Transforming Lives: A Qualitative Study Seeking Insights Into Reconstructive Surgery for Leprosy Patients in Western Maharashtra.

Introduction Leprosy remains a significant health issue, especially in areas where diagnosis and treatment face numerous barriers, leading to preventable deformities and disabilities. This study aims to explore the obstacles to reconstructive surgery for leprosy patients, from both patient and healthcare provider perspectives. By conducting a qualitative analysis, the study seeks to assess the impact of reconstructive surgery on patients' quality of life, encompassing their physical, psychological, emotional, and social well-being. Methods This qualitative study was conducted from April to May 2024. One focus group discussion (FGD) for 12 participants, along with two in-depth interviews, was conducted for the patients at a leprosy rehabilitation center in western Maharashtra who have completed leprosy treatment and have undergone reconstructive surgeries for their disability. One in-depth interview was conducted with the key informant (a healthcare provider who is a surgeon who performs reconstructive surgeries for leprosy patients). Participants were selected through purposive sampling until information saturation was achieved. Interviews were conducted in local languages and analyzed using thematic analysis to identify key barriers and themes. Results A qualitative analysis of feedback from leprosy patients who underwent reconstructive surgery (RCS) highlights the importance of family support and the transformative impact of surgery on functionality and psychological well-being. Stigmatization and fear often delayed treatment-seeking behavior, but government incentives alleviated economic burdens, and participants expressed readiness to recommend RCS to others. Surgeons emphasize the variety of surgeries performed, eligibility criteria, recovery period, and success rate of 85-90%, noting the importance of financial accessibility and a multidisciplinary approach. Suggestions for improvement include infrastructure enhancement, adequate funding, and active case detection by the National Leprosy Eradication Programme (NLEP). Conclusion The findings highlight the complex interplay of factors contributing to delays in reconstructive surgery for leprosy patients in India. Addressing these barriers requires multifaceted interventions, including increasing public awareness, improving healthcare infrastructure, and enhancing support systems for patients. Policy development should focus on these areas to reduce disparities and improve the outcomes of reconstructive surgery in resource-limited settings.

Dr. John H. Charnley: An Architect and Pioneer of the Modern Era of Hip Replacement Surgery.

Dr. John H. Charnley (1924-1982) revolutionized orthopedic surgery with his groundbreaking innovations in hip replacement with exceptional skill and a holistic thought process, which has had an impact to this day in the world of arthroplasty. His innovations have improved the lives of numerous patients who had painful and discomforting arthritis and have been instrumental in providing painless mobile joints to these patients. This article reviews Charnley's contributions to the development of low-friction arthroplasty using ultra-high-molecular-weight polyethylene and the use of acrylic bone cement for improved implant fixation. These advancements dealt with the critical issues of friction, wear, and implant stability, significantly enhancing patient outcomes and implant longevity. Charnley's work led to the global standardization of hip replacement procedures, influencing orthopedic practices globally and setting benchmarks for modern implant designs. His principles continue to inform ongoing research and advancements in hip replacement technology. This review also discusses the challenges and criticisms faced by Charnley's innovations, reflecting on their evolution and impact on contemporary orthopedic surgery. A surgeon blessed with a noble heart who would help his patients who were in trouble by going out of the way and was determined for a better tomorrow, self-driven by his compassion and ambition for treating his patients. Charnley's legacy remains pivotal in shaping the field and improving the quality of life for patients undergoing hip replacement surgery.

Advances in Tissue Engineering and Its Future in Regenerative Medicine Compared to Traditional Reconstructive Techniques: A Comparative Analysis.

Tissue engineering represents a revolutionary approach in regenerative medicine, offering promising alternatives to traditional reconstructive techniques. This systematic review explores recent advances in tissue engineering, comparing their efficacy, postoperative outcomes, and patient satisfaction to conventional methods. A comprehensive literature search was conducted across PubMed, Cochrane Library, and Google Scholar, covering studies published from 2000 to 2024. Fourteen studies were selected for final analysis based on inclusion criteria focusing on outcomes such as scar quality, postoperative pain, and patient satisfaction. The review demonstrated that tissue engineering techniques consistently provided superior cosmetic outcomes with minimal scarring compared to traditional methods. Patients undergoing tissue-engineered procedures experienced mild-to-moderate postoperative pain with rapid resolution, whereas traditional techniques resulted in moderate to severe pain requiring extended management. Furthermore, patients treated with tissue engineering reported high satisfaction rates due to improved cosmetic and functional outcomes. Despite challenges such as ensuring adequate vascularization, controlling scaffold degradation, and overcoming regulatory and cost barriers, ongoing research and development are essential to fully realize the potential of these innovative therapies. Tissue engineering offers significant advantages over traditional reconstructive techniques and has the potential to profoundly improve patient care in regenerative medicine.

