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Aim: Targeted muscle reinnervation (TMR) surgery has fundamentally changed the management of patients who have suffered or are about to undergo amputation. Providing nerve stumps with a muscle target has been shown to have profound effects on levels of post-amputation pain in relation to phantom limb pain (PLP) and neuroma pain (NP). The primary objective of this report was to quantify pain parameters for this population and to measure the impact on health-related quality of life (HRQol) before and after TMR surgery. In this case series, we evaluate the role of TMR in addressing both pain and the impact of the surgery on the patient’s quality of life.Methods: A retrospective analysis of 15 upper limb amputee patients who underwent TMR by the Relimb Unit in London, UK. Participants’ perceptions of pain were determined using the 11-point numerical (Pain) rating scale (NRS) and HRQoL was calculated using the Euroqol EQ-5D-5L questionnaire at two time points, comparing both pain and perceived quality of life pre and post surgery. The Wilcoxon Signed Rank Test was used for the NRS data and a paired sample t-test was used for the EQ-VAS data.Results: A total of 15 patients completed the evaluation. We observed statistically significant reductions in both PLP (pre-operative mean: 7.6, post-operative mean: 2.7, P < 0.05) and NP (pre-operative mean: 6.4, post-operative mean: 2.5, P < 0.05) in these patients. Similarly, HRQoL observed on the EQ-VAS scale demonstrated a significant improvement in quality of life, from 68 pre-operatively to 78 post-procedure (P < 0.05).Conclusion: This is the first quantified evaluation of changes in HRQoL after TMR surgery for upper limb amputation. There appears to be a significant improvement in both HRQoL and overall perception of pain. This finding may have important implications for funding and national resource allocation for TMR surgery. LESS      Full article

Peripheral nerve injury (PNI) is a common source of pain and disability in patients. While many patients are affected by PNI, peripheral nerve surgery advancements in the lower extremity have lagged behind the upper extremity. Subsequently, principles that have demonstrated success in the upper extremity have been implemented in the lower extremity. Interventions with recent advances include the advent of novel nerve transfers in the lower extremity and using stem cells and electrical stimulation (ES) for nerve regeneration. This article focuses on advances in nerve transfers for lower extremity PNI and provides details on the basic science and clinical applications of newer interventions. LESS      Full article

Hand surgery has undergone substantial changes in recent years, especially for reconstructive surgery techniques. We discuss the management of soft tissue defects of the thumb, discussing indications, and operative pearls and pitfalls. We cover non-operative treatment and local advancement flaps for small distal soft tissue defects and pedicled flaps for more significant defects. We also discuss composite vascularized free flaps such as second-toe neurocutaneous flaps and partial hallux transfer for compound defects or total amputations. This article aims to provide hand surgeons with an update on reconstructing an injured thumb. LESS      Full article

The recent development of robotic-assisted microsurgery and supermicrosurgery has raised great expectations to support some of the most demanding microsurgical procedures, which are applied in lymphatic reconstructive surgery to restore lymphatic vascular integrity and treat lymphedema. Procedures such as the establishment of lymphovenous anastomosis (LVA), the harvest of lymph nodes from anatomic locations that reduce donor-side morbidity and the transplantation of the vascularized lymph node flaps (VLNT) present procedures necessitating extreme precision and dexterity in often difficult-to-reach areas, thus pushing the physical limitations of the performing microsurgeon. Despite being limited in number, recent preclinical and clinical studies of independent groups using different robotic systems demonstrate the feasibility of robotic technology to perform supermicrosurgical procedures successfully. The robotic assistance offers unparalleled precision, refining the surgical techniques and minimizing potential side effects, with clinical outcomes comparable to the conventional techniques. Although the relative disadvantages of robotic assistance mostly appear to be related to adequate training and the prolonged learning curve, the technology promises to revolutionize the field of supermicrosurgery and improve the clinical outcomes of lymphatic reconstructive surgery. LESS      Full article

Aim: The aim of this systematic review was to summarize clinical and patient-reported outcomes (PROs) for various vascularized lymph node transfer (VLNT) donor sites and identify gaps in the literature to guide future research.Methods: A literature search of five databases was performed for articles related to VLNT that were published prior to November 2021. Studies that included clinical outcomes or PROs from at least five adult patients who received VLNTs to treat lymphedema were included.Results: Sixty-six studies met the study criteria. Most studies reported improved limb circumference/volume, reduction or discontinuation of conservative therapy, infection rate reduction, improved PROs, or postoperative imaging findings reflecting functional lymph nodes. There were significantly lower infection rates (P < 0.05) and a trend towards improved PROs in patients who received intra-abdominal flaps, but overall few studies reported these outcomes. There were no significant differences in complication rates at the donor or recipient site based on VLNT donor sites, or between intra-abdominal vs. extra-abdominal VLNT donor sites, although these outcomes are not uniformly reported.Conclusion: This meta-analysis identified that intra-abdominal donor sites have the potential to reduce postoperative infectious episodes more than extra-abdominal donor sites. Though recent investigations address many understudied VLNT donor sites, larger comparative studies and a standardized methodology are needed to better characterize postoperative outcomes, which can offer more concrete evidence to guide surgical practice. LESS      Full article

