Preclinical Performance of the Combined Application of Two Robotic Systems in Microsurgery: A Two-center Study.

Background: Recent advancements in the development of robotic devices increasingly draw the attention toward the concept of robotic microsurgery, as several systems tailored to open microsurgery are being introduced. This study describes the combined application of a novel microsurgical robot, the Symani, with a novel robotic microscope, the RoboticScope, for the performance of microvascular anastomoses in a two-center preclinical trial. Methods: Six novices, residents, and experienced microsurgeons (n = 18) performed five anastomoses on 1.0-mm-diameter silicone vessels with a conventional versus combined robotic approach, resulting in 180 anastomoses. Microsurgical performance was evaluated, analyzing surgical time, subjective satisfaction with the anastomosis and robotic setup, anastomosis quality using the anastomosis lapse index score, microsurgical skills using the Structured Assessment of Microsurgery Skills score, and surgical ergonomics using the Rapid Entire Body Assessment score. Results: All participants significantly improved their performance during the trial and quickly adapted to the novel systems. Surgical time significantly decreased, whereas satisfaction with the anastomosis and setup improved over time. The use of robotic systems was associated with fewer microsurgical errors and enhanced anastomosis quality. Especially novices demonstrated accelerated skill acquisition upon robotic assistance compared with conventional microsurgery. Moreover, upper extremity positioning was significantly improved. Overall, the robotic approach was subjectively preferred by participants. Conclusions: The concept of robotic microsurgery holds great potential to improve precision and ergonomics in microsurgery. This two-center trial provides promising evidence for a steep learning curve upon introduction of robotic microsurgery systems, suggesting further pursuit of their clinical integration.

Minimally Invasive Robotic-assisted Perforator-to-Perforator DIEP Flap Breast Reconstruction.

Reducing morbidity has been the goal of many reconstructive microsurgery efforts. Several techniques have been described for deep inferior epigastric perforator flap breast reconstruction to minimize abdominal donor-site morbidity. Although these techniques have certain tradeoffs, we designed a minimally invasive robot-assisted perforator-to-perforator approach to achieve minimal donor- and recipient-site morbidity. Simultaneous identification of the deep inferior epigastric artery (DIEA) and internal mammary artery (IMA) perforator was performed, followed by a small fascial incision around the dominant DIEA perforator. The IMA perforator was prepared for a prepectoral anastomosis. The short DIEA pedicle was dissected without further longitudinal fascial incision until an adequate diameter compared with the IMA perforator was reached, and a robot-assisted perforator-to-perforator anastomosis was performed prepectorally. All patients underwent reconstruction performed by a single surgeon. The smallest abdominal incision was 2.5 cm with a DIEP pedicle length of 6 cm. The average IMA perforator diameter was 1.14 mm (1.0 mm-1.2 mm). The average vein diameter was 2.0 mm (1.5-3.0 mm). The incision to closure lasted 330 minutes (313-348 minutes). Flap ischemia was 105 minutes (82-118 minutes), whereas the time for robot-assisted anastomosis was 25 minutes (22-30 minutes). All anastomoses were performed successfully. Our initial experience with robot-assisted perforator-to-perforator anastomosis for DIEP flap breast reconstruction demonstrates promise in achieving minimal patient morbidity. Raising only a very short pedicle can be compensated by adding the prepectoral IMA perforator length and enabling a good size match for small-caliber anastomosis. This technique combines important aspects of most minimally invasive DIEP flap harvests and insets.

One versus two vein anastomoses in breast reconstruction with a profunda artery perforator flap-does it make a difference.

