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Background:  Within the last 20-years, Medicare reimbursements for microsurgery have been declining, while physician expenses continue to increase. As a result, hospitals may increase charges to offset revenue losses, which may impose a financial barrier to care. This study aimed to characterize the billing trends in microsurgery and their implications on patient care., Methods:  The 2013 to 2020 Provider Utilization and Payment Data Physician and Other Practitioners Dataset was queried for 16 CPT codes. Service counts, hospital charges, and reimbursements were collected. The utilization, weighted mean reimbursements and charges, and charge-to-reimbursement ratios (CRRs) were calculated. The total and annual percent changes were also determined., Results:  In total, 13 CPT codes (81.3%) were included. The overall number of procedures decreased by 15.0%. The average reimbursement of all microsurgical procedures increased from $618 to $722 (16.7%). The mean charge increased from $3,200 to $4,340 (35.6%). As charges had a greater increase than reimbursement rates, the CRR increased by 15.4%. At the categorical level, all groups had increases in CRRs, except for bone graft (-49.4%) and other procedures (-3.5%). The CRR for free flap breast procedures had the largest percent increase (47.1%). Additionally, lymphangiotomy (28.6%) had the second largest increases., Conclusion:  Our analysis of microsurgical procedures billed to Medicare Part B from 2013 to 2020 showed that hospital charges are increasing at a faster rate than reimbursements. This may be in part due to increasing physician expenses, cost of advanced technology in microsurgical procedures, and inadequate reimbursement rates. Regardless, these increased markups may limit patients who are economically disadvantaged from accessing care. Policy makers should consider legislation aimed at updating Medicare reimbursement rates to reflect the increasing complexity and cost associated with microsurgical procedures, as well as regulating charge markups at the hospital level., Competing Interests: None declared., (Thieme. All rights reserved.)

Background:  While the number of female plastic surgeons has continued to increase over time, plastic surgery has historically been a male-dominated profession with only 15% of practicing plastic surgeons being female. Microsurgery, as a subspecialty, has been long perceived as an even more male-centric career path. The objective of this study was to determine the representation of females in the subspecialty field of microsurgery and the impact of microsurgical fellowship training., Methods:  A review of all microsurgery fellowship programs participating in the microsurgery fellowship match from 2010 to 2019 were analyzed. Fellows were identified through fellowship Web site pages or direct contact with fellowship program coordinators and directors. The current type of practice and performance of microsurgery were also identified through a Web search and direct contact with fellowship program coordinators and directors., Results:  A total of 21 programs and 317 fellows over a 10-year period were analyzed. Over this 10-year period, there was a total of 100 (31.5%) female microsurgery fellows and 217 (68.5%) male microsurgery fellows. There was a small, statistically insignificant increase in the yearly percentage of female microsurgery fellows over this 10-year period with an average yearly increase of 2.7% ( p  = 0.60; 95% confidence interval: -6.9 to 13.2%). There were significantly fewer females who continued to practice microsurgery compared to males (75 [75.0%] vs. 186 [85.7%], p  = 0.02). There was no significant difference in the current practice types (academic, private, and nonacademic hospital) between females and males ( p  = 0.29)., Conclusion:  Women are underrepresented in the field of microsurgery to a similar extent as they are underrepresented in overall plastic surgery. While there is a small insignificant increase in the number of female microsurgery fellows every year, a significantly smaller proportion of females continue to practice microsurgery compared to males., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: This work aims to review the existing use of robotics in plastic surgery., Methods: A meticulous selection process identified 22 articles relevant to this scoping review., Results: The literature on the use of robotics in plastic surgery is sparse. Nonetheless, this review highlights emerging benefits in microsurgery, breast reconstruction, and transoral surgery., Conclusion: This scoping review identifies critical articles reporting the emerging use of robotics in plastic surgery. While the scientific medical community has yet to extensively document its use, the available evidence suggests a promising future for robotics in this field.

