group B in multiple metrics. Group C achieved the highest scores and was considered a reference group. Conclusions: Structured microsurgical training was associated with improved performance in a robotic simulation setting. These findings suggest that microsurgical skills may be transferable to robotic tasks and may contribute to the early phases of robotic skill acquisition. Further studies are required to assess their impact in clinical practice.

Introduction: Ethnic rhinoplasty is a historical challenge for plastic surgeons, particularly when dealing with wide and asymmetric alar base and nostrils. The aim of this article is to describe our personal alar base resection technique, the Sequential Alar Base Resection (SABR), to increase the possibilities of symmetric and customized alar reductions, refining the alar base and nostrils, respecting the ethnic identity. Materials and Methods: We retrospectively reviewed patients who underwent SABR between January 2019 and August 2023at our clinic in Rio de Janeiro. SABR technical details, alar resection patterns and outcomes are described. Patients’ satisfaction was investigated according to the ROE questionnaire. Results: We included 423 patients. According to the mean postoperative Rhinoplasty Outcome Evaluation (ROE score), satisfactory results in nasal contour were reported. All patients had a significant improvement in terms of symmetry and harmony of the nasal base. No SABR specific complication occurred. Alar resection site morbidity was minimal. Conclusion: This study highlights that the SABR technique, by achieving alar base reduction with a two-step sequential procedure, facilitates customized alar recontouring and symmetric results, contributing to improved functional and aesthetic outcomes. The procedure has a high patient satisfaction rate, and minimal complication.

BACKGROUND:The free vascularised fibula flap (FFF) is the preferred method for managing segmental long bone defects after oncological resection or trauma. This study is one of the most extensive retrospective multicenter analysis of FFF for extremity reconstruction in Europe, aiming to inform surgical practices and update current indications for this procedure. METHODS:Data from nine European hospitals were analysed retrospectively. Patients who received FFF for traumatic injury (acute or late) or oncological resection were included. Exclusions were intra-articular, trunk, and mandibular reconstructions. Surgical data and clinical outcomes, including bone union time and complication rates, were collected. RESULTS:The study included 149 patients. The oncological group (O-F) had fewer surgical interventions prior to the FFF (1.03, 95% CI 0.59-1.47, η2=0.611) compared to the A-F (3.53, 95% CI 2.42-4.64, **p) and L-F groups (5.15, 95% CI 3.93-6.37, ****p). Bone-healing time was similar across groups, averaging 8.3 months. Skin paddle complications were strongly associated with subsequent bone-healing complications (p < 0.001, Chi-square test; OR 5.79, 95% CI 5.79-14.9). Two FFF losses (1.34%) were reported. After revision, 91% of patients achieved radiological union. CONCLUSIONS:Free fibula flap reconstruction is a definitive solution for long bone defects that come with a relatively high complication rate, especially in patients who have undergone multiple surgical procedures before undergoing an FFF after a traumatic injury.

Wearable augmented reality in neurosurgery offers significant advantages by enabling the visualization of navigation information directly on the patient, seamlessly integrating virtual data with the real surgical field. This ergonomic approach can facilitate a more intuitive understanding of spatial relationships and guidance cues, potentially reducing cognitive load and enhancing the accuracy of surgical gestures by aligning critical information with the actual anatomy in real-time. This study evaluates the benefits of a novel AR platform, VOSTARS, by comparing its targeting accuracy to that of the gold-standard electromagnetic (EM) navigation system, Medtronic StealthStation® S7®. Both systems were evaluated in phantom and human studies. In the phantom study, participants targeted 13 predefined landmarks using identical pointers to isolate system performance. In the human study, three facial landmarks were targeted in nine volunteers post-brain tumor surgery. The performance of the VOSTARS system was superior to that of the standard neuronavigator in both the phantom and human studies. In the phantom study, users achieved a median accuracy of 1.4 mm (IQR: 1.2 mm) with VOSTARS compared to 2.9 mm (IQR: 1.4 mm) with the standard neuronavigator. In the human study, the median targeting accuracy with VOSTARS was significantly better for selected landmarks in the outer eyebrow (3.7 mm vs. 6.6 mm, p = 0.05) and forehead (4.5 mm vs. 6.3 mm, p = 0.021). Although the difference for the pronasal point was not statistically significant (2.7 mm vs. 3.5 mm, p = 0.123), the trend towards improved accuracy with VOSTARS is clear. These findings suggest that the proposed AR technology has the potential to significantly improve surgical outcomes in neurosurgery.

