BackgroundWith the prevalence of burnout among surgeons posing a significant threat to healthcare outcomes, the mental toughness of medical professionals has come to the fore. Mental toughness is pivotal for surgical performance and patient safety, yet research into its dynamics within a global and multi-specialty context remains scarce. This study aims to elucidate the factors contributing to mental toughness among surgeons and to understand how it correlates with surgical outcomes and personal well-being.MethodsUtilizing a cross-sectional design, this study surveyed 104 surgeons from English and German-speaking countries using the Mental Toughness Questionnaire (MTQ-18) along with additional queries about their surgical practice and general life satisfaction. Descriptive and inferential statistical analyses were applied to investigate the variations in mental toughness across different surgical domains and its correlation with professional and personal factors.ResultsThe study found a statistically significant higher level of mental toughness in micro-surgeons compared to macro-surgeons and a positive correlation between mental toughness and surgeons' intent to continue their careers. A strong association was also observed between general life satisfaction and mental toughness. No significant correlations were found between the application of psychological skills and mental toughness.ConclusionMental toughness varies significantly among surgeons from different specialties and is influenced by professional dedication and personal life satisfaction. These findings suggest the need for targeted interventions to foster mental toughness in the surgical community, potentially enhancing surgical performance and reducing burnout. Future research should continue to explore these correlations, with an emphasis on longitudinal data and the development of resilience-building programs.

BACKGROUND: The use of dyes like Indocyanine green (ICG) and Patent blue facilitates the identification of lymphatic vessels during lymphaticovenous anastomosis (LVA) surgery. However, some patients experience “staining failure”. In these cases, no stained lymphatic vessels can be detected, making supermicrosurgical LVA even more complex. OBJECTIVE: This study aims to investigate patient-related factors that may interfere with lymphatic vessel staining during LVA. METHODS: A retrospective study was conducted on 30 patient charts, focusing on patient characteristics and the staining quality of ICG and Patent blue dye. Statistical analyses were performed to identify correlations between variables. RESULTS: Significant correlations were found between higher age and secondary lymphedema, longer duration of lymphedema in male patients until surgery and reoccurring cellulitis and Patent blue staining. Notably, recurrent infections to the lymphatic system resulted in inferior staining ability during LVA surgery. CONCLUSIONS: Due to staining failure the detection of functional lymphatic vessels remains challenging in LVA surgery. A more extensive preoperative workup is recommended for patients with recurrent cellulitis to optimize surgical feasibility and procedure quality in LVA treatment for lymphedema.

BACKGROUND:Monitoring replanted digits remains a challenging task in microsurgical units. Previous studies have indicated the perfusion index (PI), a parameter directly proportional to the blood flow, might be a useful tool. OBJECTIVE:The PI is evaluated as a monitoring tool in patients with replanted digits. METHODS:This prospective, non-interventional study includes 31 patients with revascularized or replanted digits. After successful revascularization or replantation, the PI and peripheral oxygen saturation of the affected finger and its contralateral equivalent were measured simultaneously. The values were detected by the device Radical-97® Pulse CO-Oximeter® (Masimo Corporation, 52 Discovery, Irvine, CA 92618, USA). RESULTS:The median PI of affected fingers was 3.5±0.56 for revascularized and 2.2±0.8 for replanted fingers. The difference between the PI values of replanted digits and the healthy contralateral side was highly significant (p < 0.0001). The area under the curve in the receiver operating characteristics was 0.92 for a PI difference > 80.49% and predicted a loss of replant with a specificity of 100% and a sensitivity of 75%. CONCLUSION:The assessment of the PI in patients with reperfusion of a vascular compromised digit is a useful tool to continuously monitor peripheral perfusion. The dynamic behavior of the PI is essential to detect perfusion disturbance.