Supermicrosurgical lymphaticovenular anastomosis (LVA) is the most sought-after procedure among lymphedema patients. However, the same enthusiasm is currently not shared among lymphedema surgeons due to the lackluster results of LVA. The common unfavorable experience with this famed procedure is at least partially caused by the difficulty in finding the lymph vessels. We share our time-tested indocyanine green-based lymph vessel mapping technique, which has helped us establish LVA as our procedure for all fluid-predominant lymphedema. LESS      Full article

Collagen-based supplements have become a keystone in the management of the ageing process, with proven ability to repair skin damage, bestowing a youthful and healthy appearance sought in the pursuit of beauty. Collagen is an essential scaffold protein that gives smoothness and elasticity to skin, but its production declines with age. Finding ways to tackle this problem is now strongly promoted as an effective way to transform skin and hair, repairing age-related deterioration. A growing number of scientific studies show exciting evidence that it is possible to rejuvenate ageing or damaged skin, improve function of worn joints, and support personal wellbeing and vitality. In recent times, research on the mechanisms which impact the production of collagen in skin and the ideal organization into functional fibres which give skin its characteristic elasticity and firmness has provided new insights into how this bio-scaffold can support cells, tissues and organs. The factors which influence collagen production over a lifetime (e.g., puberty, pregnancy, menopause, andropause), intrinsic factors (e.g., genetics, age, ethnicity) and extrinsic factors (e.g., UV-radiation, pollution, smoking) and the potential for new technologies, ingredients and devices to restore collagen and matrix components to their optimal condition are improving the ability to deliver anti-aging strategies with unprecedented results. This paper will review skin collagen production, structure and function throughout the lifestages, emphasizing its relationship with health, appearance and beauty. LESS      Full article

Periodontal tissue engineering involves a multi-disciplinary approach towards the regeneration of periodontal ligament, cementum and alveolar bone surrounding teeth, whereas bone regeneration specifically applies to ridge reconstruction in preparation for future implant placement, sinus floor augmentation and regeneration of peri-implant osseous defects. Successful periodontal regeneration is based on verifiable cementogenesis on the root surface, oblique insertion of periodontal ligament fibers and formation of new and vital supporting bone. Ultimately, regenerated periodontal and peri-implant support must be able to interface with surrounding host tissues in an integrated manner, withstand biomechanical forces resulting from mastication, and restore normal function and structure. Current regenerative approaches utilized in everyday clinical practice are mainly guided tissue/bone regeneration-based. Although these approaches have shown positive outcomes for small and medium-sized defects, predictability of clinical outcomes is heavily dependent on the defect morphology and clinical case selection. In many cases, it is still challenging to achieve predictable regenerative outcomes utilizing current approaches. Periodontal tissue engineering and bone regeneration (PTEBR) aims to improve the state of patient care by promoting reconstitution of damaged and lost tissues through the use of growth factors and signaling molecules, scaffolds, cells and gene therapy. The present narrative review discusses key advancements in PTEBR including current and future trends in preclinical and clinical research, as well as the potential for clinical translatability. LESS      Full article

Aim: The reason why non-calibrated hair variables poorly estimate scalp hair coverage during hair growth studies was studied.Methods: Hair productivity integrates density, diameter and daily hair growth rate. Cross-sectional studies have established hair productivity in female and male patients (480 vs. 90 controls) with self-evaluation of hair loss, phototrichogram (CE-PTG-EC) and scalp coverage scoring, (SCS). Tracking productivity of individual hair follicular units from longitudinal studies challenged the application of our methods during drug trials.Results: Hair loss means decreased productivity and increased “time to complete coverage”. The hair mass index (HMI) linearly connects productivity with clinical perception of coverage, i.e., SCS. The ensuing HMI abacus translates independently of gender, age, pattern or severity and unravelled unequal intervals between categories of the Ludwig and Hamilton classifications. With one severity grade shift, time to complete coverage varied from 21-51 days, i.e., no equality. During longitudinal studies, SCS detected improved productivity, reflecting clinically relevant responses, but remained stable in the absence of significant productivity variations. Follicular unit labelling and individual hair growth tracing showed that reversal of miniaturised hair follicles does not play a major role during drug-induced hair regrowth. The latter reflects re-activation of resting-dormant terminal hair follicles. The recovered productivity would not be possible once hair follicles enter the phase of structural-functional irreversible miniaturisation.Conclusion: Besides pattern identification, density of nanohair and HMI appear as innovative diagnostic approaches. Abrupt transformation (within one cycle) of terminal hair follicles into miniaturised ones and its reversal as the effect of active FDA-approved drugs remain highly improbable. LESS      Full article

Neck aesthetics are a vital and indispensable component of cervicofacial beauty. Cosmetic deformities may be due to congenital or acquired etiologies and successful management depends on accurately diagnosing the underlying anatomical problems and applying the appropriate surgical and non-surgical procedures to achieve the desired result. For clinical evaluation and treatment, neck anatomy may be conceptualized into three layers wherein the superficial layer consists of the skin and subcutaneous fat, the intermediate layer of platysma muscle and interplatysmal fat, and the deep layer of subplatysmal fat, digastric muscles, submandibular glands, and skeletal support structures. The goal of this article is to review neck aesthetics, cosmetic deformities, and indications for different treatment techniques by way of a systematic layered approach. LESS      Full article