Objectives: Among the transsphenoidal (TSS) approaches to pituitary tumors, the microscopic approach (MA) has historically been the predominant technique with the increasing adoption of the endoscopic approach (EA). This study investigates national trends in TSS approaches and postoperative outcomes for MA and EA through 2021., Methods: The TriNetX database was queried for patients undergoing TSS (MA and EA) between 2010 and 2021. Data were collected on demographics, geographic distribution of surgical centers, postoperative complications, stereotactic radiosurgery (SRT), repeat surgery, and postoperative emergency department (ED) visits., Results: 8644 TSS cases were queried between 2010 and 2021. MA rates were highest until 2013 when rates of EA (52%) surpassed MA (48%) and continued to increase through 2021 (81%). From 2010 to 2015 EA had higher odds of a postoperative CSF leak (OR 3.40) and diabetes insipidus (DI (OR 2.30)) versus MA (p < 0.05); from 2016 to 2021 differences were not significant. Although there was no significant difference among approaches from 2010 to 2015 for syndrome of inappropriate antidiuretic hormone (SIADH), hyponatremia, or bacterial meningitis, from 2016 to 2021 EA had lower odds of SIADH (OR 0.54) and hyponatremia (OR 0.71), and higher odds of meningitis (OR 1.79) versus MA (p < 0.05). EA had higher odds of additional surgery (either EA or MA) after initial surgery from 2010 to 2021. From 2010 to 2015 EA had lower odds of postoperative SRT compared to MA, whereas in 2016-2021 there was no statistical difference among approaches., Conclusion: This study demonstrates increasing EA adoption for TSS in the United States since 2013. Complication rates have overall improved for EA compared to MA, potentially as a result of improving surgeon familiarity and experience., Level of Evidence: 4 Laryngoscope, 133:2135-2140, 2023., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Operating microscopes and adjunctive technologies are continually refined to advance microneurosurgical care. How frequently these advances are used is unknown. In the present study, we assessed the international adoption of microneurosurgical technologies and discussed their value., Methods: A 27-question electronic survey was distributed to cerebrovascular neurosurgeon members of U.S., European, and North American neurosurgical societies and social media networks of cerebrovascular and skull base neurosurgeons. The survey encompassed the surgeons' training background, surgical preferences, and standard microneurosurgical practices., Results: Of the respondents, 56% (53 of 95) were attendings, 74% (70 of 95) were in their first 10 years of practice, and 67% (63 of 94) practiced at an academic teaching hospital. Vascular, endovascular, and skull base fellowships had been completed by 38% (36 of 95), 27% (26 of 95), and 32% (30 of 95) of the respondents, respectively. Most respondents did not use an exoscope (78%; 73 of 94), a mouthpiece (61%; 58 of 95), or foot pedals (56%; 55 of 94). All 95 respondents used a microscope, and 71 (75%) used Zeiss microscopes. Overall, 57 neurosurgeons (60%) used indocyanine green for aneurysms (n = 54), arteriovenous malformations (n = 43), and dural arteriovenous fistulas (n = 42). Most (80%; 75 of 94) did not use fluorescence. The respondents with a vascular-focused practice more commonly used indocyanine green, Yellow 560 fluorescence, and intraoperative 2-dimensional digital subtraction angiography. The respondents with a skull base-focused practice more commonly used foot pedals and an endoscope-assist device., Conclusions: The results from the present survey have characterized the current adoption of operative microscopes and adjunctive technologies in microneurosurgery. Despite numerous innovations to improve the symbiosis between neurosurgeon and microscope, their adoption has been underwhelming. Future advances are essential to improve surgical outcomes., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: Aneurysmal subarachnoid hemorrhage has a high mortality with significant impact on quality of life despite effective management strategies including endovascular treatment and/or microsurgical clipping. Although the modalities have undergone clinical comparison, they have not been evaluated on patient-reported outcomes (PROs). This study compared endovascular versus microsurgical treatment using a PRO measure., Methods: We conducted a cross-sectional telephonic survey of adult patients conducted at Hamad General Hospital, Doha, Qatar between 2017 and 2019. Candidate study participants were identified from procedure logs and hospital electronic health records for endovascular treatment (N = 32) versus microsurgical clipping (N = 32) of cerebral aneurysm. The primary outcome measure was the short version of the Stroke-Specific Quality of Life (SS-QoL) measure. The secondary outcome measure was the screened clinician-reported modified Rankin Scale (mRS) for all screened patients (n = 137). Mean scores were compared for the 2 treatment groups., Results: The SS-QoL mean score was 4.23 (standard deviation ± 0.77) in endovascular treatment and 4.19 ± 0.19 in surgical clipping (P = 0.90). In exploratory analysis, mean physical domain score was 3.17 ± 0.60 versus 2.98 ± 0.66 in endovascular treatment and surgical clipping groups, respectively. Mean psychosocial domain scores were 4.43 ± 0.85 versus 4.18 ± 0.0.92, respectively. In multivariable analysis, none of the clinical variables were significantly related to SS-QoL except vasospasm irrespective of intervention received. In secondary outcome analysis, modified Rankin Scale score was higher for endovascular treatment (P = 0.04)., Conclusions: Published evidence has supported clinical benefits of endovascular treatment for cerebral aneurysm treatment, but this study did not find any difference in PROs. Future studies of treatments should include PRO to identify potential differences from the patient's perspective., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)

Study Design: Observational study., Objective: The aim of this study was to evaluate whether inflammatory and/or muscle regeneration markers in paraspinal tissues (multifidus muscle/fat) during microdiscectomy surgery in patients with lumbar disc herniation (LDH) with radiculopathy, differ between individuals with good or poor outcome., Summary of Background Data: Structural back muscle changes, including fat infiltration, muscle atrophy, and fiber changes, are ubiquitous with LBP and are thought to be regulated by inflammatory and regeneration processes. Muscle changes might be relevant for recovery after microdiscectomy, but a link between expression of inflammatory and muscle regeneration genes in paraspinal tissues and clinical outcome has not been tested., Method: Paraspinal tissues from deep multifidus muscles and fat (intramuscular, sub-cutaneous, epidural) were harvested from twenty-one patients with LDH undergoing microdiscectomy surgery. Quantitative polymerase chain reaction (qPCR) measured expression of 10 genes. Outcome was defined as good (visual analogue scale (VAS) low back pain (LBP)+) or poor (VAS LBP-) by an improvement of >33% or ≤33% on the pain VAS, respectively. Good functional improvement was defined as 25% improvement on the physical functioning scale (PFS)., Results: Brain-derived neurotrophic factor expression in deep multifidus was 91% lower (P = 0.014) in the VAS LBP- than VAS LBP+ group. Expression of interleukin-1β in subcutaneous fat was 48% higher (P = 0.026) in the VAS LBP- than VAS LBP+ group. No markers differed based on PFS., Conclusion: Results show a relationship between impaired muscle regeneration profile in multifidus muscle and poor outcome following microdiscectomy for LDH. Inflammatory dysregulation in subcutaneous fat overlying the back region might predict poor surgical outcome.Level of Evidence: 4., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Comparison in pediatric hemorrhagic arteriovenous malformations (AVMs) to clarify the long-term neurological outcomes and prognostic predictors after surgical intervention was relatively rare, especially in the selection of surgical timing. The objective of this study was to elucidate these points. The authors retrospectively reviewed the pediatric hemorrhagic AVMs resected in their neurosurgical department between March 2010 and June 2017. The natural history was represented by rupture risk. Neurological outcome was assessed with the modified Rankin Scale (mRS) for children. Multivariate logistic regression analyses were used to assess the risk factors for disability (mRS > 2). The hemorrhagic early phase was defined as less than 30 days after bleeding. The corresponding prognosis of different surgical timing (early intervention or delayed intervention) was compared after propensity-score matching (PSM). A total of 111 pediatric hemorrhagic AVM patients were evaluated. The average patient age was 11.1 ± 4.0 years, with a mean follow-up of 4.3 ± 2.1 years. The annualized rupture risk was 9.3% for the pediatric hemorrhagic AVMs, and the annualized re-rupture risk was 9.8%. 7.2% of the patients had disabilities (mRS > 2) and 82.0% achieved neurological deficit-free (mRS < 2) at the last follow-up. Pre-treatment mRS (P = 0.042) and flow-related aneurysms (P = 0.039) were independent factors for long-term disability. In terms of short-term outcomes, early intervention was better than delayed intervention (P = 0.033), but the long-term outcomes were similar between the two groups (P = 0.367). Surgical intervention for pediatric hemorrhagic AVMs is recommended, most of the patients can achieve good neurological outcomes. Moreover, early surgical intervention is preferred after the initial hemorrhage.