Background/Objectives: Carpal tunnel syndrome (CTS) is a common entrapment neuropathy. Traditional diagnostics like EMG and NCSs are invasive and do not visualize nerve morphology. This study aims to evaluate the diagnostic and prognostic value of high-resolution ultrasonography in patients with CTS using a standardized scanning protocol and to evaluate the relationship between sonographic findings and traditional electrodiagnostic results. Methods: In this observational study with both prospective and retrospective components, 31 subjects were included. Between November 2023 and June 2024, 11 symptomatic CTS patients were scheduled for surgical decompression and 14 healthy controls were prospectively enrolled. Additionally, six post-surgical CTS patients who had undergone decompression between 2016 and 2021 were retrospectively included for comparative analysis. All underwent clinical and ultrasonographic assessments of the median nerve at predefined anatomical landmarks. EMG was performed in the CTS groups. Ultrasound was repeated at 1, 3, and 6 months postoperatively to monitor morphological changes. Results: CTS patients had significantly increased the median nerve CSA compared to controls. Postoperative ultrasound showed progressive CSA reduction correlating with clinical improvement and EMG recovery. The CSA correlated moderately to strongly with distal motor latency. Conclusions: High-resolution ultrasound is a reliable, non-invasive tool for diagnosing and monitoring CTS. Standardized protocols are needed to support broader clinical adoption and establish it as a standalone diagnostic method.

Neuronavigation is integral to modern neurosurgery. Clinical studies demonstrate its effectiveness. The primary tracking modalities in neurosurgical navigation are optical tracking systems (OTS) and electromagnetic tracking systems (EMTS). OTS remains the gold standard due to its accuracy and reliability. However, inherent inaccuracies due to brain deformation, image resolution, tool calibration, and registration errors can impact overall accuracy significantly, which differs from the system-declared accuracy. Augmented reality (AR) technologies solve traditional navigation challenges by integrating virtual information with the patient’s anatomy, enhancing the surgeon’s focus and cognitive load management. Head-mounted displays (HMDs) offer ergonomic benefits, although most AR-based neuronavigation studies have been limited to proof-of-concept trials. This study aims to evaluate VOSTARS, a novel hybrid video and optical see-through HMD designed for precision surgery, specifically in neurosurgical oncology for targeting supratentorial tumors. Previous in-vitro studies using patient-specific phantoms have shown promising results, with high accuracy in real-to-virtual target visualization and craniotomy trajectory tracing. With this work, we further assessed VOSTARS’ targeting accuracy within a realistic neurosurgery clinical workflow and compared its performance to the commercial StealthStation system on a patient-specific phantom. Our results demonstrate that users achieved the same median accuracy, 2 mm (IQR: 1 mm), over 60 measurements with both VOSTARS and the StealthStation with no statistically significant difference between the systems, confirming the non-inferiority of the VOSTARS platform compared to a commercial optical tracking-based surgical navigator.