Background: Despite its increasing incidence and prevalence throughout Western countries, lipedema continues to be a very enigmatic disease, often misunderstood or misdiagnosed by the medical community and with an intrinsic pathology that is difficult to trace. The nature of lipedemic tissue is one of hypertrophic adipocytes and poor tissue turnover. So far, there are no identified pathways responsible, and little is known about the cell populations of lipedemic fat. Methods: Adipose tissue samples were collected from affected areas of both lipedema and healthy participants. For single-cell RNA sequencing analysis, the samples were dissociated into single-cell suspensions using enzymatic digestion and then encapsulated into nanoliter-sized droplets containing barcoded beads. Within each droplet, cellular mRNA was converted into complementary DNA. Complementary DNA molecules were then amplified for downstream analysis. Results: The single-cell RNA-sequencing analysis revealed three distinct adipocyte populations at play in lipedema. These populations have unique gene signatures which can be characterized as a lipid generating adipocyte, a disease catalyst adipocyte, and a lipedemic adipocyte. Conclusions: The single-cell RNA sequencing of lipedemic tissue samples highlights a triad of distinct adipocyte subpopulations, each characterized by unique gene signatures and functional roles. The interplay between these adipocyte subtypes offers promising insights into the complex pathophysiology of lipedema.

CD8 T lymphocytes are classically viewed as cytotoxic T cells. Whether human CD8 T cells can, in parallel, induce a tissue regeneration program is poorly understood. Here, antigen-specific assay systems revealed that human CD8 T cells not only mediated cytotoxicity but also promoted tissue remodeling. Activated CD8 T cells could produce the epidermal growth factor receptor (EGFR)-ligand amphiregulin (AREG) and sensitize epithelial cells for enhanced regeneration potential. Blocking the EGFR or the effector cytokines IFN-γ and TNF could inhibit tissue remodeling. This regenerative program enhanced tumor spheroid and stem cell–mediated organoid growth. Using single-cell gene expression analysis, we identified an AREG+, tissue-resident CD8 T cell population in skin and adipose tissue from patients undergoing abdominal wall or abdominoplasty surgery. These tissue-resident CD8 T cells showed a strong TCR clonal relation to blood PD1+TIGIT+ CD8 T cells with tissue remodeling abilities. These findings may help to understand the complex CD8 biology in tumors and could become relevant for the design of therapeutic T cell products.

Background: Due to the high frequency of postoperative complications after body-contouring surgeries, the need for a unifying postoperative complication grading system that correlates with outcomes is of key importance. Here we therefore consider the application of the Clavien–Dindo classification to evaluate postoperative complications after body-contouring surgeries. Methods: A retrospective study on 602 patients who underwent body-contouring surgery between 2009 and 2015 at our institution was performed. The length of hospital stays, age, sex, follow-up visits, and postoperative complications were evaluated and classified using the Clavien–Dindo classification. Results: We raised a total of 672 body-contouring procedures on 602 patients (563 female, 39 male). According to the Clavien–Dindo System, the severity of postoperative complications following body-contouring procedures was significantly correlated with the duration of hospitalization (mean 5.8 ± 2.7 days) and the number of follow-up visits (mean 4.4 ± 4.7). Conclusions: The Clavien–Dindo classification offers a valid prediction for postoperative hospital stay and the number of follow-up visits after body-reshaping surgery. By becoming a validated and reliable grading system that correlates patients’ outcomes after body-contouring procedures, this classification has the potential to significantly improve patients’ healthcare and quality of life.