The long-term stability of coil embolization (CE) of complex intracranial aneurysms (CIAs) is fraught with high rates of recanalization. Surgery of precoiled CIAs, however, deviates from a common straightforward procedure, demanding sophisticated strategies. To shed light on the scope and limitations of microsurgical re-treatment, we present our experiences with precoiled CIAs. We retrospectively analysed a consecutive series of 12 patients with precoiled CIAs treated microsurgically over a 5-year period, and provide a critical juxtaposition with the literature. Five aneurysms were located in the posterior circulation, 8 were large-giant sized, 5 were calcified/thrombosed. One presented as a dissecting-fusiform aneurysm, 9 ranked among wide neck aneurysms. Eight lesions were excluded by neck clipping (5 necessitating coil extraction); 1 requiring adjunct CE. The dissecting-fusiform aneurysm was resected with reconstruction of the parent artery using a radial artery graft. Three lesions were treated with flow alteration (parent artery occlusion under bypass protection). Mean interval coiling-surgery was 4.6 years (range 0.5-12 years). Overall, 10 aneurysms were successfully excluded; 2 lesions treated with flow alteration displayed partial thrombosis, progressing over time. Outcome was good in 8 and poor in 4 patients (2 experiencing delayed neurological morbidity), and mean follow-up was 24.3 months. No mortality was encountered. Microsurgery as a last resort for precoiled CIAs can provide-in a majority of cases-a definitive therapy with good outcome. Since repeat coiling increases the complexity of later surgical treatment, we recommend for this subgroup of aneurysms a critical evaluation of CE as an option for re-treatment.

Brainstem hemangioblastomas are benign, highly vascular tumors located in the mesencephalon, pons, and medulla oblongata. Although surgical resection is currently considered the main therapeutic option for symptomatic lesions, evidence supporting the application of microsurgery has not been systematically assessed. This meta-analysis aims to evaluate the safety and efficacy of surgical treatment for brainstem hemangioblastomas. A comprehensive search of the PubMed, Embase, and Web of Science databases was performed to identify all English language publications reporting the outcomes of surgical treatment for brainstem hemangioblastomas. Studies from January 1990 to July 2019 with ≥ 10 cases were included. We analyzed the surgical outcomes, including gross total resection, mortality, neurological morbidity, and functional outcome according to the McCormick Scale or Karnofsky Performance Scale. Thirteen studies with 473 cases were included. The pooled proportion of gross total resection was 98% (95% confidence interval (CI), 94-100%). Overall mortality and neurological morbidity were 4 (95% CI, 2-6%) and 13% (95% CI, 7-20%), respectively. Favorable functional outcomes at the last follow-up were achieved in 85% (95% CI, 78-92%) of all patients. Improved or stable functional outcomes at long-term follow-up were achieved in 94% (95% CI, 89-97%) of patients. This meta-analysis revealed that surgical treatment for brainstem hemangioblastomas is technically feasible and effective with lasting patient benefits and cure.

Pineal region tumors are extremely deep-seated and surgically challenging. The exposure and visualization obtained by microscopic surgery are relatively limiting. The application of high-definition endoscopes has recently provided neurosurgeons with a much more magnified and clearer view of the anatomy in the pineal region. The present study was performed to compare endoscopic-assisted surgery (ES) with microsurgery (MS) for pineal region tumors. We retrospectively analyzed patients admitted to our hospital for treatment of pineal region tumors from January 2016 to June 2019. All patients consented to undergo tumor resection with ES or MS. We compared the extent of resection, postoperative rate of hydrocephalus, complications, and outcomes between the two groups to estimate the safety and efficacy of ES. In total, 41 patients with pineal region tumors were divided into 2 groups: the ES group (n = 20) and MS group (n = 21). The rate of gross total resection was significantly higher in the ES than MS group (90.0% vs. 57.1%, p = 0.04). The rate of postoperative hydrocephalus was significantly lower in the ES than MS group (11.8% vs. 52.9%, p = 0.03). No significant differences were found in complications or the Karnofsky Performance Score between the two groups. ES can be used to safely and effectively achieve complete resection of pineal region tumors. In patients with obstructive hydrocephalus, ES provides a new way to directly open the aqueduct for cerebrospinal fluid recovery following tumor resection.

Lasers have been used in otolaryngology for more than 40 years and are widely considered an established way of addressing laryngeal pathology, benign and malignant. Carbon dioxide (CO 2 ) laser is considered a gold standard, but over the last 2 decades, a new technology has been developed and established in other medical specialties, not so much in Ear Nose and Throat (ENT), the diode laser. It consists of a flexible fiber that passes through a hollow guidance system and is capable of reaching certain angled spots easier than straight beam systems. Portability, lower cost, easier setup, and improved photocoagulation are just some of the many features rendering it an excellent choice for the surgeon and the patient. The few studies published worldwide for the usage and efficacy of this system show no major differences related to the oncologic outcome and survival rate of patients having an early glottic tumor between diode laser microsurgery and CO 2 laser cordectomy. Nevertheless, the advantages offered by fiber-optic laser surgery render it a worthy and perhaps equal alternative for treating this kind of pathology.

The robotic platform offers theoretical and practical advantages to microsurgical male infertility surgery. These include reduction or elimination of tremor, 3-dimensional visualization, and decreased need for skilled surgical assistance. This article reviews the application of robotic surgery to each of the 4 primary male infertility procedures: vasectomy reversal, varicocelectomy, testicular sperm extraction, and spermatic cord denervation. Historical perspective is presented alongside the available outcomes data, which are limited in most cases. Before the robotic approach can be widely adopted, further clinical trials are needed to compare outcomes and costs with those of other validated surgical techniques., Competing Interests: Disclosure The authors have nothing to disclose., (Published by Elsevier Inc.)

