Primary Lymphovenous Anastomosis After Extended Soft Tissue Resection in the Medial Thigh for Reduction of Lymphocele and Lymphedema.

INTRODUCTION: Postoperative chronic lymphocele and lymphedema represent severe burdens for soft tissue sarcoma patients who are already physically handicapped after an extensive surgery and a long recovery time. Incidences are high in the upper medial thigh. We have shifted our focus to lymphedema and lymphocele risk reduction with immediate lymphovenous anastomosis (LVA) after sarcoma resection. METHODS: We performed immediate lymphatic reconstruction in 11 patients after soft tissue sarcoma resection in the upper medial thigh. The postoperative course was followed up closely, and postoperative occurrence of lymphocele and lymphedema was clinically assessed. A literature search outlining the latest clinical data, current treatment strategy landscape, and their application into clinical practice was added to the investigation. RESULTS: A total of 19 LVA and 2 lympho-lymphatic anastomoses were performed in 11 patients immediately after tumor resection in an end-to-end manner. We found a postoperative lymphedema rate of 36% and a postoperative lymphocele rate of 27%. Mean follow-up time was 17 months. Average tumor volume was 749 cc. Our literature search yielded 27 articles reporting on immediate LVA in cancer patients. Incidences of secondary lymphedema after LVA for lymphedema prevention vary between 0% and 31.1%. Lymphocele prevention with LVA is poorly studied in sarcoma patients. CONCLUSION: Immediate lymphatic reconstruction improved the overall postoperative course of our patients. The current literature does not serve with high-quality studies about primary LVA preventing lymphedema and lymphocele formation. We conclude that this technique should be seen as an additional concept to achieve overall better postoperative outcomes in these challenging surgical settings. We strongly recommend to either anastomose or ligate severed lymphatics under the microscope primarily after sarcoma resection in the upper medial thigh area.

Evaluation of the Effect of Botulinum Toxin A on the Lymphatic Endothelial Cells.

INTRODUCTION: Botulinum toxin A (BoTA) is a neurotoxin formed by Clostridium botulinum, with a broad medical application spectrum. While the primary effect of BoTA is on the muscles, the effects of BoTA in other systems including the blood vasculature have already been examined, revealing unexpected actions. However, no studies exist to the best of our knowledge regarding the potential effects of BoTA on the lymphatic vascular system, possessing a critical role in health and disease. Isolated human lymphatic endothelial cells (LECs) were cultured in dedicated in vitro culture systems. The analysis including imaging and cell culture approaches as well as molecular biology techniques is performed to examine the LEC alterations occurring upon exposure to different concentrations of BoTA. MATERIALS AND METHODS: Human LECs were cultured and expanded on collagen-coated petri dishes using endothelial basal medium and the commercial product Botox from Allergan as used for all our experiments. Harvested cells were used in various in vitro functional tests to assess the morphologic and functional properties of the BoTA-treated LECs. Gene expression analysis was performed to assess the most important lymphatic system-related genes and pathways. RESULTS: Concentrations of 1, 5 or 10 U of BoTA did not demonstrate a significant effect regarding the proliferation and migration capacity of the LECs versus untreated controls. Interestingly, even the smallest BoTA dose was found to significantly decrease the cord-like-structure formation capacity of the seeded LECs. Gene expression analysis was used to underpin possible molecular alterations, suggesting no significant effect of BoTA in the modification of gene expression versus the starvation medium control. CONCLUSION: LECs appear largely unaffected to BoTA treatment, with an isolated effect on the cord-like-structure formation capacity. Further work needs to assess the effect of BoTA on the smooth-muscle-cell-covered collecting lymphatic vessels and the possible aesthetic implications of such an effect, due to edema formation. LEVEL OF EVIDENCE V: 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 .

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.

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.

A Distinct Cytokine Profile and Stromal Vascular Fraction Metabolic Status without Significant Changes in the Lipid Composition Characterizes Lipedema.