Robotic-assisted laparoscopic modified ureteroplasty using lingual mucosa grafts or appendiceal flaps for the management of complex ureteral strictures: a retrospective cohort study.

OBJECTIVE: To evaluate the feasibility, safety and efficacy of robot-assisted laparoscopic modified ureteroplasty using a lingual mucosa graft (LMG) or an appendiceal flap (AF) for complex ureteral strictures and summarize our experience. METHODS: A total of 16 patients with complex ureteral strictures (range: 1.5-5 cm) who underwent robotic-assisted laparoscopic-modified ureteroplasty and were admitted to our hospital from May 2022-October 2023 were retrospectively analyzed. We used modified presuture methods in patients who needed the posteriorly augmented anastomotic technique to reduce anastomotic tension. Perioperative variables and outcomes were recorded for each patient. RESULTS: The operation under robot-assisted laparoscopy was successfully performed in all sixteen patients (12 with LMG ureteroplasty and 4 with AF ureteroplasty) without conversion to open surgery. The mean length of the ureteral structure was 2.90 ± 0.90 cm (range: 1.5-5 cm), the mean operation duration was 209.69 ± 26.74 min (range: 170-255 min), the median estimated blood loss was 75 (62.5) ml (range: 50-200 ml), and the duration of postoperative hospitalization was 10.44 ± 2.10 d (range: 7-14 d). The follow-up time in this group was 6 ~ 21 months. The success rate of the surgery was 100%. CONCLUSION: Robot-assisted laparoscopic modified ureteroplasty using AF or LMG is a safe and feasible operation for complex ureteral strictures and deserves to be popularized.

[Peripheral nerve grafting]. / Nerventransplantation.

OBJECTIVE: Peripheral nerve lesions often lead to significant and permanent loss of motor and sensory function. The aim of peripheral nerve grafting is to bridge nerve defects. INDICATIONS: When tension-free nerve repair is not possible, peripheral nerve grafting is indicated. CONTRAINDICATIONS: Local infection, insufficient soft tissue coverage, significant muscle atrophy or joint contraction in case of "motor" nerve grafting, lack of microsurgical instruments or experience, life-threatening injuries. SURGICAL TECHNIQUE: Exposure and preparation of the nerve stumps. Choosing and preparation of the donor nerve. Approximation. Nerve repair. Nerve reconstruction must always be tension-free as nerve repair with tension frequently leads to disruption of nerve healing and poor functional outcome. Autologous nerve grafting from various donor sites leads to excellent functional results with little sensory deficits at the donor regions. POSTOPERATIVE MANAGEMENT: Limited immobilization, physiotherapy, ergotherapy, regular clinical and neurological assessments. RESULTS: Outcome of peripheral nerve grafting may, for example, depend on defect length, caliber and quality of the injured nerve, quality of the donor nerve, microsurgical expertise of the surgeon, time of reconstruction, and age of the patient.

A Novel Sliding Knot Technique Without a Knot Pusher for Laparoscopic Pelvic Floor Surgery.

INTRODUCTION AND HYPOTHESIS: Challenges in intracorporeal knot tying can be addressed with extracorporeal slip knots, simplifying the process of tying and managing tissue tension using a knot pusher. However, existing extracorporeal knot techniques are difficult owing to their complexity, the finesse required with thin yarns, and extensive training needs. We developed a new laparoscopic extracorporeal slip knot technique that can be used with a conventional needle driver or standard clamps, offering the advantages of being cost-effective and easy to learn. METHODS: The technique involves passing the active strand over another loop and securing it with the nondominant hand. A Kelly clamp is then wound around both loops three times in a tornado-like motion, passing the instrument over the active loop and under the passive one, and grasping the active strand. The passive strand is pulled to approximate the knot to the tissue and is tightened by the tension of the passive strand. RESULTS: This method has proven effective in various laparoscopic procedures such as sacrocolpopexy, colposuspension, pectopexy, myomectomy, and hysterectomy, facilitating surgeries without complications. CONCLUSIONS: The tornado knot technique is a feasible and safely locked sliding extracorporeal knot that can be easily learned, especially by surgeons who are accustomed to open surgery.