Objective: To evaluate the incidence of nonconvulsive status epilepticus (NCSE) after surgery for ruptured intracranial aneurysms, to define factors associated with this complication, and to determine its impact on the outcome., Patients and Methods: Clinical and neurophysiological data of 66 patients with aneurysmal subarachnoid hemorrhage (aSAH) who underwent continuous EEG (cEEG) monitoring after microsurgical clipping (53 cases) or endovascular coiling (13 cases) of the ruptured aneurysm were analyzed retrospectively. The diagnosis of NCSE was based on the American Clinical Neurophysiology Society and Salzburg Consensus criteria., Results: NCSE was revealed in 10 patients (15 %), all of whom underwent craniotomy and aneurysm clipping. In comparison to the subgroup without NCSE, among those who were diagnosed with this complication there was a significantly greater proportion of men (70 % vs. 34 %; P = 0.041), cases with the Glasgow Coma Scale score at admission < 13 (90 % vs. 36 %; P = 0.004), the Hunt and Hess aSAH grades 3-5 (90 % vs. 45 %; P = 0.013), and hydrocephalus (70 % vs. 29 %; P = 0.044). In addition, they required a significantly longer hospital stay (medians, 62.5 vs. 39.5 days; P = 0.015) and showed trend for the lower rate of favorable disability outcomes (20 % vs. 54 %; P = 0.084)., Conclusions: NCSE is encountered rather often after the microsurgical clipping of ruptured intracranial aneurysms, especially in severely disabled patients with high-grade aSAH and/or associated hydrocpephalus, and may significantly affect the clinical course and prolong recovery. cEEG monitoring may be helpful for timely diagnosis and treatment of this complication., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Epidermoids cysts are relatively rare, benign, congenital tumours, representing from 0.3% to 1.8% of all intracranial lesions. When extradural, they are most commonly reported in the temporal or parietal bones as intradiploic lesions; when intradural their most common location is the cerebellopontine angle and less frequently the middle cranial fossa. Herein we present a unique case of an extradural-intraosseous epidermoid cyst of the anterior clinoid process, integrating our single-case experience into a focused literature review of these lesions, when located in the middle cranial fossa., Case Description: A 49 years old man came to our attention with history of head trauma. Urgent brain CT and elective brain MRI showed imaging suggestive for an anterior clinoid process epidermoid cyst. Through a pterional approach, the lesion was completely removed with microsurgical endoscope assisted technique. MRI at one year follow up showed no recurrence., Methods: Current literature on epidermoid cysts located in middle cranial fossa was reviewed. A total of 22 papers, containing 70 epidermoid cyst were selected for the review. Symptoms at presentation; anatomic location; surgical approach; extent of resection and recurrence; outcome after surgery and at follow up were analysed for each case., Conclusions: In the 70 published cases of middle fossa epidermoid cysts, the majority presented with trigeminal neuralgia. Most of the cases were operated through a pterional approach, while recent literature showed an increasing interest in endonasal endoscopic techniques. Subtotal resection is not a straight predictive value for recurrence; post-operative neurological deficits incidence is low and generally resolve at follow-up., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Learning Objectives: After reviewing this article, the participant should be able to: 1. Understand the trends in reconstruction using flaps. 2. Understand the surgical anatomy and elevation of the three best flaps: superficial circumflex iliac artery perforator, profunda artery perforator, and thin anterolateral thigh perforator. 3. Understand the core principle and the modern evolution of microsurgery. 4. Be acquainted with new microsurgical tips to maximize outcomes., Summary: Plastic surgery has a long history of innovation expanding the conditions we can treat, and microsurgical reconstruction has played a pivotal role. Freestyle free flaps now create another paradigm shift in reconstructive surgery, relying on a better understanding of anatomy and physiology, opening the door to patient-specific customized reconstruction. This article aims to provide information regarding useful and practical new advances in the field of microsurgery.

Objective: During the coronavirus disease 2019 (COVID-19) pandemic, neurosurgeons all around the globe continue to operate in emergency cases using new self-protective measures. Personal protective equipment (PPE) use is recommended in all surgeries. The authors have experienced varying degrees of field of view (FOV) loss under the surgical microscope with different PPE. Herein, they aimed to investigate the effects of different PPE on FOV while using the surgical microscope., Methods: Fifteen neurosurgeons and neurosurgery residents participated in this study. Three kinds of PPE (safety spectacles, blast goggles, and face shields) were tested while using a surgical microscope. FOV was measured using a 12 × 12-cm checkered sheet of paper on which every square had an area of 25 mm2 under the microscope. The surgical microscope was positioned perpendicular to the test paper, and the zoom was fixed. Each participant marked on the test sheet the peripheral borders of their FOV while using different PPE and without wearing any PPE. A one-way repeated-measures ANOVA was performed to determine if there was a significant difference in FOV values with the different PPE., Results: FOV was significantly different between each PPE (F[3, 42] = 6339.845, p < 0.0005). Post hoc analysis revealed a significant decrease in the FOV from the naked eye (9305.33 ± 406.1 mm2) to blast goggles (2501.91 ± 176.5 mm2) and face shields (92.33 ± 6.4 mm2). There were no significant FOV changes with the safety spectacles (9267.45 ± 410.5 mm2)., Conclusions: While operating under a surgical microscope safety spectacles provide favorable FOVs. Face shields increase the eye piece-pupil distance, which causes a severe reduction in FOV.

Objective: To evaluate the results of microsurgical clipping for single intracranial aneurysm (SIA) and multiple intracranial aneurysms (MIA) and compare the outcomes., Methods: All patients who underwent surgery for intracranial aneurysm (IA) at our institution over a 3-year period (June 2013 to May 2016) were included in this study., Results: A total of 157 patients with 225 IAs were included. Forty-one of these patients had MIA (109 IAs, mean, 2.7 ± 1.2; range, 2-7), and remaining 116 had SIA. In the patients with MIA, all aneurysms were secured during the same admission whenever possible. Depending on the locations of the IAs and condition of brain during surgery (tense/lax), all aneurysms were secured on same day (in a single session, single or multiple craniotomy in 28 patients) or on different days (multiple sessions in 13 patients). Postoperative control angiography (DSA) before discharge could be done for 216 aneurysms (MIA, n = 105; SIA, n = 111). Successful occlusion of the aneurysm from circulation was noted in 96.2% (101/105) of MIA and 93.7% (104/111) of SIA. Follow-up of 6 months or longer was available for 146 patients. A modified Rankin Scale score ≤2 was considered a good outcome. Univariate analysis of the entire group revealed no significant difference in clinical outcomes between patients with SIA and MIA both at discharge (good outcome: MIA, 82.9%; SIA, 93.1%; P = 0.068) and at a final follow-up of ≥6 months (good outcome: MIA, 87.2%; SIA, 94.4%; P = 0.164). Clipping for MIA was not associated with poor outcome in multivariate analysis., Conclusions: Comparable clinical outcomes and high rates of complete aneurysm occlusion following microsurgical clipping can be expected in patients with SIA and patients with MIA., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Spinal intradural tumors can be classified as intradural extramedullary or intramedullary tumors. Spinal meningiomas are among the most frequent intradural, extramedullary tumors (IDEMs), representing 12 % of all meningiomas and 25-45 % of all intradural spinal tumors., Objective: To evaluate postoperative outcome, defined by mortality, tumor recurrence and modified Rankin Scale in patients with spinal meningiomas. Furthermore, to identify factors related to these outcome measures and define possible prognosticators., Methods: A large single center retrospective analysis of 166 consecutive spinal meningioma patients during a 29-year period (1989-2018)., Results: Female to male ratio was 5.15 to 1. Of all 166 resected tumors, 159 were WHO grade I and seven were WHO grade II. Histopathologically, the psammomatous type was most common (42.8 %). The thoracic region was the most frequent location (71.1 %), followed by cervical and lumbar locations. A complete resection (Simpson I-III) was achieved in 88.7 %. In 12 cases (7.2 %) recurrences of a spinal meningioma occurred after an interval of 0.70-13.78 years. Postoperative complications consisted of CSF leakage and wound healing problems. Three patients died of direct postoperative complications (1.8 %), nine patients died in follow-up due to unrelated causes. Post-operative complications were related to the overall outcome (p = 0.029). Clinical outcome showed improvement in 117 patients out of 148 (79.1 %) according to modified Rankin Scale; 24 patients remained stable and 7 patients deteriorated. Patients with pre-existing bladder/bowel problems and incomplete resections had higher chance of recurrences. Younger patients also had a higher recurrence rate. Follow-up ranged from 0 to 23 years, median of 0.77 years, most were discontinued after 2 years., Conclusions: The primary treatment of spinal meningiomas remains surgery. Complete resection of spinal meningiomas is achieved in most of the cases, however preserving and improving neurological status has priority over complete tumor resection. Morbidity and mortality is relatively low. Longer follow-up periods are recommended, since recurrences can occur after 10-15 years., (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)

