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UNLABELLED: Patients with upper limb lymphedema and lower limb lymphedema experience a wide range of physical and psychological symptoms that affect quality of life. The benefits of lymphatic reconstructive surgery for patients with lymphedema are undisputed. However, recording volume reduction alone may be insufficient with regard to postoperative outcome because measurements are often inadequate, depend on many factors, and do not reflect improvement in quality of life. METHODS: We conducted a prospective single center study patients receiving lymphatic reconstructive surgery. Patients received volume measurements preoperatively and at standardized postoperative intervals. To evaluate patient-reported outcomes, patients completed the following questionnaires: LYMPH-Q Upper Extremity Module, quickDASH, SF 36, Lymphoedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphoedema, and Lower Extremity Functional Scale at the aforementioned intervals. RESULTS: We included 55 patients with upper limb lymphedema (24%) and lower limb lymphedema (73%) of lymphedema grades I-III. Patients received lymphovenous anastomosis only (23%), free vascularized lymph node transfer (35%) or a combination of both (42%). Analysis of patient-reported outcome measurements revealed improvements with respect to a broad range of complaints, particularly physical function, symptoms, and psychological well-being. There was no correlation between the extent of volume reduction and improvement in quality of life (Pearson correlation coefficient below ±0.7; P > 0.05). CONCLUSIONS: Based on a broad range of outcome measurements, we observed an improved quality of life in almost all patients, even in those without measurable volume loss of the extremity operated on, which emphasizes the need for a standardized use of patient-reported outcome measures to evaluate the benefits of lymphatic reconstructive surgery.

Robotic systems have recently been introduced into micro- and supermicrosurgery showing potential benefits for reconstructive surgery. After showing the feasibility and safety of using the Symani Surgical System® for lymphatic microsurgical procedures in humans, we present the results of the first twenty-two patients operated with the robot. The main goal of the study was to determine the learning curve using the Symani Surgical System® . In addition, we aimed at exploring the potential of robot-assisted anastomosis for lymphatic, free flap, and nerve reconstruction and defining the advantages and drawbacks of implementing the system into our daily routine. The operating times were compared between robotic-assisted and hand-sewn anastomoses. Moreover, outcomes and complications were recorded. In this first patient series, anastomotic times were significantly faster with the hand-sewn technique (14.1±4.3 min) when compared with the robot-assisted technique (25.3±12.3 min; p<0.01). However, the learning curve was very steep, and the time needed to perform the anastomosis has been consistently decreasing over time to the point where in the last operations, the times to perform particularly lympho-venous anastomoses were comparable between the two groups. Based on our experience up to date, robot-assisted surgery shows a promising potential in opening up new frontiers in reconstructive microsurgery, e.g., the reliable performance of anastomoses on even smaller blood and lymphatic vessels or on structures deeper within the body cavities, e.g., the thoracic duct.

Invasive fungal infections from Saksenaea, a fungus belonging to the Mucorales, have been rarely reported in central European climate zones. This study aims to raise awareness of invasive cutaneous infections with Saksenaea species. The first case of a cutaneous infection was diagnosed in Switzerland in an immunocompetent 79-year-old patient. A minor skin trauma of her left lower leg led to a fulminant infection causing necrosis and extensive loss of tissue. The combination of surgical debridement and administration of antifungal agents averted a prolonged course with a possible worse outcome. A pedicled hemisoleus muscle flap was used to reconstruct the defect and treatment was continued for 63 days. Methods: A systematic review in accordance with the Preferred Reporting Items for Systematic review and Meta-Analysis guidelines was conducted to identify all European cases of infection with Saksenaea species in immunocompetent hosts. The epidemiology, clinical presentation, microbiological diagnosis, and management of cases reported in Europe were summarized and analyzed. Conclusions: The prognosis of soft tissue infections with Saksenaea species. depends on early diagnosis and appropriate antifungal and surgical treatment. Reconstruction can be successful under ongoing antifungal treatment.