Recent advancements in Plastic Surgery and Regenerative MedicineQuery have revolutionized tissue repair, remodeling, and regeneration. A promising approach involves Mesenchymal Stem cells and from the adipose–derived Stromal Vascular Fraction, aimed at improving tissue healing post the use of synthetic materials. This integration shows potential in mitigating adverse effects of synthetic materials like dermal fillers, offering new clinical interventions for tissue repair and regeneration. This article explores the benefits, complications, and applications of these technologies in Plastic Surgery and Cosmetic Medicine, focusing on their mechanisms of action and future perspectives. Level of evidence: Not ratable

Background: Extracellular Vesicles are pivotal mediators in intercellular communication, facilitating the exchange of biological information among healthy, pathological and tumor cells. Between the diverse subtypes of extracellular vesicles, exosomes have unique properties, clinical and therapeutical applications, even towards cancer. Breast cancer ranks as one of the most prevalent malignancies across the globe. Both the tumor core and its surrounding microenvironment engage in a complex, orchestrated interaction that facilitates the cancer’s growth and spread. Methods: The most valuable and significant PubMed Literature about extracellular vesicles and adipose–derived stem cells exosomes was selected and analyzed in order to report their biological properties and potential applications, in particular on the Triple–Negative Breast Cancer. Results: Adipose–derived stem cells exosomes represent a potential tool to target the tumor core of the Triple–Negative Breast Cancer, its microenvironment and surrounding tissues including metastasis. The authors are developing a supportive Triple–Adipose–derived stem cells Exosomes [T.A.E.] Technology against breast cancer in order to perform a selective preconditioning of the cancer before or while the traditional oncological treatments are running. Conclusion: The possibility to exploit the impact of Adipose–derived stem cells exosomes within the T.A.E. Technology against the Triple–Negative breast cancer is real, highlighting a new era for supportive measures against breast cancer.Keywords: Extracellular vesicles; Exosomes; Adipose–derived stem cells, Tumor microenvironment, Triple–Negative Breast Cancer, T.A.E. Technology.

Given that scars are acknowledged as the primary cause of postoperative dissatisfaction following reduction mammoplasty, it is imperative to comprehend the patient’s visual perception of different scar patterns in order to enhance patient satisfaction. To achieve this, eye-tracking technology provides an unbiased method of evaluating how observers assess breast scars. 58 participants (32 females and 26 males) between the ages of 19 and 82 years (mean age of 29.47 ± 10.98 years) were shown 18 color photographs, taken at 3 viewing angles (right 45° oblique, frontal and frontal view with arms raised), from 6 patients undergone reduction mammoplasty with the inverted T-scar technique (3 patients) or no-vertical-scar technique (3 patients). The images were presented to every participant for a fixed duration of 5 s each. Eye-tracking device was used to collect and analyze the gaze data of viewers. The nipple-areola complex (NAC) and the periareolar scar captured observers’ gaze faster, had longer duration and more count of eye fixation than all other parts of breast scars, regardless of the viewing angle and scar pattern. Moreover, the scar region in the inverted T-scar pattern received greater and faster visual attraction of observer’s gaze than the no-vertical-scar pattern. The NAC and the periareolar scar seem to be perceived as the most important regions for breast aesthetics. The findings can be helpful to assist plastic surgeons in determining the most appropriate technique for reduction mammoplasty, meanwhile underlining the importance of a fine periareolar scar and symmetric NAC for excellent aesthetic outcomes. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Zusammenfassung Hintergrund Real World Evidence (RWE) gewinnt in der Bewertung medizinischer Maßnahmen zunehmend an Bedeutung und ergänzt Befunde von kontrollierten klinischen Studien. Gleichzeitig sieht sich der RWE-Ansatz erheblichen methodischen und ethischen Herausforderungen gegenüber. Phytopharmaka haben ihren Platz in der Therapie durch Heilberufe und in der Selbstmedikation bei leichteren Beschwerden sowie Symptomen, die nachhaltig die Lebensqualität beeinflussen. Die aktuell geforderten Schlüsselstudien für die Arzneimittelzulassung bilden die Folgen einer ärztlichen Verordnung und/oder der Selbstmedikation jedoch nur unzureichend ab. Im Rahmen eines Workshops werden daher die Nutzbarkeit von RWE für die Forschung im Bereich Phytopharmaka sowie methodische Grundlagen zum Aufbau eines Phytoregisters diskutiert. Methoden Der Workshop bestand aus 2 Teilen: Impulsreferate zu den Themen RWE und Phytotherapie und die Erarbeitung der Basis eines Positionspapiers mithilfe der Methodik des nominalen Gruppenprozesses. Ergebnisse Die Impulsreferate umfassten interdisziplinäre Argumente aus den Bereichen Forschung und Praxis der Phytotherapie, Registererstellung, Versorgungsforschung, künstliche Intelligenz und Telemedizin. Im nominalen Gruppenprozess wurden die Chancen und Risiken der Phytotherapie sowie inhaltliche, methodische und praktische Aspekte eines Phytoregisters diskutiert (Fokus, Mehrwert und methodische Standards des Registers, Finanzierung, erwartete Kritik, Analysemethoden und Stellenwert im Vergleich zu anderen medizinischen Bereichen). Schlussfolgerungen Register sind ein zunehmend akzeptierter Weg, um Evidenz in Ergänzung zu klinischen Studien zu generieren. Der schrittweise Aufbau eines Registers für Phytopharmaka mit klar definierten methodischen Kriterien und der Erfassung von patientenzentrierten Endpunkten bietet die Chance, die wissenschaftliche Fundierung der Anwendung und des klinischen Nutzens von Phytopharmaka zu erweitern.