This article summarizes the major changes seen in lymphatic microsurgery and microvascular surgery in first 20 years of the 21st century. Lymphatic microsurgery is discussed first, as more advances have been seen in imaging of the lymphatic system, lymphatico-venous anastomosis, and vascularized lymph node transfers. During the past 2 decades, there have been more patient population changes than major technical evolutions in microvascular surgery, although new techniques and modifications emerged and became clinical routines, with the landscape of microvascular surgery evolving in this time period., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: A prospective, randomized, controlled clinical study was conducted with surgery performed by the same surgeon. The aim was to present a new technique for preserving the ligament flavum during lumbar microdiscectomy, and to evaluate whether this helps prevent postoperative fibrosis and improve outcome., Methods: From January to December 2017, 251 patients with indication for microdiscectomy were randomly divided into test group using ligament flavum preservation technique and control group using conventional procedures. Visual analogue scale (VAS) scores and Oswestry Disability Index (ODI) were assessed before the surgery, and 3 days, 1 month, 6 months, 1 year and 2 years after the operation respectively. The grade of epidural fibrosis on MRI after 6 months was evaluated by two radiologists independently and double-blindly., Results: Both groups' VAS and ODI were significantly improved after surgery, but there was no significant difference between two groups at 3d and 1 month after operation. The grade of epidural fibrosis in test group was significantly lower than that in control group at 6 months postoperative. The VAS and ODI were significantly lower in test group than that in control group at 6 months,1 year and 2 years after operation., Conclusion: Preservation of more ligament flavum is practicable during the procedure of microdiscectomy. It can prevent postoperative epidural fibrosis, and is helpful to achieve a better clinical outcome., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Head and neck reconstructive microsurgery is constantly innovating because of a combination of multidisciplinary advances. This article examines recent innovations that have affected the field as well as presenting research leading to future advancement. Innovations include the use of virtual surgical planning and three-dimensional printing in craniofacial reconstruction, advances in intraoperative navigation and imaging, as well as postoperative monitoring, development of minimally invasive reconstructive microsurgery techniques, integration of regenerative medicine and stem cell biology with reconstruction, and the dramatic advancement of face transplant., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: The repair of unruptured intracranial aneurysms has increased since 2000. In this study, we analyzed the Nationwide Readmission Database (NRD) to determine the rate of 90-day readmission. Our objective is to examine readmission trends after unruptured aneurysm repair., Methods: This study used the 2013 and 2014 NRD. Patient data included standard demographic, comorbidity, and payer information. We selected patients who had undergone microsurgical or endovascular repair for a nonruptured aneurysm. We excluded patients who were under 18 years of age, had a subarachnoid hemorrhage, or were discharged to home the same day. Readmission was calculated by counting the number of days between the end of the index visit and earliest readmission date., Results: A total of 2180 of 29,694 patients (7.34%) were readmitted within 90 days of their initial hospitalization. They were younger (mean, 52.6 years; 95% confidence interval [CI], 51.4-53.8) than patients not readmitted (mean, 57.4 years; 95% CI, 57.1-57.8; P < 0.0001). In total, endovascular repair was more frequent than microsurgery (79.8% vs. 20.2%, respectively). Mean days to readmission was 41.8 (95% CI, 39.7-43.9) and was higher for women (P < 0.0001). The odds ratio for readmission after an endovascular repair was 1.54 (95% CI, 1.27-1.86)., Conclusions: In this study of over 28,000 patients treated for an unruptured aneurysm, the 90-day readmission rate was 7.34%. Endovascular patients had higher odds of readmission than microsurgical patients. Patients with common medical comorbidities (hypertension, obesity, renal failure, and diabetes) were less likely to be readmitted than patients without those conditions., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Mastoidectomy is considered an aerosol-generating procedure. This study examined the effect of wearing personal protective equipment on the view achieved using the operating microscope., Methods: ENT surgeons assessed the area of a calibrated target visible through an operating microscope whilst wearing a range of personal protective equipment, with prescription glasses when required. The distance between the surgeon's eye and the microscope was measured in each personal protective equipment condition., Results: Eleven surgeons participated. The distance from the eye to the microscope inversely correlated with the diameter and area visible (p < 0.001). The median area visible while wearing the filtering facepiece code 3 mask and full-face visor was 4 per cent (range, 4-16 per cent)., Conclusion: The full-face visor is incompatible with the operating microscope. Solutions offering adequate eye protection for aerosol-generating procedures that require the microscope, including mastoidectomy, are urgently needed. Low-profile safety goggles should have a working distance of less than 20 mm and be compatible with prescription lenses.