Justinian Rhinotmetos: A Byzantine Rhinoplasty?

In the eighth century, Justinian II was overthrown from his position as ruler of the Byzantine Empire. The young ruler's nose was amputated, and he was exiled. Ten years later, he regained the throne in a bloody coup. For decades, researchers have debated if Justinian also regained his nose through the ancient Indian rhinoplasty surgical technique, largely based on the Carmagnola statue in modern Venice. While a fascinating possibility, we ultimately conclude that it is highly unlikely that this ever occurred.

Management of the Crooked Nose: Structural, Preservation, or Camouflage Techniques.

The asymmetric nose is challenging for even the most experienced rhinoplasty surgeons. It has often been referred to as the crooked, twisted, and deviated nose and describes any nose that has deviation of the nasal dorsum and pyramid from the facial midline. This article summarizes the senior author's (SPM) approach and application of structural and preservation concepts to correct the underlying causes of the crooked nose.

Reduction cheiloplasty with lateral wedge excisions in cheilitis granulomatosa.

This case presents a method of reductive cheiloplasty: Conway's method with lateral and bilateral wedge excisions contained to the vermillion. It was performed on a female patient with cheilitis granulomatosa after 4 years of trying different medical therapies without effect. The surgery successfully reduced the increased volume, facilitating improved aesthetics and function while preserving oral function, muscle strength as well as sensitivity with no recurrence at the 15-month follow-up. We encourage early collaboration between dermatologists and plastic surgeons regarding the timing of a potential surgery when treating cheilitis granulomatosa.

Parents caring and sham-feeding their child born with Esophageal atresia at home while waiting for reconstructive surgery.

PURPOSE: For children with Esophageal atresia who have to wait for reconstructive surgery, long hospital stay, delayed introduction of oral feeds and hampered oro-motor function has traditionally been draw-backs for this treatment as the patients have minimal training of oro-motor function while waiting for surgery. In this paper, we present the concept of sham-feed at home awaiting reconstructive surgery with the aim to obliviate these problems. The aim was to describe the characteristics of patients with Esophageal atresia waiting for reconstructive surgery sham-feeding at home by their parents and further describe adverse events that arose. METHODS: The study is a retrospective descriptive single center study on all children with a delayed reconstruction of Esophageal atresia who was sham-fed by their parents at home before reconstructive surgery between January 2010 and January 2023 at the Karolinska University Hospital, Stockholm. RESULTS: Nine patients where home waiting for reconstructive surgery for a median of 72 days. No adverse events were reported related to the sham-feed procedure at home. The children had reconstructive surgery at a median 120 days of age. Five of the children ate full meals orally day 8-27 after surgery. Two children ate fully before 1 year after surgery. Two children had surgery less than 1 year ago and were not eating fully orally at the time of data collection. CONCLUSION: Sham-feeding at home by the parents was safe and feasible with the benefits of a prolonged time out of hospital awaiting reconstructive surgery.

Unresectable squamous cell carcinoma in a patient with spina bifida.

Spina bifida is a congenital malformation of foetal neural structures which may present as a skin fold or sac containing cerebrospinal fluid and neural structures with a variety of neurological deficits. Surgical repairs of spina bifida may not ensure complete functions, neural improvement or recovery. We present this palliative report of an adult male in his early 40s with a medical history of meningocele repair in his infancy, with long-standing Marjolin ulcers, fractures, contractures, diverting ileostomy and urostomy and a fungating mass externally measuring 33×25 cm. The mass involved the buttocks, perineum and scrotum with a tumour overlying the meningocele and extending into the thigh through an internally draining tract. Factors such as immobility, pressure injuries and poor social support in the setting of chronic disability led to a conservative approach in the management of this unresectable carcinoma.

Von Willebrand Factor Antigen, Biomarkers of Inflammation, and Microvascular Flap Thrombosis in Reconstructive Surgery.