ABSTRACTIntroductionLymphedema, a debilitating characterized by localized fluid retention and tissue swelling, results from abnormalities in the lymphatic system. In the case of primary lymphedema, this condition is attributed to malformations in lymphatic vessels or nodes, and it is marked by a relentless progression leading to irreversible tissue fibrosis after repetitive inflammation. Many questions regarding its treatment, such as the choice of the type of intervention and the timing, still remain unanswered. This study aims to present our comprehensive approach to treat this challenging condition.MethodsTo elucidate our approach, we conducted a retrospective chart review of 42 patients treated for primary lymphedema at 3 hospitals between July 2010 and December 2022. The study included two patient groups, those with early‐stage disease (20) and those in the advanced stages (22). We outline our algorithm, based on our clinical experience in Taiwan. Patients were followed for at least 12 months post‐treatment, and assessments were made, including photographic evidence.ResultsA total of 42 patients participated in our study: 20 in the early stage and 22 in the late stage. Our approach yielded significant functional improvements and symptom regression in both groups. In the early‐stage cohort, all 20 patients underwent VLNT procedures and SAL, with 15 (75%) undergoing unilateral procedures and 5 (25%) bilateral. Among the advanced‐stage patients, 12 (54.5%) were treated with the modified Charles' procedure, and 10 (45.5%) with RRPP.The outcomes showed an average circumference reduction of 4.1 cm (2.9–5.3) after VLNT and liposuction. Reductions were noted at various levels: 5.7 cm (4.6–6.8) at mid‐thigh, 4.3 cm (2.5–6.1) at mid‐calf, 3.5 cm (2.7–4.3) at the ankle, and 1.4 cm (0.7–2.1) at mid‐foot. Tonicity decreased by 5.9% (5.2–6.6), indicating significant tissue softening. Tissue removal averaged 3.7 kg (2.9–4.5) after the modified Charles' procedure and 2.6 kg (2.3–2.9) after RRPP.Patients experienced a mean of 3 (2–4) episodes of cellulitis per year, with no cellulitis in early‐stage treated limbs during the follow‐up period. Complications were minimal, including 4 partial skin graft losses that healed with conservative treatment and 3 postoperative infections after the modified Charles' procedure, treated successfully with antibiotics. No major complications were reported at the lymph node flap donor site.ConclusionPrimary lymphedema poses a considerable challenge, primarily due to its relentless progression if left untreated. The existing literature offers limited guidance on its management. Our algorithm, developed over years of experience, aims to fill this gap. By integrating surgical and conservative interventions, as well as individualized patient follow‐up, we provide a comprehensive framework for managing both early and late‐ stage cases.

Background: Injuries to the digital distal phalanx often result in functional impairments such as loss of grip and sensation, along with aesthetic challenges. Various reconstructive techniques, including the use of adipofascial flaps, have been explored to address these issues. The homodigital dorsal adipofascial reverse flap (HDARF) has demonstrated promising results in restoring both functionality and aesthetics. However, a comparative evaluation between adipofascial flaps and other commonly used techniques, such as V-Y advancement flaps and cross-finger flaps, remains limited. Objective: This retrospective study evaluates the long-term functional and aesthetic outcomes of adipofascial flap reconstructions for pulp defects, focusing on sensory recovery and patient satisfaction. Methods: Between 2010 and 2022, 20 patients (14 men, 6 women) with digital pulp defects underwent reconstruction using adipofascial flaps in a single-stage procedure. Injuries included avulsion and crush injuries, distributed across various digits. Sensory recovery was assessed using the Semmes–Weinstein monofilament test and two-point discrimination. Joint mobility, cold intolerance, and aesthetic satisfaction were also evaluated. Results: All flaps were successfully reconstructed within 24 h of trauma. Sensory recovery was excellent, with Semmes–Weinstein scores ranging from 1.65 to 2.83, comparable to the uninjured hand. Two-point discrimination averaged 1–5 mm in most cases. Cold intolerance persisted in four patients, and mild nail dystrophy was noted in three cases, with one case of nail absence. Aesthetic satisfaction was high in 19 patients. Conclusions: The adipofascial flap effectively restores function and aesthetics in pulp defects, offering superior sensory recovery, high patient satisfaction, and minimal complications. Its regenerative potential and adaptability make it a valuable option for fingertip reconstruction, supporting its continued use in clinical practice.

BACKGROUND:Arteriovenous malformations (AVMs) are rare vascular anomalies associated with considerable morbidity and high recurrence rates. Their management remains challenging, with no universally accepted protocol. This study presents a standardized surgical approach developed at our institution, emphasizing early intervention, reconstruction with pedicled flaps or hybrid free flaps with venous bridging, and multidisciplinary care. PATIENTS AND METHODS:A retrospective analysis of 16 patients (5 men and 11 women; aged 15-59 years) treated for extremity AVMs between 2010 and 2024 was conducted. Inclusion criteria encompassed AVMs in the limbs requiring surgical intervention with flap reconstruction. The key innovations in our treatment protocol were surgical excision using the "pineapple technique" and reconstruction with pedicled or hybrid free flaps with venous bridging to mitigate thrombotic risks. RESULTS:Indications for surgery included pain, numbness, bleeding, and chronic ulceration. Flap reconstruction had a 100% success rate, with complications occurring in 30% of cases. The recurrence rate was also 30% and recurrences were successfully managed through re-excision. DISCUSSION AND CONCLUSION:Our findings support a multidisciplinary approach combining embolization and surgical excision with optimized reconstruction to minimize complications. Our protocol demonstrated the effectiveness of early, aggressive intervention and suggested its broader applicability, particularly in using pedicled flaps or hybrid free flaps with venous bridging over conventional free flaps to improve outcomes.