Robotic microsurgery has emerged as a new technology with potential benefits for reconstructive surgery. We report the first-in-human use of the Symani surgical system to perform lympho-venous and arterial anastomosis for lymphatic reconstruction. In five patients, 10 robot-assisted anastomoses were performed. Next to lympho-venous anastomoses, two patients received a free vascularized lymph node transfer. Motion scaling was set to 10×. Visualization was either achieved with a 3D system or an optical microscope. All anastomoses were patent as confirmed by ICG. Despite a longer time to perform the first anastomoses with the robot, we observed a decline in duration of anastomosis. Among the advantages of the system were a high accuracy in placing the stitches even in very small and fragile vessels or when performing anastomoses with size mismatches. The challenges encountered included the lack of a touch sensation and the necessity to develop a "see-feel." This could be achieved surprisingly well because the force necessary to close dilator and needle holder via the manipulators was perceived as comparable to using conventional micro instruments. Our data confirm feasibility and safety of the robotic system to perform lymphatic surgery. Larger patient cohorts and inclusion of surgeons at different training levels will be necessary to investigate the true potential of robotics in microsurgery. In addition, robot-assisted surgery shows a promising potential in opening up new frontiers in reconstructive microsurgery (eg, the reliable performance of anastomoses on even smaller blood and lymphatic vessels or on structures deeper within the body cavities-eg, the thoracic duct).

Background Fat grafting has been gaining attention in tissue augmentation over the past decade, not only for lipofilling, but also for its observed regenerative properties and overall skin texture improvement. Objectives The aim of this study was to analyze the effect of nanofat grafting on scars, wrinkles, and skin discolorations in our clinic. Methods Nanofat was prepared by a standard emulsification and filtration protocol. The resulting liquid was injected intradermally or directly into the scar tissue. Skin quality was evaluated based on a scoring system, and patient satisfaction was documented. Three physicians compared and analyzed standardized pre- and posttreatment photographs in respect to general improvement of skin aesthetics. Results Fifty-two patients were treated with nanofat from November 2013 to April 2016. The mean (± standard deviation) posttreatment follow up was 155 ± 49 days and average volume of harvested fat amounted to 165 cc. The primary harvesting areas were the abdomen and flanks, and the injected volume of nanofat ranged from 1 to 25 mL (mean, 4.6 mL). A total of 40 scars (76% of all patient defects) were effectively treated as well as 6 patients with wrinkles, and 6 patients with discoloration. Posttreatment clinical evaluations showed a marked improvement of scar quality and a high patient satisfaction. The results in our clinic showed that nanofat grafting softened the scars, made discolorations less pronounced, and wrinkles appeared less prominent. Conclusions Nanofat grafting has been shown to have beneficial effects in the treatment of scars, wrinkles, and skin discolorations. Level of Evidence: 4

BACKGROUND Lymphoedema is a progressive and potentially disabling disease. A growing number of studies show promising clinical results after microsurgical reconstruction. However, this treatment is currently not supported by level 1 evidence and insurance coverage is variable. METHODS Electronic records of 55 patients with limb lymphoedema, who were eligible for lymphovenous bypass surgery and/or lymphatic tissue transfer in our department from 2017 to 2020, were reviewed. Correspondence between our department and health insurers was analysed. A web-based search and individual telephone interviews were conducted to identify health insurer policies. RESULTS We included 42 patients undergoing 46 operations and evaluated the correspondence between our department and nine different health insurers. Overall, reimbursement of costs was approved in 67% (n = 31) of all surgeries and was refused in 33% (n = 15). The mean number of applications for reconsideration sent to insurers was 1.3 ± 0.7. The time between confirmation of the indication and the final decision ranged from 6 to 300 days (mean 50 days). Reimbursement of cost coverage ranged from 0% to 100% depending on the individual insurance company. No insurance company had policies publicly available online and all stated that they determine coverage only when provided with specific patient details on a case-by-case basis. CONCLUSION Insurance companies in Switzerland do not have a uniform policy regarding cost coverage for lymphatic surgery procedures. Moreover, the decision process appeared to be rather uniform within the respective insurance company and independent of the individual case. Standardised evaluation criteria including patient reported outcome measures should be developed to underscore the beneficial effects of lymphatic surgery and facilitate insurance coverage.