Background: Microvascular flap surgery has become a routine option for defect correction. The role of von Willebrand factor antigen (VWF:Ag) in the pathophysiology of flap complications is not fully understood. We aim to investigate the predictive value of VWF:Ag for microvascular flap complications and explore the relationship between chronic inflammation and VWF:Ag. Methods: This prospective cohort study included 88 adult patients undergoing elective microvascular flap surgery. Preoperative blood draws were collected on the day of surgery before initiation of crystalloids. The plasma concentration of VWF:Ag as well as albumin, neutrophil-to-lymphocyte ratio (NLR), interleukin-6, and fibrinogen were determined. Results: The overall complication rate was 27.3%, and true flap loss occurred in 11.4%. VWF:Ag levels were higher in true flap loss when compared to patients without complications (217.94 IU/dL [137.27-298.45] vs. 114.14 [95.67-132.71], p = 0.001). Regression analysis revealed the association between VWF:Ag and true flap loss at the cutoff of 163.73 IU/dL (OR 70.22 [10.74-485.28], p = 0.043). Increased VWF:Ag concentrations were linked to increases in plasma fibrinogen (p < 0.001), C-reactive protein (p < 0.001), interleukin-6 (p = 0.032), and NLR (p = 0.019). Conclusions: Preoperative plasma VWF:Ag concentration is linked to biomarkers of inflammation and may be valuable in predicting complications in microvascular flap surgery.

The Clavien-Dindo Classification for Body-Contouring Surgery Complications: Evaluation of 602 Cases.

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.

Comparative Analysis of Commercially Available Extracellular Matrix Soft Tissue Bioscaffolds.

Decellularized extracellular matrix (dECM) products are widely established for soft tissue repair, reconstruction, and reinforcement. These regenerative biomaterials mimic native tissue ECM with respect to structure and biology and are produced from a range of tissue sources and species. Optimal source tissue processing requires a balance between removal of cellular material and the preservation of structural and biological properties of tissue ECM. Despite the widespread clinical use of dECM products there is a lack of comparative information on these products. This study provides a comparative analysis of 12 commercially available dECM products. One group of products consisted of materials intended for dermal repair including ovine forestomach matrix (OFMm), porcine peritoneum (PPN), porcine placenta (PPC), and porcine small intestinal submucosa (SISu). The second group, intended for load-bearing reconstruction, consisted of material derived from ovine forestomach matrix (OFMo), porcine urinary bladder matrix (UBM), porcine small intestinal submucosa (SISb and SISz), human dermis (ADM), porcine dermis (PADM), and fetal/neonatal bovine dermis (BADM). A minimally processed product consisting of human placental tissue was included as a control. Products were compared histologically and by agarose gel electrophoreses to assess structural features and decellularization. Structurally, some dECM products showed a well-preserved collagen architecture with a broad porosity distribution, whereas others showed a significantly altered structure compared with native tissue. Decellularization varied across the products. Some materials surveyed (OFMm, PPN, PPC, OFMo, UBM, SISz, ADM, PADM, and BADM) were essentially devoid of nuclear bodies (mean count of <5 cells per high-powered field [HPF]), whereas others (SISu and SISb) demonstrated an abundance of nuclear bodies (>50 cells per HPF). Pathology assessment of the products demonstrated that OFMm, OFMo, and PADM had the highest qualitative assessment score for collagen fiber orientation and arrangement, matrix porosity, decellularization efficiency, and residual vascular channels scoring 10.5 ± 0.8, 12.8 ± 1.0, and 9.7 ± 0.7 out of a maximum total score of 16, respectively. This analysis of commercially available dECM products in terms of their structure and cellularity includes 12 different commercial materials. The findings highlight the variability of the products in terms of matrix structure and the efficacy of decellularization.

Functional and Aesthetic Comparison between Grafts and Local Flaps in Non-Melanoma Skin Cancer Surgery of the Face: A Cohort Study.

Background: Non-melanoma skin cancers represent more than 90 % of malignant skin tumors, with an incidence of 19.46 cases/100,000 people per year in Italy; however, their real incidence is underestimated. Although there are several therapeutic strategies, the only one that can guarantee a 95 % healing rate and the possibility of performing histological examination is surgical excision with subsequent reconstruction of the injured area with direct closure and with skin graft, local, regional, or free flaps in cases involving greater damage. Material and Methods: Fifty-four patients underwent post-oncological head/face reconstructive surgery with skin graft or local flap between November 2021 and February 2023. The aesthetic outcomes (and the subsequent impact on the patients' lives) were assessed using the Vancouver Scar Scale, Manchester Scar Scale, and Visual Analog Scale with scars ranked by three independent surgeon observers. Results: Patients who received reconstruction with local flaps demonstrated improved aesthetic and functional satisfaction, as well as improved aesthetic evaluation by independent surgeons. Conclusions: The use of local flaps permits a more pleasing reconstruction (functionally and aesthetically) of post-oncological tissue defects of the face.

The prevalence and predictors of reconstructive surgery in pediatric burn care.