BACKGROUND: The profunda artery perforator (PAP) flap has gained popularity as a reliable alternative in breast reconstruction. Extensive research has focused on its vascular supply, dissection techniques, and broader applications beyond breast reconstruction. This study aims to investigate the correlation between the number of veins anastomosed for the PAP flap and postoperative complications. METHODS: A retrospective study was conducted to evaluate the outcomes of breast reconstructions with PAP flaps at our institution between 2018 and 2022. A total of 103 PAP flaps in 88 patients were included. Statistical analysis was performed to compare outcomes between flaps with one vein anastomosis and those with two vein anastomoses. Patient characteristics, intra and postoperative parameters were analysed. RESULTS: One vein anastomosis was used in 36 flaps (35.0%), whereas two vein anastomoses were used in 67 flaps (65.0%). No significant differences were found in patient characteristics between the one vein and two vein groups. The comparison of ischemia times between flaps with one versus two veins revealed no statistically significant difference, with mean ischemia times of 56.2 ± 36.8 min and 58.7 ± 33.0 min, respectively. Regarding outcomes, there were no statistically significant differences in secondary lipofilling, revision of vein anastomosis, or total flap loss between the two groups. Fat necrosis was observed in 5 (13.9%) one vein flaps and 5 (7.5%) two vein flaps, indicating no statistically significant difference between the two groups (p = .313). In the one vein group, the most frequently employed coupler ring had a diameter of 2.5 mm. In the two vein group, the most prevalent combination consisted of a 2.0 mm diameter with a 2.5 mm diameter. CONCLUSION: Based on our study results, both one vein anastomosis and two vein anastomoses are viable options for breast reconstruction with PAP flap. The utilization of either one or two veins did not significantly affect ischemia time or flap loss. Fat necrosis exhibited a higher incidence in the single-vein group; however, this difference was also not statistically significant. These findings underscore the effectiveness of both approaches, providing surgeons with flexibility in tailoring their surgical techniques based on patient-specific considerations and anatomical factors.

Psychological well-being as a motive for and result of post-bariatric body contouring procedures.

Objective: This study investigates whether psychological well-being in post-bariatric patients seeking body contouring procedures differs from those who do not seek body contouring procedures, those who have already undergone body contouring procedures, and those who are unsure about body contouring procedures. Methods: An anonymous, nonrandomized, cross-sectional survey study was designed. Psychological well-being of four groups of post-bariatric-patients (undergone body contouring procedures, seeking body contouring procedures, not seeking body contouring procedures, unsure about body contouring procedures) were compared. Results: A total of 345 patients were included in this study. No significant difference between patients seeking body contouring procedures and those not seeking body contouring procedures was found with regard to depressive symptoms, self-esteem, and body image. Patients who had already undergone body contouring procedures scored lower on depressive symptoms (p = 0.035) and reported feeling more attractive (p < 0.001) and less insecure (p = 0.030) than patients who had not yet undergone body contouring procedures but sought it. Satisfaction with the result of the body contouring procedures was associated with lower depression levels (p < 0.001), higher self-esteem (p < 0.001) and a more positive body-image (p < 0.001). Conclusions: Depressive symptoms or low self-esteem are not motivational factors for post-bariatric patients to seek body contouring procedures. Body contouring procedures are associated with improvement in psychological well-being in post-bariatric patients. Patients' satisfaction with the result of the body contouring procedures is significantly associated with positive psychological well-being.

Patient-Reported Outcomes of Liposuction for Lipedema Treatment.

BACKGROUND: Lipedema, as a disabling and consequential disease, is gaining more awareness due to its potential omnipresence. Patients suffering from lipedema show a characteristic painful display of symmetric accumulations of adipose tissue. The combination of swelling, pain and decreased quality of life (QOL) is outstanding for the diagnosis. The aim of this study was to identify the effect of liposuction in terms of the QOL for patients and underline important factors of current and pending research regarding surgical therapy of lipoedema. METHODS: Patients suffering from lipedema prior to and after receiving liposuction at our hospital were included in this study. Patients completed a lipedema-specific self-designed 50 item questionnaire: the World Health Organization Quality of Life BREF (WHOQOL-BREF) and the Patient Health Questionnaire 9 (PHQ-9). A linear mixed model was used for outcome analysis. RESULTS: In total, 511 patients completed a questionnaire prior to the surgery at primary presentation to the hospital and a total number of 56 patients completed a questionnaire after liposuction. A total of 34 of these patients filled in both questionnaires prior to and after surgery. The general characteristics of the disease, such as daily symptoms and psychological health, pertinently improved after surgery. CONCLUSIONS: Liposuction can have a general improving effect on the QOL of patients, both in private and professional life. Liposuction may currently be the most evident and promising method in the treatment of lipedema.

Use of the superficial inferior epigastric vein in breast reconstruction with a deep inferior epigastric artery perforator flap.