Objective: Despite the popularity of rhinoplasty, outcome research has been mainly limited to single-surgeon or single-institution reports. Therefore, we performed a multi-institutional analysis to present a broader portrait of the postoperative outcomes and risk factors for adverse events after rhinoplasty surgery. Methods: We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2009–2019) to identify patients who underwent rhinoplasty. The postoperative outcomes of interest included 30-day mortality, reoperation, readmission, and surgical and medical complications. We also analyzed risk factors for complication occurrence, including patient comorbidities and preoperative laboratory values. Results: We identified 835 patients, 72% (n=602) of whom underwent a primary, 21% (n=175) a secondary, and 6.7% (n=58) a cleft nasal deformity procedure. The average patient age was 41±17 years, with most patients being female (n=472; 57%) and white (n=643; 77%). Complications rates were generally low, with reoperation (n=19; 2.3%) and superficial incisional infection (n=9; 1.1%) account for the most common general and surgical adverse event, respectively. Multivariable analysis revealed male sex (P=0.04) and higher ASA scores (P<0.0001) as risk factors for complications. Low serum albumin (P=0.04) and hematocrit (P=0.003) levels were associated with the occurrence of any complication, whereas low serum albumin (P=0.02) also correlated with the incidence of surgical adverse events. Conclusion: Complication rates after rhinoplasty were overall low and seemed to correlate with male sex and ASA scores. We identified preoperative albumin and hematocrit as predictive biomarkers of adverse events. Preoperative nutritional optimization and management of low hematocrit may improve postoperative outcomes.

Background Recurrent scandals involving breast implants have revealed that scientific evidence on the performance of these devices is lacking, and passive monitoring systems are not capable of detecting problems at an early stage. The German health authorities therefore decided to implement a prospective, mandatory registry. Objectives The aim of this article was to provide information about the advantages of implementing a mandatory registry, the potential hurdles involved, and to establish structural requirements that future registries can use. Methods Since 2018, the authors have assisted the German Ministry of Health in refining the Implant Law and its implementation. They adapted an internationally consented dataset, promoted international data amplification and conducted monthly trial inputs for over 2 years. By identifying several key issues they were able to assist in developing solutions. Results The cooperation with the authorities was characterized by appreciation of the authors’ expertise and previous international work. Challenges included data privacy issues, federal competence, longitudinal follow-up, and contact data; as well as associated costs and technical solutions for data inclusion and the use of information technology to communicate with stakeholders. Addressing these challenges required considerable interference with personal rights and complementary measures for all stakeholders. Extensive structural precautions were taken to safeguard personal data privacy as far as possible. Conclusions The authors’ experience and lessons learned can guide registries seeking to engage in high levels of evidence data. The authors describe their approach, the obstacles they encountered, and the strategies employed to overcome the setbacks of other registries.