Lipedema is an adipose tissue disorder characterized by the disproportionate increase of subcutaneous fat tissue in the lower and/or upper extremities. The underlying pathomechanism remains unclear and no molecular biomarkers to distinguish the disease exist, leading to a large number of undiagnosed and misdiagnosed patients. To unravel the distinct molecular characteristic of lipedema we performed lipidomic analysis of the adipose tissue and serum of lipedema versus anatomically- and body mass index (BMI)-matched control patients. Both tissue groups showed no significant changes regarding lipid composition. As hyperplastic adipose tissue represents low-grade inflammation, the potential systemic effects on circulating cytokines were evaluated in lipedema and control patients using the Multiplex immunoassay system. Interestingly, increased systemic levels of interleukin 11 (p = 0.03), interleukin 28A (p = 0.04) and interleukin 29 (p = 0.04) were observed. As cytokines can influence metabolic activity, the metabolic phenotype of the stromal vascular fraction was examined, revealing significantly increased mitochondrial respiration in lipedema. In conclusion, despite sharing a comparable lipid profile with healthy adipose tissue, lipedema is characterized by a distinct systemic cytokine profile and metabolic activity of the stromal vascular fraction.

Osteoidosis leads to altered differentiation and function of osteoclasts.

In patients with osteomalacia, a defect in bone mineralization leads to changed characteristics of the bone surface. Considering that the properties of the surrounding matrix influence function and differentiation of cells, we aimed to investigate the effect of osteoidosis on differentiation and function of osteoclasts. Based on osteomalacic bone biopsies, a model for osteoidosis in vitro (OIV) was established. Peripheral blood mononuclear cells were differentiated to osteoclasts on mineralized surfaces (MS) as internal control and on OIV. We observed a significantly reduced number of osteoclasts and surface resorption on OIV. Atomic force microscopy revealed a significant effect of the altered degree of mineralization on surface mechanics and an unmasking of collagen fibres on the surface. Indeed, coating of MS with RGD peptides mimicked the resorption phenotype observed in OIV, suggesting that the altered differentiation of osteoclasts on OIV might be associated with an interaction of the cells with amino acid sequences of unmasked extracellular matrix proteins containing RGD sequences. Transcriptome analysis uncovered a strong significant up-regulation of transmembrane glycoprotein TROP2 in osteoclastic cultures on OIV. TROP2 expression on OIV was also confirmed on the protein level and found on the bone surface of patients with osteomalacia. Taken together, our results show a direct influence of the mineralization state of the extracellular matrix surface on differentiation and function of osteoclasts on this surface which may be important for the pathophysiology of osteomalacia and other bone disorders with changed ratio of osteoid to bone.

Donor site aesthetics and morbidity after DIEP flap breast reconstruction-A retrospective multicenter study.

The deep inferior epigastric artery perforator flap (DIEP) has gained widespread popularity in autologous breast reconstruction due to its natural aesthetic results and muscle-sparing design. However, donor site results regarding aesthetic outcome are often less favorable. We therefore aimed to identify crucial factors that might increase the risk for abdominal bulging and an impaired aesthetic appearance. We conducted a multicenter study evaluating all patients receiving autologous breast reconstruction using a DIEP flap between 2013 and 2017. Medical records were analyzed with special attention to flap technique, number of perforators, localization of perforator, and donor site complications. In addition, the aesthetic appearance of the abdominal donor site was evaluated by blinded clinicians at one-year follow-up. A total of 242 patients underwent DIEP flap breast reconstruction. Abdominal bulging occurred in 7%. Further subgroup analysis revealed a significant correlation between abdominal bulging and two or more perforators (P = .003), the use of lateral row perforators (P = .009), and a higher BMI (P = .002). Obesity (P = .003) and higher patient's age (P = .003) could be identified as risk factors for an undesirable appearance of the donor site. We recommend the use of a medial-row single perforator whenever possible in order to optimize donor site morbidity and decrease the risk of abdominal bulging. Proper patient selection and careful donor site closure following a standardized approach should be performed to limit the risk of aesthetically undesirable results.