Background: Autologous breast reconstruction is highly regarded in reconstructive surgery after mastectomy. DIEP flap reconstruction represents the gold standard for autologous breast reconstruction. The major advantages of DIEP flap reconstruction are its adequate volume, large vascular caliber and pedicle length. Despite reliable anatomy, there are procedures where the plastic surgeon's creativity is required, not only to shape the new breast, but also to overcome microsurgical challenges. An important tool in these cases is the superficial epigastric vein (SIEV). Methods: 150 DIEP flap procedures performed between 2018 and 2021 were retrospectively evaluated for SIEV use. Intraoperative and postoperative data were analyzed. Rate of anastomosis revision, total and partial flap loss, fat necrosis and donor site complications were evaluated. Results: In a total of 150 breast reconstructions with a DIEP flap performed in our clinic, the SIEV was used in 5 cases. The indication for using the SIEV was to improve the venous drainage of the flap or as a graft to reconstruct the main artery perforator. Among the 5 cases, no flap loss occurred. Conclusions: Use of the SIEV is an excellent method to expand the microsurgical options in breast reconstruction with DIEP flap surgery. It provides a safe and reliable procedure to improve venous outflow in cases of inadequate outflow from the deep venous system. The SIEV could also provide a very good option for fast and reliable application as an interposition device in case of arterial complications.

Mastopexy Strategies for Ptotic Breasts in Patients Choosing Autologous Reconstruction Following Prophylactic Mastectomy.

BACKGROUND: Autologous breast reconstruction is a reliable solution for many patients after mastectomy. While this technique represents a standardized approach in many patients, patients with ptotic breasts may require a combination of procedures to achieve an aesthetically pleasing result. METHODS: We reviewed the mastectomy and free-flap breast reconstruction procedures performed at our institution from 2018 to 2022 in patients with ptotic breasts. The technique used to address the ptosis was put in focus as we present the four strategies used by our reconstructive surgeons. We performed two different one-stage and two different two-stage procedures. The difference between the two-stage procedures was the way the nipple areola complex was treated (inferior dermal pedicle or free skin graft). The difference between the one-stage procedures was the time of execution of the mastopexy/breast reduction (before or after the mastectomy and autologous breast reconstruction). RESULTS: The one-stage procedure was performed with a free NAC in three patients and with a pedicled NAC in five patients. The two-stage procedure was performed in seven patients, with six of them undergoing mastopexy before and one patient undergoing mastopexy after the bilateral mastectomy and autologous reconstruction. No flap loss or total loss of the nipple areola complex occurred. Partial NAC loss was observed in five breasts in the single-stage group without any occurrence in the double-stage group. CONCLUSIONS: While both one- and two-stage procedures were performed in a safe fashion with satisfactory results at our institution, larger trials are required to determine which procedure may yield the best possible outcomes. These outcomes should also include oncological safety and patient-reported outcomes.

Breast Reconstruction with DIEP Flap: The Learning Curve at a Breast Reconstruction Center and a Single-Surgeon Study.

Although microsurgical breast reconstruction represents a very interesting and rewarding field of plastic surgery, appropriate microsurgical training is not possible in every plastic surgery department. In this retrospective study, we present the learning curve of our plastic surgery department as a whole and of a single microsurgeon assessing breast reconstruction procedures with a deep inferior epigastric artery perforator (DIEP) flap between July 2018 and June 2021. The present study included 115 patients and 161 flaps. Cases were stratified into single DIEP/double DIEP groups and into early and late groups based on the flap order. Surgery times and postoperative complications were analyzed. Regarding the institution, the length of hospital stay was lower in the late group than in the early group (single 7.1 ± 1.8 vs. 6.3 ± 1.5 days, p = 0.019; double 8.5 ± 3.8 vs. 6.6 ± 1.4 days, p = 0.043). Apart from that, no statistically significant differences were found between the start and end of our study. In terms of the single surgeon, there was a significant improvement in the total surgery time (single 296.0 ± 78.7 vs. 227.5 ± 54.7 min, p = 0.018; double 448.0 ± 85.6 vs. 341.2 ± 43.1 min, p = 0.008), flap ischemia time (53.6 ± 15.1 vs. 40.9 ± 9.5 min, p = 0.007) and length of stay among the compared groups. There was no significant difference in flap loss rate or other complications between the early and late groups. Further performance of surgeries seemed to improve the surgeon's skills as well as the overall experience of the medical institution.