Study Design: A prospective randomized controlled study., Objective: To clarify whether percutaneous transforaminal endoscopic discectomy (PTED) has better clinical outcomes and less surgical trauma compared with microendoscopic discectomy (MED)., Summary of Background Data: Two kinds of minimally invasive spine surgeries, PTED and MED, are now widely used for the treatment of lumbar disc herniation (LDH). It is still a controversial issue to choose the proper surgical approach., Methods: In this single-center, open-label, randomized controlled trial, patients were included if they had persistent signs and symptoms of radiculopathy with corresponding imaging-confirmed LDH, and were randomly allocated to PTED or MED group. The primary outcome was the score of Oswestry Disability Index (ODI) and the secondary outcomes included the score of Medical Outcomes Study 36-Item Short-Form Health Survey bodily pain and physical function scales, European Quality of Life-5 Dimensions, and Visual Analogue Scales for back pain and leg pain., Results: A total of 250 participants were randomly assigned to two treatment groups, 241 of that received the specific surgical procedure. Two hundred twenty-two patients (92.1%) have completed the 2-year follow-up. Both the primary and secondary outcomes did not differ significantly between the two treatment groups at each prespecified follow-up time (P > 0.05). For PTED, the postoperative improvement of ODI score in the median herniation subgroup was less compared with paramedian subgroup. For MED, less improvement of ODI score was found in far-lateral herniation subgroup compared with paramedian subgroup. Total complication rate over the course of 2 year was 13.44% in PTED group and 15.57% in MED group (P = 0.639). Ten cases (8.40%) in PTED group and five cases (4.10%) in MED group suffered from residue/recurrence of herniation, for which reoperation was required., Conclusion: Over the 2-year follow-up period, PTED did not show superior clinical outcomes and did not appear to be safer procedure for patients with LDH compared with MED. PTED had inferior results for median disc herniation, whereas MED did not appear to be the best option for far-lateral disc herniation., Level of Evidence: 2.

Ideal management of unruptured intracranial aneurysms (UIAs) and ruptured intracranial aneurysms (RIAs) is a controversial issue. Over the last few decades, a significant paradigm shift has occurred away from open microsurgical clipping toward endovascular coil embolization. Multiple studies have been performed with mixed results. Some studies suggest that endovascular treatment produces better clinical and functional outcomes, but is associated with increased need for retreatment. Other studies report increased durability in aneurysms treated with microsurgical clipping, but that clipping may be associated with worse functional outcomes in some cases. Further complicating the dialogue are variable costs associated with different treatment modalities, including country-dependent cost differences. Here we provide a review of some of the major studies comparing open surgery versus endovascular treatment for both RIAs and UIAs to distill their key findings and corresponding implications for clinical practice. We relate these research results to our institution's experience with RIAs and UIAs and describe our approach to treatment of these conditions. Finally, we discuss implications of the paradigm shift for both open and endovascular surgery, including educational initiatives directed toward preserving important microsurgical tenets in the setting of diminishing surgical volume., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Giant intracranial aneurysms (GIAs), if left untreated, have an extremely poor natural history. Despite many reports about the surgical treatment of GIAs, their long-term clinical and angiographic results are unclear. To our knowledge, this study reports the longest clinical and angiographic follow-up of microsurgically treated GIAs in the English literature., Methods: Between January 1997 and December 2017, 70 patients with giant anterior circulation aneurysms treated using microsurgery were retrospectively reviewed. The applied microsurgical techniques and especially long-term clinical and angiographic follow-up data were evaluated., Results: The mean aneurysm size was 29.2 mm (range, 25-58 mm). The aneurysm neck was occluded in 61 patients (87.2%). Nine aneurysms were clipped using an aneurysm clip compression technique. In 8 patients (11.4%), the aneurysm neck was found smaller at surgery than expected according to angiographic findings. Postoperative angiograms showed complete occlusion in 52 of 61 patients (85.2%). The treatment results at discharge were excellent-good (modified Rankin Scale score ≤2) in 75.3% of the patients. The overall mortality was 7.6%. At long-term clinical follow-up (mean, 105.2 months), 48 patients (78.6%) showed excellent-good outcome. At late angiographic follow-up (mean, 98.0 months), no recurrence was seen in patients with complete aneurysm closure., Conclusions: Most giant anterior circulation aneurysms can be successfully clipped, with acceptable morbidity and mortality. Some giant aneurysms have a smaller neck than expected. The aneurysm clip compression technique is useful in clipping of GIAs. This longest clinical and angiographic follow-up in the literature shows that clip ligation has excellent durability in GIAs, also., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction : The current gold standard technique for lumbar disc herniation (LDH) is open lumbar microdiscectomy. The use of a tubular retractor system in the microdiscectomy technique can minimize tissue trauma by muscle-splitting sequential dilation during the surgical approach. This review aimed to describe the devices and surgical procedure of this minimally invasive microdiscectomy (MI-MD) and to discuss the pros and cons of the use of tubular retractors. Areas covered : Published medical literatures were extensively reviewed to summarize the practical devices and techniques related to the MI-MD for LDH. The placement of the tubular retractor by gradual muscle-splitting dilation technique may reduce muscle damage and postoperative wound pain. The use of flexible arm may easily change the tube direction and create a wide surgical field. Expert opinion : With reference to published literature, the MI-MD provides comparable clinical outcomes with less tissue trauma and early recovery. Development of devices for MI-MD is still ongoing. Extensive studies, including high-quality randomized trials, are required to establish a more practical and relevant MI-MD technique.

Aim: To summarize the clinical outcomes, follow-up results and to discuss the optimal therapeutic strategy for pericallosal artery aneurysms (PAAs)., Material and Methods: From January 2013 to May 2017, the charts of 49 patients with PAAs, representing 2.43% of 2,018 consecutive patients with intracranial aneurysms (IAs) were reviewed. The clinical and radiological data of these patients were retrospectively analyzed., Results: There were no technical failures in the clipping group, but one patient in the coiling group presented rebleeding during the operation, resulting in a poor prognosis. Although the difference was not significant, the coiling group had a better complete recovery rate than the clipping group [overall: coiling, n=20 (87.0%) vs clipping, n=11 (68.8%), p=0.33; unruptured PAAs: coiling, n=12 (92.3%) vs clipping, n=5 (83.3%); ruptured PAAs: coiling, n=8 (80%) vs clipping, n=6 (60%), p=0.63]. One patient in the coiling group exhibited recurrence. No patients experienced rebleeding during the follow-up period in either group., Conclusion: In our study, both endovascular coiling and microsurgery were technically feasible and achieved favorable clinical outcomes in patients with PAAs. Longer radiological follow-up is necessary. Patients should be evaluated by a multidisciplinary team prior to determining the optimal treatment modality.