Lymphovenous Anastomosis for the Treatment of Thoracic Duct Lesion: A Case Report and Systematic Review of Literature.

BACKGROUND: Chylous leak is an uncommon complication after head and neck surgery and typically results from a lesion of the thoracic duct (TD). Beside conservative treatment, different minimally invasive and surgical procedures exist, of which almost all lead to a total closure of the TD. METHODS: We report on a rare case of microsurgical lymphovenous anastomosis to treat a TD lesion. An additional systematic review on surgical procedures to treat TD lesions with special attention to lymphovenous anastomoses was performed according to the PRISMA guidelines. RESULTS: A 52-year-old patient with a chylous fistula after modified radical neck dissection was successfully treated by a lymphovenous anastomosis of the TD and external jugular vein with additional coverage by sternocleidomastoid muscle flap. The patient showed a complete resolution of chylous leak with an uneventful postoperative course.The systematic search of literature yielded 684 articles with 4 case reports on lymphovenous anastomosis in chylous leak with a high success rate. Other surgical techniques include transcervical, thoracoscopic, or video-assisted thoracoscopic TD ligation, either alone or combined with a local muscle flap. CONCLUSIONS: Lymphovenous anastomosis of the TD is a feasible and safe technique allowing for treatment of cervical TD lesions, especially if minimally invasive procedures fail. Compared with other techniques, lymphatic circulation can successfully be maintained.

Autologous Breast Reconstruction with SIEA Flaps: An Alternative in Selected Cases.

BACKGROUND: The deep inferior epigastric perforator flap has been shown to be a reliable option for autologous breast reconstruction. A further refinement in the transfer of lower abdominal tissue is the superficial inferior epigastric artery (SIEA) flap that does not require any incision of the rectus abdominis fascia or muscle and is superior regarding donor-site morbidity. OBJECTIVES: We conducted a retrospective study to assess reliability and outcomes of autologous breast reconstruction using SIEA flaps. METHODS: We performed autologous breast reconstruction in 1708 patients at our department between 2009 and 2018. Of those, 28 patients that underwent breast reconstruction using a SIEA flap were included for a retrospective chart review. RESULTS: Given an overall flap loss rate of 1.8%, we observed total flap necrosis following a SIEA flap in four patients (13%). All cases were secondary to arterial thrombosis. We further recognized a significant correlation between flap failure and a history of spontaneous deep vein thrombosis (p < 0.0001). There was no statistically significant relationship between flap failure and obesity (BMI > 30 kg/m2;p = 0.9) or flap failure and a history of abdominal operations (p = 0.6). CONCLUSIONS: The SIEA flap provides a reasonable option for autologous breast reconstruction with the great advantage of minimal donor-site morbidity. Nevertheless, its use should be preserved to selected cases with favorable anatomy. We therefore recommend proper patient selection based on preoperative computed tomography angiography, intraoperative clinical evaluation and history of hypercoagulable state. LEVEL OF EVIDENCE IV: 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.

[Robotic-Assisted Lymphatic Surgery]. / Robotisch-assistierte Lymphchirurgie.

Surgical robotic systems specifically developed for microsurgery are increasingly being used in recent years, particularly in reconstructive lymphatic surgery. Currently, there are two robotic systems that are used in microsurgery. Both systems feature tremor reduction and motion scaling technologies, which are intended to optimise the surgeon's precision and dexterity. In the Department of Plastic Surgery and Hand Surgery at the University Hospital Zurich, the Symani Surgical System is used in many microsurgical and supermicrosurgical procedures. It is mainly used in reconstructive lymphatic surgery, especially for robotic-assisted lymphovenous anastomosis, microvascular anastomosis of lymph node flaps, and it is used in central lymphatic surgery. The robot enables smaller surgical approaches for deep anatomical structures with enhanced surgical precision. In combination with an exoscope, it can also improve the ergonomics of the microsurgeon.

Lipidomic Analysis of Microfat and Nanofat Reveals Different Lipid Mediator Compositions.