Comparison of surgical and patient-reported outcomes between 85 profunda artery perforator flaps and 122 deep inferior epigastric perforator flaps as first-choice treatment for breast reconstruction.

BACKGROUND: The profunda artery perforator (PAP) flap for breast reconstruction was first published in 2012. Since then, many centers implemented its application as second-line treatment for breast reconstruction in cases where patient characteristics make the deep inferior epigastric perforator (DIEP) flap not feasible to perform. In our center, we established the PAP flap as a first-line procedure for a multitude of reasons for a specific patient population. This study describes perioperative measure, clinical outcomes, and patient-reported outcome measures in comparison to the gold standard, the DIEP flap. METHODS: In this study, we analyzed all PAP flaps and DIEP flaps performed in a single center between March 2018 and December 2020. We present patient characteristics, surgical technique, perioperative care, surgical outcomes, and complications. The Breast-Q was used to assess patient-reported outcome measures. RESULTS: A total of 85 PAP flaps and 122 DIEP flaps were performed within 34 months. Average follow-up was 11.6 ± 5.8 months for the PAP group and 11.1 ± 5.8 months for the DIEP group (p = 0.621). Patients' average body mass index was higher in the DIEP flap recipients. Operation time was shorter and ambulation faster in PAP flap recipients. DIEP flap application resulted in higher Breast-Q scores. CONCLUSIONS: While the PAP flap demonstrated favorable perioperative measures, outcome measures were better with the DIEP flap. The PAP flap is fairly new and demonstrates high potential while still showing a need for refinement compared to the DIEP flap.

The Influence of Obesity on Melanoma and Sentinel Lymph Node Diagnosis: A Retrospective Monocentric Study in 1001 Patients.

(1) Background: While obesity is a known independent risk factor in the development of melanoma, there is no consensus on its influence on melanoma prognosis. (2) Methods: In a monocentric retrospective study, data was collected from patients who underwent sentinel lymph node (SLN) biopsy for stage IB-IIC melanoma between 2013 and 2018. Patients were divided into groups according to their body mass index (BMI). The association between BMI and melanoma features, as well as the risk factors for metastases in SLN were examined. (3) Results: Of the 1001 patients, 336 had normal weight (BMI < 25), 402 were overweight (BMI >= 25 and <30), 173 obese (BMI >= 30 and <35) and 90 extremely obese (BMI >= 35). Overweightness and obesity were associated with higher tumor thicknesses at time of diagnosis. Ulceration was not influenced by the patient's weight. Metastases in sentinel lymph node was almost twice more likely in extremely obese patients than in normal weight patients. Independent risk factors for metastases in SLN in our study were tumor thickness, ulceration, and BMI > 35. (4) Conclusions: This is the first study to show higher metastases rates in high-BMI patients with melanoma, raising important questions regarding the screening and treatment of this specific patient population.

Tolerance Induction in Vascularized Composite Allotransplantation-A Brief Review of Preclinical Models.

Pre-clinical studies are an obligatory tool to develop and translate novel therapeutic strategies into clinical practice. Acute and chronic rejection mediated by the recipient's immune system remains an important limiting factor for the (long-term) survival of vascularized composite allografts (VCA). Furthermore, high intensity immunosuppressive (IS) protocols are needed to mitigate the immediate and long-term effects of rejection. These IS regiments can have significant side-effects such as predisposing transplant recipients to infections, organ dysfunction and malignancies. To overcome these problems, tolerance induction has been proposed as one strategy to reduce the intensity of IS protocols and to thereby mitigate long-term effects of allograft rejection. In this review article, we provide an overview about animal models and strategies that have been used to induce tolerance. The induction of donor-specific tolerance was achieved in preclinical animal models and clinical translation may help improve short and long-term outcomes in VCAs in the future.

Transgenic skin biomechanical properties following first lifesaving epidermal regeneration using combined gene and cell therapy.