Study Design: Level 3, cohort study., Objective: The aim of this study was to assess long-term clinical outcome, and rate of reoperation following microsurgical subtotal discectomy (MSD)., Summary of Background Data: Lumbar disc herniation (LDH) is a common cause of discomfort. Studies with >25 years of follow-up are rare and the reported rate of clinical success and reoperation are not well understood., Methods: Retrospectively, files with complete documentation of preoperative and postoperative neurological status, process during hospitalization, detailed report of MSD, outpatient visit notes, and full contact information of patients who underwent MSD for the treatment of LDH with a minimum follow-up of 25 years were reviewed. Patients were contacted for personal follow-up assessment which included Oswestry Disability Index (ODI), EQ-5D, and MacNab criteria, usage of pain medication for leg and back pain, limitations in daily life, and repeated procedures at the lumbar spine., Results: A total of 355 patients were randomly selected and contacted for final follow-up and 158 patients with a mean follow-up 32 years participated in the study. Clinical success rate was 86.0%, mean ODI was 9% (0-58%), 69.6% of the patients were pain free, 13.9% of patients reported the daily intake of pain medication for back and leg pain. Reoperations were performed in 47 of the patients (29.7%), whereas the rate for recurrent disc herniation at the same level was 8.2%. Reoperation within the first 2 years after initial MSD had negative influence on clinical success. The preoperative physical working status and sex and working status had no influence on the clinical success., Conclusion: The MSD is an effective technique to achieve a high rate of patient satisfaction, and high rate of functional recovery. The overall reoperation rate is 30% within 30 years but only 8.2% of the patients underwent reoperation because of recurrent disc herniation at the same level., Level of Evidence: 3.

Cold resection for small colonic polyps, and larger lesions, is being rapidly and widely adopted. Driven by an impressive safety and cost profile compared with conventional polypectomy, these advantages are offset by the limitations of smaller and shallower resection, and absent thermal effects that may permit persistence of residual neoplasia. To overcome this, optimal cold snare technique requires inclusion of a margin of normal mucosa and a piecemeal resection technique for larger polyps. This article examines the fundamentals of cold snare resection and evidence for its application, theorizes on limits to its application, and identifies areas for further research., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Over the past few decades, there have been numerous paradigm shifts in male reproductive surgery, resulting from a combination of technologic advancements in both the operating room and the laboratory. The operating microscope transformed the field of male reproductive surgery, enabling novel techniques and higher precision for the treatment of male-factor subfertility. The subsequent widespread adoption of microsurgical approaches was largely responsible for the emergence of a cadre of highly specialized male infertility microsurgeons. The advent and evolution of in vitro fertilization/intracytoplasmic sperm injection was a concurrent story that further revolutionized the field. The ability to achieve fertilization and pregnancy with just a single sperm changed the ways in which male reproductive surgeons could approach a wide range of pathologies from obstructive to nonobstructive causes, culminating in the microdissection testicular sperm extraction procedure for the treatment of nonobstructive azoospermia. Here we review the recent advancements in fertility-enhancing male reproductive surgery for the treatment of four disease processes: varicocele, obstruction of the excurrent ductal system, ejaculatory duct obstruction, and nonobstructive azoospermia. While examining the great strides of the past, we look forward to exciting developments on the horizon., (Copyright © 2019 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Studies from different Western countries have reported a rapid increase in spinal surgery rates, an increase that exceeds by far the growing incidence rates of spinal disorders in the general population. There are few studies covering all lumbar spine surgery and no previous studies from Norway., Objectives: The purpose of this study was to investigate trends in all lumbar spine surgery in Norway over 15 years, including length of hospital stay, and rates of complications and reoperations., Design: A longitudinal observational study over 15 years using hospital patient administrative data and sociodemographic data from the National Registry in Norway., Setting and Participants: Patients aged ≥18 years discharged from Norwegian public hospitals between 1999 and 2013., Outcome Measures: Annual rates of simple (microsurgical discectomy, decompression) and complex surgical procedures (fusion, disc prosthesis) in the lumbar spine., Results: The rate of lumbar spine surgery increased by 54%, from 78 (95% CI (75 to 80)) to 120 (107 to 113) per 100 000, from 1999 to 2013. More men had simple surgery whereas more women had complex surgery. Among elderly people over 75 years, lumbar surgery increased by a factor of five during the 15-year period. The rates of complications were low, but increased from 0.7% in 1999 to 2.4% in 2013., Conclusions: There was a substantial increase in lumbar spine surgery in Norway from 1999 to 2013, similar to trends in other Western world countries. The rise in lumbar surgery among elderly people represents a significant workload and challenge for health services, given our aging population., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Recurrent lumbar disc herniation is a common negative sequela of primary discectomy. Repeat discectomy versus spinal fusion is constantly debated, and successful outcomes from both treatments remain unclear. Several meta-analysis studies have not reported re-operative rates between the two treatment methods; therefore, we seek to report these outcomes in the following systematic review and meta-analysis design study. The primary objective was to compare re-operative rates between repeat discectomy and fusion treatment. The secondary objectives included comparing clinical improvement, operative time, blood loss, complications, and postoperative hospital stay between repeat discectomy and fusion treatment. The data were gathered from the following sources: PubMed Medline, Ovid Medline, Cochrane database, and Google Scholars. Only comparative studies in humans were selected. There were initially 182 citations found. After the analysis, we found four studies that were compatible with our inclusion criteria. The meta-analysis showed that the re-operative rate seemed to be higher in the discectomy group (9.09%) compared with the fusion group (2.00%), but the difference was not statistically significant. The primary cause of re-operation in the discectomy group is recurrent disc herniation. Two causes of re-operation in the fusion group are adjacent segmental degeneration and implant removal. Operative time and postoperative stay were significantly less in the discectomy group. The improvement rate was not different between the two groups. In conclusion, no difference in re-operation rates between the two surgical treatments was found based on the results of our study. Both treatment techniques have equal improvement rates and complications., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Infertility due to obstructive azoospermia may be treated effectively by surgical reconstruction or by retrieval of sperm from the epididymis or testis, followed by in vitro fertilization with intracytoplasmic sperm injection. This replaces the ASRM documents titled "Sperm retrieval for obstructive azoospermia" and "The management of infertility due to obstructive azoospermia," last published in 2008., (Copyright © 2019 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Evaluation of differences in neuropsychological outcomes in patients undergoing surgical clipping (SC) vs endovascular coiling (EC) for unruptured cerebral aneurysms is essential in guiding patients seeking treatment of asymptomatic cerebral aneurysms., Objective: To perform a prospective longitudinal analysis of neuropsychological outcomes in patients who underwent microsurgery or coiling for unruptured cerebral aneurysms., Methods: SC (50 patients), EC (35 patients), and healthy controls (43 individuals) were included. A detailed neuropsychological evaluation was performed at baseline and at 2 wk, 3 mo, 6 mo, and 12 mo. Student's t-test was utilized for comparing neuropsychological outcomes among the 3 groups. A mixed-effects model allowed for evaluation of neuropsychological outcome changes among the groups over time., Results: Both the SC and EC groups had nonsignificant differences in procedure-related complications. SC patients had the greatest initial declines in short-term memory, fine motor control, and executive functioning; however, these patients also recovered to a greater degree in neuropsychological functionality. Over the next year, all groups achieved similar neuropsychological outcomes with no significant differences among groups., Conclusion: Whereas the initial decline in neuropsychological functioning was greater for SC patients, 1 yr after treatment there was no significant difference in neuropsychological outcome among the SC, EC, and healthy control groups., (Copyright © 2018 by the Congress of Neurological Surgeons.)