Lagophthalmos is the incomplete closure of the eyelids posing the risk of corneal ulceration and blindness. Lagophthalmos is a common symptom of various pathologies. We aimed to program a convolutional neural network to automatize lagophthalmos diagnosis. From June 2019 to May 2021, prospective data acquisition was performed on 30 patients seen at the Department of Plastic, Hand, and Reconstructive Surgery at the University Hospital Regensburg, Germany (IRB reference number: 20-2081-101). In addition, comparative data were gathered from 10 healthy patients as the control group. The training set comprised 826 images, while the validation and testing sets consisted of 91 patient images each. Validation accuracy was 97.8% over the span of 64 epochs. The model was trained for 17.3 min. For training and validation, an average loss of 0.304 and 0.358 and a final loss of 0.276 and 0.157 were noted. The testing accuracy was observed to be 93.41% with a loss of 0.221. This study proposes a novel application for rapid and reliable lagophthalmos diagnosis. Our CNN-based approach combines effective anti-overfitting strategies, short training times, and high accuracy levels. Ultimately, this tool carries high translational potential to facilitate the physician’s workflow and improve overall lagophthalmos patient care.

Background: The use of negative pressure wound therapy (NPWT) in superinfected wounds is controversial. The mechanism of action is unclear, but recent studies have shown lower atmospheric oxygen levels within the dressing. Therefore, different oxygen-favoring bacteria and fungi might benefit or face impaired thriving attached to a standard NPWT-device. After 48 hours, colonies were separately harvested from the agar and foam. Optical density (OD) was obtained in order to Results: For all tested microorganisms, no overall significant differences were found compared to controls. Subanalysis showed lower OD levels from the agar beneath Conclusion: NPWT removed bacteria and fungi from the wound surface but accumulation is found within the foam. The use of NPWT showed no influence on bacterial or fungal growth selection. With superinfected wounds, the use of NPWT should thoroughly be evaluated as toxins and virulence factors may not fully be evacuated.

The perioperative use of vasopressors in free flap surgeries is controversially debated. The predominant concern is pedicle blood supply will be negatively affected, thus leading to increased post-operative complications. However, little is known about the relationship between vasopressor use and its impact on intrinsic blood supply of free flaps. Comorbidities that diminish blood circulation may cause a higher risk of necrosis from vasopressor use due to the decreased intrinsic free flap blood supply. The aim of this study is to establish the role of peri-operative vasopressors in free flap necrosis based on flap localization and patients’ comorbidities

OBJECTIVE:Since the first use of silicone implants by Cronin in 1962, there have been several attempts to introduce alternative filling materials for breast implants on the market. A promising new development are lightweight implants, whose filler material is one third lighter than conventional silicone gel. While these implants have been used primarily for aesthetic augmentation, a benefit could be expected particularly in post-mastectomy reconstruction.MATERIALS AND METHODS:Since 2019, 92 operations using lightweight implants have been performed at our clinic, 61 of them for breast reconstruction after mastectomy. These have been compared to 92 breast reconstructions using conventional silicone implants.RESULTS:The average volume of the lightweight implants was 30% higher than of the conventional implants (452 ml resp. 347 ml), whereas the implant weight was comparable in both groups (317 g resp. 347 g). Grade 3-4 capsular fibrosis was seen in 6 cases in both groups; revision was required 9 times (lightweight implants) and 7 times (conventional silicone implants) during the follow-up period.DISCUSSION:To our knowledge, this is the first study to investigate the use of lightweight implants in breast reconstruction. With exception of the filler material, the implants used in the two groups were comparable in shape and surface. The inserted lightweight implants had a greater volume but nearly the same weight as the conventional implants and were used in patients with a higher body mass index. Thus, lightweight implants were preferred in patients whose reconstruction required a larger implant volume.CONCLUSION:Lightweight implants are a new alternative for breast reconstruction especially in case that larger implant volume is demanded. The increased complication rate has to be verified in further studies.