BACKGROUND: In 2017, we reported the first life-saving regeneration of virtually an entire epidermis by combined gene and stem cell therapy. Recently, we demonstrated excellent long-term stability of this transgenic epidermis. Skin quality in this experimental approach and its potential application in other conditions were elucidated here regarding long-term outcomes of biomechanical properties. PATIENTS AND METHODS: Analysis of biomechanical properties including skin elasticity, anisotropy and friction was performed on multiple body sites 24, 36 and 60 months following transplantation. Firstly, the sites were matched against and compared to remaining stable non-transgenic areas as well as to a control group of 13 healthy subjects. Parameters for skin elasticity, deformation and friction were assessed non-invasively. RESULTS: Biomechanical properties of the transgenic epidermis showed encouraging results in comparison to both the remaining stable non-transgenic skin as well as healthy controls. Skin elasticity was comparable to the controls. Skin friction showed some decrease in both transgenic and non-transgenic areas as compared to the controls. CONCLUSIONS: The excellent functional outcomes of the transgenic epidermis demonstrate stable long-term results of this novel combined gene and stem cell therapy for epidermal regeneration. Thus, other applications for this technology, such as treatment of specific burns, should be explored.

[New Technologies in Microsurgery: Potential, Indications and Economical Aspects - Report of the Consensus Workshop of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels (DAM)]. / Neue Technologien in der Mikrochirurgie: Potential, Indikationen und ökonomische Aspekte ­ Konsensus-Bericht der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße (DAM).

Recently, several new technologies to support microsurgeons have received European market approval. This article summarizes and discusses the impressions of an expert panel to classify the potential of new technologies in terms of benefits for the surgeon, specific indications and economic aspects during the 42nd Annual Meeting of the German-speaking Working Group for Microsurgery of Peripheral Nerves and Vessels (DAM) in Graz, Austria. In general, the expert panel addressed the principles and prerequisite for the successful establishment of new technologies and, in particular, novel optical and robotic systems. For this purpose, the current scientific literature was reviewed and initial clinical experience in the context of case series and retrospective studies was presented by the members of the expert panel. In the ensuing discussion, it was pointed out that it will first be necessary to identify patient subgroups in which the use of the new technologies is most likely to achieve a clinical benefit. Since clinical approval has already been granted for some systems, an approach can be developed for immediate clinical application from the simplest possible use to ever finer applications, i. e. from microsurgery to supermicrosurgery. Initially, funding for cost-intensive systems would presumably not be possible through revenue from standard care, but only through grants or subsidized clinical trials. In a final survey, the majority of meeting participants see the need for a price reduction of both visualization and surgical robotics technologies to enable widespread clinical establishment. Likewise, a majority of participants would prefer a combination of an exoscope or robotic microscope and a surgical robot for clinical use. The present consensus work addresses the development of a strategy for the effective establishment of new technologies, which should further increase the surgical quality of selected interventions.

After weight loss, what skin removal procedure has the most effect using Body Q metrics?

BACKGROUND: Although postbariatric body contouring procedures have the ultimate goal of restoring quality of life, there currently exist minimal data assessing the effect of these procedures. OBJECTIVES: To identify the most important body contouring procedure for quality of life (QoL). SETTING: University Hospital, Online Questionnaire, Germany. METHODS: A cross-sectional study was designed using a validated version of the internet-based Body Q questionnaire, which was distributed among patients using social media and patient events. RESULTS: A total of 460 patients (443 female, 17 male) participated and fulfilled inclusion criteria. Of those patients, 191 (41.5%) had already undergone surgery, and the rest served as the control group. Patients in a postoperative status had a significantly (P < .05) higher QoL regarding all body regions. Additionally, patients who underwent body contouring surgery showed significantly higher QoL in regard to sexuality, society, body image, and psychosocial metrics. Abdominoplasty represents the most important procedure for QoL. The control group showed the greatest dissatisfaction in the area of the inner thighs. CONCLUSION: Body contouring procedures have been shown to significantly restore and enhance a patient's QoL. Conducting contouring surgeries is specifically associated with an increase in body image satisfaction as well as patient acceptance of certain body regions.

Characteristics and Patient Reported Outcome Measures in Lipedema Patients-Establishing a Baseline for Treatment Evaluation in a High-Volume Center.