OBJECTIVE: This study aimed to examine the prevalence and predictors of reconstructive surgery among pediatric burn patients in the Netherlands. METHODS: Pediatric burn patients were identified through the Dutch Burn Repository R3. Eligibility criteria included a burn requiring hospital admission or surgical treatment at one of the Dutch burn centers in 2009-2019. First, patient, burn, and treatment characteristics were summarized using descriptive statistics. Second, time to the first reconstructive surgery was modelled using Kaplan Meier curves. Third, a prediction model was developed using univariate and multivariate logistic regression. The model's performance was assessed using calibration, discrimination, and explained variance. Fourth, internal validation was performed using bootstrapping. RESULTS: Approximately three percent (n = 84) of pediatric patients (n = 3072) required reconstructive surgery between the initial burn-related hospital admission and September 2021. Median time to the first reconstructive surgery was 1.2 (0.7-1.6) years. Most surgeries were performed on the face, arm, neck, hand, or anterior trunk, owing to contractures or hypertrophic scarring. Predictors of reconstruction included the etiology, anatomical site, extent of full-thickness burn, surgical treatment in the acute phase, and length of hospital stay. CONCLUSION: Our study provided an overview of the prevalence and independent predictors of reconstructive surgery in the pediatric burn population.

Reconstructive surgical therapy of peri-implant defects with ribose cross-linked collagen matrix and crosslinked hyaluronic acid - a prospective case series.

OBJECTIVE: To investigate the efficacy of ribose-crosslinked collagen (RCLC) matrices functionalized by crosslinked hyaluronic acid (xHya) for reconstructive treatment of class I and III (b-c) peri-implantitis lesions in a transmucosal healing mode. MATERIALS AND METHODS: Thirteen patients presenting with 15 implants were included in this prospective case series. Upon flap reflection, the implants were thoroughly decontaminated employing glycine powder air polishing and adjunctive sodium hypochlorite. For defect augmentation, xHyA was administered to the bony defect walls, exposed implant surfaces, and the RCLC matrix before defect grafting. The full-thickness flap was readapted and sutured around the implant neck for transmucosal healing. Baseline and respective values at the 12 months post-op evaluation were recorded for the clinical parameters peri-implant probing depth (PPD), buccal soft tissue dehiscence (BSTD) and bleeding on probing (BoP). Furthermore, two independent investigators analyzed radiographic changes in the defect area. The mean changes for all variables were analyzed with a paired t-test. RESULTS: The initial mean PPD was 7.2 ± 1.9 mm, and BoP was present in 63% of sites. After 12 months, PPD at the latest visit was 3.2 ± 0.66 mm, which amounted to a respective 3.9 ± 1.85 mm reduction, while the BoP frequency dropped to 10% at all sites. Radiographic bone fill was accomplished for 62.8% of the former defect area, accompanied by a mean MBL gain of 1.02 mm around the treated implants (all p < 0.001). CONCLUSIONS: Within the limits of this case series, we conclude that the proposed treatment sequence substantially improved peri-implant defects and offered a simplified but predictive technique. CLINICAL RELEVANCE: Reconstructive treatment approaches for peri-implantitis are effective but remain non-superior to open flap debridement. Further research on novel biomaterial combinations that may improve reconstructive treatment outcomes are warranted. Ribose-crosslinked collagen matrices biofunctionalized by hyaluronic acid used in this study yield improved clinical and radiographic peri-implant conditions after 12 months.

Postoperative Complications Following Reduction Mammaplasty in Relation to Patient Body Mass Index.