Purpose Lipofilling has been established as a standard technique for contour enhancement following breast reconstruction. However, there is a paucity in current literature regarding the use of this technique for complete reconstruction of the female breast as an alternative to conventional techniques, such as expander or flap-based procedures. In particular, the influence of pre-operative irradiation for successful reconstruction has rarely been examined in published studies. Here, the authors describe their experience with successful fat injection in pre-radiated breasts in comparison with non-pre-radiated patients. Methods In this retrospective study, we examined a total of 95 lipofilling treatments on 26 patients (28 breasts). All of them experienced mastectomy following breast cancer; local breast defects after partial resection of the gland were not included in this study. In total, 47 lipofilling procedures in 12 non-irradiated patients (14 breasts) and 48 procedures in 14 irradiated women (also 14 breasts) were performed. Per session, approximately 297 ± 112 cc of adipose tissue was grafted in group A (no radiotherapy) and approximately 259 ± 93 cc was grafted in group B (radiotherapy). Results Among the group of women without pre-operative radiation, 71% of breast reconstructions limited to lipofilling only showed constant engraftment of fat tissue with a successful reconstructive result, whereas only 21% of the patients with pre-radiated breasts showed complete reconstruction of the breast with a permanent fat in-growth. Conclusion Preoperative radiotherapy significantly impedes successful completion of breast reconstructions planned only by autologous fat transfer. Patients should be selected individually and carefully for complete breast reconstruction using lipofilling only.

SUMMARY:Digital-nerve lesions result in a loss of tactile sensation reflected by an anesthetic area (AA) at the radial or ulnar aspect of the respective digit. Available tools to monitor the recovery of tactile sense have been criticized for their lack of validity. Precise quantification of AA dynamics by three-dimensional (3D) imaging could serve as an accurate surrogate to monitor recovery after digital-nerve repair. For validation, AAs were marked on digits of healthy volunteers to simulate the AA of an impaired cutaneous innervation. The 3D models were composed from raw images that had been acquired with a 3D camera to precisely quantify relative AA for each digit (3D models, n = 80). Operator properties varied with regard to individual experience in 3D imaging and image processing. In addition, the concept was applied in a clinical case study. Results showed that images taken by experienced photographers were rated as better quality ( P < 0.001) and needed less processing time ( P = 0.020). Quantification of the relative AA was not altered significantly, regardless of experience level of the photographer ( P = 0.425) or image assembler ( P = 0.749). The proposed concept allows precise and reliable surface quantification of digits and can be performed consistently without relevant distortion by lack of examiner experience. Routine 3D imaging of the AA has the great potential to provide visual evidence of various returning states of sensation and to convert sensory nerve recovery into a metric variable with high responsiveness to temporal progress.

BACKGROUND:Recent studies have demonstrated that local application of corticosteroids reduces wound exudation following abdominoplasty and other reconstructive surgical procedures. On the other hand, corticosteroids might provoke wound healing disturbances due to their immunosuppressive effects.OBJECTIVE:The main objective of this study was to gain further information about the impact of the corticosteroid triamcinolone on cell migration in abdominoplasty patients.METHODS:An in-vitro scratch assay wound healing model was applied to observe cell migration of fibroblasts cultured with nutrient medium containing human seroma aspirate±triamcinolone.RESULTS:There were no significant differences regarding cell migration when fibroblasts were incubated with triamcinolone + seroma containing culture medium compared to seroma containing culture medium without triamcinolone.CONCLUSIONS:The performed in-vitro study suggests that triamcinolone does not decelerate fibroblast cell migration which is considered as a surrogate of wound healing.