Peripheral nerve injuries are extremely devastating, and their management is exceedingly complex. Microsurgical repair is the mainstay of treatment and this includes direct nerve repair, nerve grafts, nerve tubes and nerve transfers. Today, nerve transfers are being widely performed due to an increased understanding of cortical plasticity, motor re-education and perioperative rehabilitation, and they are now known to produce excellent functional outcomes. This manuscript reviews the current strategies for nerve repair, including comments on outcomes, with special emphasis on existing nerve transfer techniques., Competing Interests: None

Purpose: In the field of head and neck microvascular surgery, there are currently no clear, universally accepted recommendations on the intraoperative, preoperative, and postoperative management of these patients., Materials and Methods: A 23-question cross-sectional survey was distributed to otolaryngologists who perform microvascular reconstruction. Information about practice setting, fellowship training background, intraoperative practice, postoperative practice, and surgical complications were analyzed., Results: Complete survey responses were received from 102 (32.8% response rate) of surveyed otolaryngologists who perform microvascular surgery. A great degree of variability was noted in intraoperative and postoperative care of free flap patients. Overall, self-reported free flap survival-rates were relatively high, despite the variability in practice, with the majority of surgeons (74%) reporting flap survival rate of 96-100%. Complication rates requiring return to the operating room were low; all respondents reported <20% overall complications with <10% re-operation rates due to vascular complications., Conclusion: An increasing number of microvascular-trained otolaryngologists are performing free flaps. Self-reported free flap survival rates are high and complication rates are low, despite significant variability in intraoperative and postoperative practices among otolaryngologists performing microvascular flap reconstruction. By identifying these differences among surgeons, we hope to provide the impetus for further academic dialog and prospective trials., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Aim:  To achieve a favorable risk-benefit balance for hand transplantation, an immunomodulatory protocol was developed in the laboratory and translated to clinical application., Methods:  Following donor bone marrow infusion into transplant recipients, hand and arm allografts have been maintained on low-dose tacrolimus monotherapy., Results:  Good-to-excellent functional recovery has been achieved in patients compliant with medication and therapy, thus restoring autonomous and productive lives., Conclusion:  The risk-benefit balance can be tilted in favor of the hand transplant recipients by using an immunomodulatory protocol with minimum immunosuppression., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background:  Nerve transfer can be broadly separated into two categories: proximal nerve graft and/or transfer and distal nerve transfer. The superiority of proximal nerve graft/transfer over distal nerve transfer strategy has been debated extensively, but which strategy is the best has not yet been defined. Each technique has its own advantages and disadvantages. However, proximal nerve graft/transfer is still the main reconstructive procedure based on the principle of "no diagnosis, then no treatment." Proximal nerve transfer can avoid iatrogenic injury where the lesion is still in continuity and neurolysis is the only procedure without further cutting the nerve., Results:  Our clinical and experimental study show that proximal nerve grafts/transfers yield at least equal or better results compared to distal nerve transfers. Proximal nerve grafts/transfers remain the mainstay of my reconstructive strategy. Proximal nerve graft/transfer offers more accurate diagnosis and proper treatment to restore shoulder and elbow functions simultaneously. Distal nerve transfers can offer more efficient elbow flexion., Conclusion:  Combined, both strategies in primary nerve reconstruction are especially recommended when there is no healthy or not enough donor nerve available Distal nerve transfers should be considered as a complementary option for proximal nerve grafts/ transfers., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

It has been half a century since Susumu Tamai reported on the first thumb replantation. The evolution of reconstructive microsurgery has continually added new applications of the operating microscope for reconstructive surgery and has had profound impact on countless patients. From the time of Harold Gillies until today, the reconstructive ladder has evolved to a reconstructive elevator with the "penthouse" floor being represented by vascularized composite allotransplantation., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Purpose: To develop a better understanding of pediatric intracranial aneurysms (PIAs)., Methods: All PIAs treated in our center from January 2012 to April 2017 were retrospectively included. Clinical data, treatment summaries, and follow-up outcomes were retrieved and analyzed., Results: A total of 66 PIAs were found in 64 patients with a mean age of 11.4 ± 5.7 years, 68.8% of whom were male. The most common symptoms were seizure (n = 7, 63.6%) for the 0-5 age group and headache (n = 38, 71.7%) for the 6-18 age group. Fifty-one PIAs (77.3%) were located in the anterior circulation, with the middle cerebral artery (MCA) being the most common site (n = 28, 42.4%). Fifteen patients (23.4%) had PIAs that were pseudoaneurysms, and nine of them (60%) had a combined history of head trauma. Thirty-five patients (54.7%) had distal arterial aneurysms, and 21 of them (60%) presented with seizure. During a mean follow-up time of 1.6 ± 1.2 years, 79.7% of patients (n = 51) had favorable outcomes, 5 patients (7.8%) died, and the remaining 8 patients (12.5%) had unfavorable outcomes with severe neurological deficits., Conclusion: Apart from characteristics consistent with previous studies, several new findings regarding PIAs were reported, including a difference in the most common symptoms in different age groups, the MCA as the predominant location of PIAs, the high ratio of pseudoaneurysms and their head trauma etiology, and the incidence of distal arterial aneurysms and their relationship with the risk of seizures.