Lipedema patients suffer not only from visual stigma but also reduction in their quality of life through pain and performance loss in daily life. In clinical practice, it is still difficult to reliably diagnose the disease. This study aims to provide further insights into the characteristics of lipedema patients of all stages and provide a baseline prior to surgery for a surgical treatment evaluation by means of patient-reported outcome measures. METHODS: Patients completed a lipedema-specific questionnaire containing 50 items, the World Health Organization Quality of Life BREF (WHOQOL-BREF) and the Patient Health Questionnaire 9 (PHQ-9). The data were analyzed using SPSS statistics 27. Patients who had already received liposuction were excluded. RESULTS: Five hundred and eleven patients were included, of whom 337 completed the PHQ9 and 333 completed the WHOQOL-BREF questionnaires. The general characteristics of lipedema patients, especially the daily symptoms, are described. Previous observations, such as the frequent occurrence of hypothyroidism and the low rate of type 2 diabetes, were confirmed. Over 49% suffer from severe impairments in their jobs, whereby the disease shows a familial accumulation. The results of the WHOQOL-BREF and the PHQ-9 suggest a high level of mental stress. DISCUSSION: As surgical intervention in lipedema patients is gaining traction, its effects should be well-documented. Therefore, a comprehensive baseline needs to be established prior to surgical treatment. The psychological components are just as important as the inclusion of daily impairments.

Free flap breast reconstruction using a novel robotic microscope.

INTRODUCTION: Robotic-assisted surgery (RAS) has evolved over the past decades. Currently, novel robotic systems for microsurgery are being launched onto the European market. This novel microscope (RoboticScope®, BHS, Innsbruck, Austria) is a high-definition camera system, connected to an augmented reality headset, projecting a clear image with high magnification in front of the surgeon's eyes. Motion tracking translates the surgeon's head movements onto the system via a multi-axis robotic arm. We report the first use of the robotic microscope for autologous breast reconstruction in humans. METHODS: In May 2020, ten autologous breast reconstructions were performed by our Team. Five reconstructions (three PAP flaps, one bilateral DIEP flap) were conducted with the robotic microscope and matched to five reconstructions using a conventional microscope. We compared ischaemia times, times for arterial and venous anastomosis, and complications. RESULTS: All procedures were performed successfully and safely. Overall time for anastomosis was 31 min (+/- 7 min) in the robotic group and 25 min (+/- 7 min, p = 0.30) in the control group. Flap ischaemia was 54 min (+/- 8 min) in the robotic group and 52 min (+/- 22 min, p = 0.87) in the control group. No intraoperative complications such as venous thrombosis or arterial embolism occurred. CONCLUSION: Robotic microscopes provide the technology to combine flexibility to choose different angles during pedicle preparation and improve the stationary procedure of vessel anastomosis. Novel robotic systems tailored towards refinement in microsurgery hold great potential for implementation in Plastic Surgery procedures.

Initial experience with the superficial circumflex iliac artery perforator (SCIP) flap for extremity reconstruction in Caucasians.

BACKGROUND: The superficial circumflex iliac artery perforator (SCIP) flap has been established in Asia to provide an excellent option for soft tissue defect coverage. The main advantage of this delicate flap is its very thin design. However, the adoption of this technique in other parts of the world has been rarely reported. METHODS: In this retrospective study, we analyzed outcomes of 32 SCIP flaps in a Caucasian patient population. The procedures were performed at our institution between March 2019 and August 2020. We present patient characteristics, surgical technique, perioperative care, and flap applications as compared to the Asian approaches. RESULTS: Patients' average BMI was 28.7. Flap anatomy and flap thickness at the superficial fascial plane differed significantly within our population. With 1.7 mm on average, the arterial diameter was higher than reported in the literature. Flaps were based on an axial perforator in 52% of cases. The SCIP flap was performed safely in the majority of cases. The surgical flap elevation approach was modified toward speedy perforator identification. CONCLUSIONS: The SCIP flap offers superior opportunities for thin soft tissue defect coverage with excellent functional outcomes in Caucasian patients. Based on higher BMI and anatomical differences as compared to Asian patient populations, modifications of flap elevation were necessary to increase reliability. More outcome reports from outside Asia need to become available to advance SCIP flap application internationally.