BACKGROUND: Microfat and nanofat are commonly used in various surgical procedures, from skin rejuvenation to scar correction, to contribute to tissue regeneration. Microfat contains mainly adipocytes and is well suited for tissue augmentation, and nanofat is rich in lipids, adipose-derived stem cells, microvascular fragments, and growth factors, making it attractive for aesthetic use. The authors have previously demonstrated that the mechanical processing of microfat into nanofat significantly changes its proteomic profile. Considering that mechanical fractionation leads to adipocyte disruption and lipid release, they aimed to analyze their lipidomic profiles for their regenerative properties. METHODS: Microfat and nanofat samples were isolated from 14 healthy patients. Lipidomic profiling was performed by liquid chromatography tandem mass spectrometry. The resulting data were compared against the Human Metabolome and LIPID MAPS Structure Database. MetaboAnalyst was used to analyze metabolic pathways and lipids of interest. RESULTS: From 2388 mass-to-charge ratio features, metabolic pathway enrichment analysis of microfat and nanofat samples revealed 109 pathways that were significantly enriched. Microfat samples revealed higher-intensity levels of sphingosines, different eicosanoids, and fat-soluble vitamins. Increased levels of coumaric acids and prostacyclin were found in nanofat. CONCLUSIONS: This is the first study to analyze the lipidomic profiles of microfat and nanofat, providing evidence that mechanical emulsification of microfat into nanofat leads to changes in their lipid profiles. From 109 biological pathways, antiinflammatory, antifibrotic, and antimelanogenic lipid mediators were particularly enriched in nanofat samples when compared with microfat. Although further studies are necessary for a deeper understanding of the composition of these specific lipid mediators in nanofat samples, the authors propose that they might contribute to its regenerative effects on tissue. CLINICAL RELEVANCE STATEMENT: Profiling the unique lipid mediators in nanofat and microfat enhances our understanding of their different therapeutic effects and allows us to link these specific mediators to antiinflammatory, pro-regenerative, or healing properties. Ultimately, this insight can advance personalized therapeutic strategies, where a specific type of fat is selected based on its optimal therapeutic effect.

Lipidomic analysis of microfat and nanofat reveal different lipid mediator compositions.

BACKGROUND: Microfat and nanofat are two commonly used techniques in various surgical procedures from skin rejuvenation to scar correction that are known to contribute to tissue regeneration. While microfat mainly contains adipocytes and is well suited for tissue augmentation, nanofat is rich in lipids, adipose derived stem cells, microvascular fragments, and growth factors, making it attractive for esthetic use. We have previously demonstrated that the mechanical processing of microfat into nanofat significantly changes its proteomic profile. Considering that mechanical fractionation leads to adipocyte disruption and lipid release, we aimed to analyze the lipidomic profile for its regenerative properties. METHODS: Microfat and nanofat samples were isolated from fourteen healthy patients. Lipidomic profiling was performed by liquid chromatography tandem mass spectrometry. Resulting data was compared against the Human Metabolome and LIPID MAPS® Structure Database. Metaboanalyst was used to analyze metabolic pathways and lipids of interest. RESULTS: From 2,388 mass-to-charge ratio features, metabolic pathway enrichment analysis between microfat and nanofat samples revealed 109 pathways that were significantly enriched. While microfat samples revealed higher intensity levels of sphingosines, different eicosanoids and fat-soluble vitamins, increased levels of coumaric acids and prostacyclin were found in nanofat. CONCLUSIONS: This is the first study that has analyzed the lipidomic profile of micro- and nanofat, providing evidence that mechanical emulsification of microfat into nanofat leads to changes in their lipid profile. From 109 biological pathways, anti-inflammatory, anti-fibrotic and anti-melanogenic lipid mediators were particularly enriched in nanofat samples when compared to microfat. Although further studies are necessary to have a deeper understanding on the composition of these specific lipid mediators in nanofat samples, we propose that they might contribute to its regenerative effects on tissue.