Numerous approaches have been employed to treat chronic lymphocele and cutaneous lymphatic fistulas (LFs) with little success. Given a high incidence and substantial consequences for patients, there is an ongoing demand for effective therapeutic and preventive strategies. The aim of this study was to evaluate the results after microscopic lymphatic ligation (MLL) and lymphovenous anastomosis (LVA) as a therapeutic and preventive approach in this context. Methods Demographic data, surgical characteristics, complications, and the overall outcome of all patients undergoing surgery for postoperative LF from 2014 to 2019 were collected retrospectively. Patients were categorized in accordance with predefined inclusion/exclusion criteria and with their treatment. Statistical analysis was conducted using descriptive, summary statistics to identify a central tendency. Results Thirty-four patients underwent indocyanine-green-lymphangiography guided revision surgery for LF. Two patients were lost to follow-up at 6 months. LF was successfully treated in all patients (n = 32) with a multimodal approach. Only MLL was performed in 22 patients and MLL/LVA in 10 patients. LF resolved in 78% of all patients with MLL only or MLL/LVA. In the remaining 22%, LF resolved after additional sclerotherapy within 3 months. Conclusions Treatment of LF should follow a standardized staged surgical approach to optimize outcome. LF was treated successfully in all our patients. We therefore propose a multimodal interdisciplinary approach to this common clinical problem that includes adjunctive sclerotherapy.

Surgery trainees use videos as a means to learn about surgical procedures. YouTube is the biggest online video platform and used for educational content as well but the medical information provided does not undergo peer review or other forms of scientific screening and can thus be of poorer quality. We performed a systematic review that examined the quality of educational videos about surgery and plastic surgery in particular on YouTube. The focus was towards studies on the benefit of YouTube videos for surgical trainees. A literature review was performed to determine the educational quality of plastic surgery videos found on YouTube. Articles reviewing the educational quality of videos about surgical procedures, their accuracy, and their utility for surgical trainees were included. An additional review was performed evaluating the literature about the quality of educational plastic surgery videos. Eleven articles were selected reviewing the educational quality of videos about surgical procedures. Six studies were fully assessed and evaluated concerning the quality of educational plastic surgery videos. There currently seems to be a lack of comprehensive educational surgery and in particular plastic surgery-related information on YouTube. The popularity of YouTube among surgical trainees is high. The quality of available educational surgical video content varies widely. It is in the interest of plastic surgery teaching institutions to provide trainees with high-quality educational video material.

INTRODUCTION Identification of patent lymphatic vessels without fibrosis and with high flow is difficult but crucial in the preoperative planning of lymphaticovenous anastomosis (LVA). Lymphatic vessels on the operating field cannot always be visualized preoperatively because of the anatomical and physiological characteristics of lymphedema tissue. The purposes of this study were to demonstrate our clinical experience in identifying indocyanine green (ICG)-negative lymphatics intraoperatively and to emphasize the therapeutic potential of performing anastomoses with ICG-negative lymphatics. METHODS Indocyanine green-positive lymphatic ducts were marked preoperatively in 5 patients with lower extremity lymphedema; moreover, if ICG-negative lymphatics were identified during surgery, they were used for additional LVA thus implementing multiple anastomoses in one surgical setting. RESULTS In total, 33 LVAs were performed in 5 patients with lower extremity lymphedema, of which 11 LVAs were implemented with ICG-negative lymphatics. Immediately after the anastomosis, a strong lymphatic drainage could be appreciated in all cases. Six months postoperatively patients reported a subjective decrease in limb circumference and pressure sensation. CONCLUSIONS We believe that ICG-negative lymphatics found intraoperatively should be evaluated for additional LVAs in order to maximize drainage effect and might provide better outcomes.