Background: Reduction mammaplasty is a common procedure that is performed for both aesthetic reasons and quality-of-life improvement. It is performed largely to help the patient achieve a proportionate breast size for their individual body type, with the goal of restoring anatomical proportionality and psychological wellness while reducing chronic neck, back, and shoulder pain. The common risks of breast reduction include bleeding, scarring, infection, poor wound healing, fat necrosis, nipple necrosis, and/or seroma. This study is designed to show that patients with a body mass index (BMI) of >30.0 kg/m2 are at higher risks for all complications. Methods: This retrospective study analyzed medical records of 236 patients who underwent breast reduction mammaplasty from January 2015 to February 2022 by a single surgeon at a single institution. Patients were divided into 2 groups based on their BMI: the non-obese group with a BMI ≤29.9 kg/m2 and the obese group with a BMI ≥30.0 kg/m2 and above. This study compares postsurgical outcomes and complications in relation to patient BMI. Results: Of 236 total patients, 104 (44%) had complications specified by predetermined criteria. Of those 104 patients with complications, 94 (90.38%) had a BMI ≥30.0 kg/m2. Predetermined complications were as follows: 24 patients (23.08%) experienced wound dehiscence, 23 of whom had a BMI ≥30.0 kg/m2; 9 patients (8.65%) experienced hematomas, all of whom had a BMI ≥30.0 kg/m2; 37 patients (35.58%) were found to have superficial wounds, 32 of whom had a BMI ≥30.0 kg/m2; 39 (37.5%) were found to have a seroma, 35 of whom patients were found to have a BMI ≥30.0 kg/m2; 25 patients (24.04%) experienced fat necrosis, 24 of whom had a BMI ≥30.0 kg/m2; 3 patients (2.88%) experienced nipple necrosis, all of whom had a BMI ≥30.0 kg/m2; 20 patients (19.23%) experienced infection, 19 of whom had a BMI ≥30.0 kg/m2. Conclusions: On the basis of data gathered and the statistics performed, patients with a BMI ≥30.0 kg/m2 were 4.86 times more likely to have postsurgical complications than those with a BMI <30.0 kg/m2.

Donor-site safety in microvascular lymph node transfer for breast cancer-related lymphedema using reverse lymphatic mapping-A prospective study.

BACKGROUND: Vascularized lymph node transfer (VLNT) is one option among other surgical treatments in the management of breast cancer-related lymphedema (BCRL). The cause of concern regarding VLNT harvested from the groin has been the potential development of secondary lower-extremity lymphedema. This study explored the risks associated with donor-site morbidity following groin VLNT, with or without concomitant breast reconstruction. METHOD: The cohort comprised data from the Lymfactin® Phase I and II trials, conducted from 2016 to 2019, that used perioperative reverse lymphatic mapping. The volume of the lower extremities was measured preoperatively and at 3, 6, and 12 months postoperative, and the adverse events were documented during study visits. RESULTS: Altogether, 51 women with a mean age of 55.5 years were recruited. The mean duration of BCRL was 31.8 months. Among these, 25 (49%) underwent VLNT (VLNT-group) and 26 (51%) underwent VLNT in combination with breast reconstruction (VLNT-BR group). The groups were similar in terms of age, (p = 0.766), BMI (p = 0.316), and duration of BCRL (p = 0.994). Across a period of one year, the volume difference between the lower extremities changed by 22.6 ml (range: -813 to 860.2 ml) (p = 0.067). None of the patients had lower-extremity volume difference exceeding 10% at the 12-month follow-up visit. The most frequent adverse events were postoperative pain (17.7%), wound healing issues (11.8%), and seroma formation (11.8%). Most adverse events (64.6%) were classified as minor. CONCLUSIONS: This prospective study demonstrated that groin VLNT with reverse lymphatic mapping appears safe and does not increase the risk of secondary donor-site lymphedema within one year postoperatively.

Three-dimensional virtual reality-assisted surgical planning for neuronavigated sacrectomy of a chordoma: a technical note.

PURPOSE: Sacral chordomas are slow growing but locally aggressive tumours with a high rate of local recurrence if not completely removed. Surgical resection with negative margins represents the most important survival predictor but it can be challenging to accomplish. Thanks to improvements in intraoperative imaging and surgical techniques, en bloc resection through a partial sacral resection with wide surgical margins has become feasible but it comes with a significant morbidity rate. In this technical note we detail the virtual reality-assisted surgical planning used during resection. METHODS: A 70-year-old patient underwent en bloc resection of the tumor by an antero-posterior two-stage surgery approach. Pre-operatively, based on MR- and CT-imaging, virtual objects were designed, representing the tumour, the surrounding bone and the neurovascular structures. This 3D-model was used to plan the well delimited partial sacral resection and the posterior surgical approach. Intraoperatively the instruments were registered, allowing for a real-time visualization of the tumor, of the neurovascular structures, and for an optimal margin control resection. RESULTS: Postoperatively the patient was intact in the lower extremities, without any deficit up to S1 roots. An intentional middle-low sacral amputation of S2-S5 roots was necessary to have a wide resection with free margins. At follow-up, the patient did not present any lower extremities motor deficit with an improvement of sensory function on S1 dermatome. CONCLUSION: Three-dimensional virtual reality-assisted surgical planning for neuronavigated sacrectomy in chordoma is useful, feasible and safe. This technology can increase surgeon's chances to perform a larger margin-free resection decreasing the risk of neurovascular damage.