Learning curve of robotic assisted microsurgery in surgeons with different skill levels: a prospective preclinical study.

Achieving precision in microsurgery requires skill, adequate instruments and magnification, as well as extensive training. Dedicated surgical robotic systems have enhanced and expanded the application of (super-)microsurgical techniques by introducing motion scaling and providing improved surgeon ergonomics. In this prospective preclinical trial, we analyzed the learning curve in robotic assisted microsurgery in 13 participants including medical students, residents, and attending physicians. Data on demographics as well as prior experience in surgery, microsurgery, and gaming were collected. In three study sessions, the participants performed nine microsurgical anastomoses each on 2 mm vessel models using the Symani® Surgical System in combination the VITOM 3D exoscope. A senior expert microsurgeon reviewed the de-identified and blinded videos and scored all anastomoses using a modified "Structured Assessment of Microsurgical Skills" (SARMS) score. All participants significantly reduced their time needed per anastomosis and their overall SARMS score, as well as individual scores for motion and speed throughout the trial. We saw a significant correlation of prior years of practice in surgery with the overall mean time and mean SARMS score. In a separate analysis of the three sessions, this influence could no longer be seen in the last session. Furthermore, we found no significant effect of gender, age, hand dominance, or gaming experience on speed and quality of the anastomoses. In this study of 117 robotic assisted anastomoses, a rapid improvement of performance of all participants with different surgical skills levels could be shown, serving as encouraging evidence for further research in the implementation of microsurgical robotic systems.

Arm lymphedema after vascularized lymph node harvest following Covid-19 vaccination.

There is evidence that COVID-19 vaccines may affect the lymphatic system. We report a case of a 40-year-old female who had undergone lymph node transfer for treating primary lymphedema of the legs. Six months later, the patient developed lymphedema of the right arm closely related to mRNA vaccination against COVID-19.

Outcomes of Fat Grafting in the Active Versus Quiescent Phase of Localized Scleroderma.

Introduction: Progressive hemifacial atrophy (PHA) and linear scleroderma (LS) are both rare conditions and defined by atrophy and/or sclerosis of the skin and subcutaneous tissue. The ideal timing of reconstructive intervention in these patients is controversial. We compared the outcome and satisfaction of autologous lipofilling performed during active and stable phases of the diseases in adults. Methods: A retrospective chart review was conducted with all patients diagnosed with PHA or LS between 2007 and 2019 in our department. We analysed demographic data, clinical features, and surgical procedures. The changes in symmetry, volume and skin texture were rated by surgeons at 1 week, 3 months and 6 months compared to the preoperative presentation. We compared the outcomes of patients treated during the active and the stable phase of the disease. Additionally, patients were asked to fill out a quality-of-life questionnaire. Results: We found a total of 11 patients diagnosed with PHA and LS, 8 of whom had undergone autologous fat injections to correct facial asymmetry. Of those, 4 patients were treated in their active and 4 in their stable phase. We found similar treatment outcomes in both groups. The social component had the greatest negative effect on patient's quality of life. Conclusion: In this small cohort, autologous fat grafting during the active phase did not appear to be inferior to fat grafting during the stable phase. It could be a safe technique for correction of PHA and LS during the active phase of disease.