Background and Objectives: Lymphedema is a chronic and progressive condition that leads to significant morbidity, including recurrent infections, fibrosis, and functional limitations. Conservative treatments often offer limited relief, particularly in severe cases. Vascularized lymph node transfer (VLNT), especially using the gastroepiploic lymph node flap, has emerged as a promising intervention. This study evaluates the long-term outcomes of gastroepiploic VLNT combined with suction-assisted lipectomy (SAL) for extremity lymphedema. Materials and Methods: A retrospective review was conducted on 53 patients treated for lymphedema at our clinic in Taiwan from January 2016 to August 2023. The inclusion criteria required patients to have persistent lymphedema for at least six months despite conservative treatment. VLNT was performed using a laparoscopic approach, and postoperative assessments included limb circumference measurements, lymphoscintigraphy, and tonicity evaluations. Results: Follow-up data were collected for a minimum of 12 months. At a mean follow-up of 14.2 months, significant reductions in limb circumference were observed—35.5% ± 24.9% for upper limbs and 32.2% ± 4.5% for lower limbs. Tonicity improved by 6.2%, and no cellulitis episodes were reported post-surgery. Minor complications included hematoma and sensory changes, with no major donor-site morbidity. Lymphoscintigraphy confirmed improved lymphatic drainage. Conclusions: Gastroepiploic VLNT combined with SAL is an effective and safe treatment for severe extremity lymphedema, providing significant improvements in limb size and tissue tonicity. This technique offers a promising solution for refractory cases.

Background: Reconstruction of the nasal lining is one of the most technically demanding aspects of total nasal reconstruction. Traditional techniques such as folded flaps, mucosal grafts, and skin substitutes have limitations in terms of volume, donor site morbidity, and long-term functional outcomes. Dermal regeneration templates (DRTs) have recently gained attention for their regenerative potential in complex wounds, but their application in intranasal mucosal regeneration remains underreported. Methods: We present the case of a 77-year-old man with a third recurrence of basal cell carcinoma involving the nasal pyramid. Following radical resection of the nasal skeleton and anterior septum, total nasal reconstruction was performed using a contralateral forehead flap. The internal surface of the flap was lined with a single-layer dermal regeneration template. The nasal framework was rebuilt with autologous costal cartilage. Additional mucosal advancement flaps were used to cover the new septum. Results: Histological analysis performed two weeks after flap inset revealed early neomucosa formation adjacent to the dermal template. A second biopsy performed at one-year follow-up confirmed complete mucosalization of the inner lining, with mature glandular structures integrated within the tissue. No postoperative complications were observed, and the patient reported satisfactory functional and aesthetic outcomes. Conclusions: This case represents the first documented instance of spontaneous mucosalization of a dermal regeneration template used as inner lining in total nasal reconstruction. The findings suggest that DRTs may serve not only as passive scaffolds, but also as active promoters of mucosal regeneration when placed in a suitable environment. This approach may offer a valuable alternative in cases where conventional lining options are limited or contraindicated.

Minimally invasive surgery (MIS) is the standard approach for early-stage lung cancer, offering benefits such as reduced recovery time, shorter hospital stays, and minimized postoperative pain. However, these techniques require advanced motor skills and a deep understanding of thoracic anatomy. Recent technological advancements, specialized surgical instruments, and energy devices, have further improved MIS capabilities. Despite these advancements, the steep learning curve of video-assisted thoracic surgery (VATS) and robotic-assisted thoracic surgery (RATS) highlights the need for structured simulation-based education to ensure patient safety and optimize skill acquisition. Simulation training provides a risk-free environment for developing technical proficiency before operating on real patients. Virtual simulators, such as LapSim and V-Trainer, are widely used to familiarize trainees with endoscopic instruments and procedural techniques. However, real analog models remain essential for refining motor skills, depth perception, and tactile feedback, which are crucial for complex thoracic procedures. Traditional training methods using wet labs or cadaveric models pose limitations in cost, availability, and ethical concerns. The integration of high-realistic physical anatomical models, including 3D printed anatomical components, represents a promising alternative, offering high-fidelity surgical simulations that mimic real-life operative conditions. At the University of Pisa's EndoCAS Interdipartimental Center for Computer Assisted Surgery, a structured training program incorporating lung phantoms in a 3D-printed thoracic cage, virtual simulation, and stepwise lobectomy simulations have been developed to enhance thoracic surgery education. This study presents our experience with a hybrid simulation approach, based on the combination of virtual and physical simulation, in lobectomy training, emphasizing its role in bridging theoretical learning with handson surgical practice, ultimately improving technical skills and clinical confidence among thoracic surgery residents.