Introduction: L'hémiatrophie faciale progressive (HFP) et la sclérodermie linéaire (SL) sont toutes deux des affections rares définies par l'atrophie ou la sclérose de la peau et des tissus sous-cutanés. Le moment idéal pour procéder à une intervention reconstructive chez ces patients. Les auteurs comparent les résultats et la satisfaction associés à un lipofilling autologue effectué pendant les phases active et stable de la maladie chez les adultes. Méthodologie: Les auteurs ont procédé à une analyse rétrospective des dossiers de tous les patients ayant obtenu un diagnostic d'HFP ou de SL entre 2007 et 2019 au sein de leur département. Ils ont analysé les données démographiques, les caractéristiques cliniques et les interventions chirurgicales. Les chirurgiens ont évalué les changements de symétrie, du volume et de la texture de la peau par rapport à la présentation préopératoire au bout d'une semaine, de trois mois et de six mois. Les auteurs ont comparé les résultats chez les patients traités pendant les phases active et stable de la maladie. De plus, les patients ont été invités à remplir un questionnaire sur leur qualité de vie. Résultats: Les auteurs ont recensé un total de onze patients ayant un diagnostic d'HFP ou de SL, dont huit ont subi des injections de graisse autologues pour corriger une asymétrie faciale. De ce nombre, quatre ont été traités pendant la phase active et quatre, pendant la phase stable. Les auteurs ont observé des résultats thérapeutiques semblables dans les deux groupes. L'aspect social avait l'incidence la plus négative sur la qualité de vie des patients. Conclusion: Dans cette petite cohorte, la greffe de graisse autologue pendant la phase active ne semblait pas donner de moins bons résultats que la greffe de graisse pendant la phase stable. Cette technique pourrait être sécuritaire pour corriger une HFP ou une SL pendant la phase active de la maladie.

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.

Analysis of different outcome parameters and quality of life after different techniques of free vascularized lymph node transfer.

OBJECTIVE: Vascularized lymph node transfer (VLNT) has become an important surgical technique in the treatment of lymphedema. Considering the different available regions available for flap harvest, we aimed to analyze different donor sites for VLNT with respect to donor site morbidity, impact on limb volume, and patient-reported outcome measurements (PROMs). METHODS: A single-center prospective study of all patients undergoing VLNT at the Department of Plastic Surgery and Hand Surgery of the University Hospital Zurich between September 2016 and 2023 was conducted. Lymph nodes were harvested either from the omentum (gastroepiploic [GE]-VLNT), the lateral thoracic wall (LTW), or the superficial inguinal region (SI-VLNT). Volume measurements and PROMs were assessed preoperatively and at different postoperative intervals. RESULTS: Overall, 70 patients with upper limb lymphedema (21%) or lower limb lymphedema (79%) with different lymphedema stages were included. There were 49 patients who underwent GE-VLNT, followed by LTW-VLNT (n = 16) and SI-VLNT (n = 5). Lymph node harvest from the SI was associated with a significantly higher frequency of seroma development. The average percentage volume loss related in comparison to the preoperative volume of the affected limb was 9% after GE-VLNT, 10% after LTW-VLNT, and 5% after SI-VLNT without a significant difference between the groups. PROMs revealed significant improvements for physical functioning, symptoms and psychological well-being, with no differences between the VLNT techniques. CONCLUSIONS: VLNT leads to a significant improvement of quality of life and can decrease limb volume effectively, regardless of the selection of donor site. GE-VLNT has become our flap of choice owing to its low donor site morbidity and its properties that allow a double transplantation while avoiding a second donor site.

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.

Robotic-assisted Lymphovenous Anastomosis of the Central Lymphatic System.

Background: Recent advances in robotic microsurgery have enabled the application of robotic technology in central lymphatic reconstruction. Although the use of microsurgical robots demands careful consideration of associated costs and potentially prolonged operating times, it may offer improved surgical approaches and enhanced accessibility to deeper anatomical structures such as the thoracic duct (TD). Methods: We report on successful reconstruction of the central lymphatic system using the Symani Surgical System in four patients with lesions of the central lymphatic system. The patients were of different age (range: 8 mo-60 y) and had variable conditions, including central conducting lymphatic anomaly and other rare anomalies of the central lymphatic pathways. Results: Depending on the underlying pathology, a cervical access (n = 1) or median laparotomy (n = 3) was chosen to access the TD and perform anastomosis with a nearby vein. In all patients, anastomoses were patent, and chyle leakage decreased postoperatively. From a surgical perspective, the Symani Surgical System improved the precision of the microsurgeon and accessibility to the deep-lying TD. Conclusion: Considering the high morbidity and rarity of pathologies of the central lymphatic system, robotic-assisted microsurgery holds substantial promise in expanding and improving the microsurgical treatment for central lymphatic anomalies.