With little donor-site morbidity, adipofascial flaps have become a flexible reconstructive choice, providing thin, flexible, well-vascularized tissue. For both cosmetic improvement and functional restoration, they are being utilized more across several anatomical areas. This systematic review aims to comprehensively analyze the clinical indications, surgical techniques, outcomes, and complications of adipofascial flaps across all anatomical regions. A systematic search was conducted in PubMed, Google Scholar, and the Cochrane Library from database inception to August 2025, following PRISMA 2020 guidelines. Studies were included if they reported clinical outcomes of adipofascial flaps in human reconstructive surgery with at least three patients. Case reports, reviews, experimental or animal studies, and non-English articles were excluded. The primary outcomes were flap survival, complications, donor-site morbidity, and functional or aesthetic results. Thirty-two studies involving a total of 951 patients and 951 adipofascial flaps were included. Overall flap survival exceeded 95

Ethnic nose rhinoplasty is one of the most technically and conceptually challenging plastic surgery procedures due to the complex nasal anatomy and aesthetic preferences. The procedure aims to reshape and project the nasal tip, enhance and strengthen the dorsum, and reduce the size of the alar base, approaching Western beauty standards. It requires tip plasty with significative tip re-projection, leading to a typical asymmetry between the new tip and the nasal bridge, requiring dedicated dorsal reconstruction. The aim of this article is to describe our Free Diced Dorsal Augmentation (FDDA) technique for ethnic nose dorsal reconstruction, sharing our tips and tricks. We retrospectively reviewed patients who underwent FDDA rhinoplasty at our institution in Rio de Janeiro between January 2019 to January 2023, describing our personal technique. The minimum follow-up was 1 year. We assessed procedure related complications, differences in nasal dorsal shape and contour, global symmetry and patients’ satisfaction according to the rhinoplasty outcomes evaluation (ROE) questionnaire. 812 patients including 641 primary and 171 secondary rhinoplasties were included in the study. Complications were minimal, only one patient required revision surgery due to nasal contour asymmetries. Aesthetic results were satisfactory, as assessed by the mean postoperative ROE score. This study has demonstrated that our FDDA approach, employed on several ethnic noses, is a safe and effective procedure, with high patients’ satisfaction. Meticulous intraoperative diced cartilage preparation together with appropriate postoperative pharmacological and physical prevention of inflammation and edema contribute to our long-lasting results. Level III, therapeutic study.

Background and Objectives: Significant progress has been made in skin cancer diagnosis, with a surge in available technologies in recent years. Despite this, the practical application and integration of these technologies in dermatology and plastic surgery remain uneven. Materials and Methods: A comprehensive 20-question survey was designed and distributed using online survey administration software (Google Forms, 2018, Google, Mountain View, CA, USA) from June 2023 to September 2023. The survey aimed to assess the knowledge and utilization of dermatologic diagnostic advancements among plastic surgeons in various European countries. Results: Data were obtained from 29 plastic surgeons across nine European countries, revealing a notable gap between diagnostic technologies and their routine use in surgical practice. The gap for some technologies was both cognitive and applicative; for electrical impedance spectroscopy (EIS) and multispectral imaging, only 6.9% of the sample knew of the technologies and no surgeons in the sample used them. In the case of other technologies, such as high-frequency ultrasound (HFUS), 72.4% of the sample knew about them but only 34.5% used them, highlighting a more significant application problem. Conclusions: Spotlighting this discrepancy provides a valuable foundation for initiating collaborative efforts between units and facilitating knowledge exchange among diverse specialists. This, in turn, contributes to advancing clinical practice by integrating the innovative opportunities presented by ongoing research.

Lymphedema is a complex clinical condition that appears as a result of the failure of the lymphatic system function, and it is characterized by edema, fibrosis, and adipose deposition [...]