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Lymphatic surgery has evolved from palliative debulking procedures to physiologic reconstruction using microsurgical and supermicrosurgical techniques. Despite this progress, the publications that have most influenced this evolution have not been systematically examined. This study aimed to analyze the 50 most-cited publications in lymphatic surgery, assessing their bibliometric characteristics, study designs, levels of evidence, and thematic contributions to lymphedema surgical management. The Web of Science Core Collection was searched for articles on surgical treatment of lymphedema from inception to November 7, 2025. The 50 most-cited articles were identified and analyzed for citation count, citation density (citations per year), authorship, geographic origin, journal distribution, and keyword frequency. Studies were categorized by design and evaluated according to the Oxford Centre for Evidence-Based Medicine levels of evidence. Concise summaries were generated to facilitate access to key findings. Published between 2004 and 2023, the top 50 articles accumulated 4612 citations (mean 92.2, median 75.5). Citation density ranged from 3.9 to 32.5 citations per year. Plastic and Reconstructive Surgery was the most represented journal (n = 14). Asian institutions predominated, with Japan (n = 16) and Taiwan (n = 11) accounting for 54% of publications. Case series were the most common study design (n = 24). Most studies provided Level 4 or 5 evidence (74%), although two Level 2 randomized controlled trials were identified. Keyword analysis identified supermicrosurgery, lymphaticovenular anastomosis, and indocyanine green lymphography as the most recurring technical concepts. This bibliometric analysis highlights seminal publications underlying the development of supermicrosurgical techniques such as lymphaticovenous anastomosis and vascularized lymph node transfer. The results demonstrate a strong Eastern contribution to innovation. While observational studies predominate, the near-total absence of Level 1 evidence and the presence of only two Level 2 trials underscore the need for well-designed prospective comparative studies to establish standardized treatment algorithms.

Level of evidence: IV.

Breast remodelling after reconstructive surgery often requires secondary volume restoration and contour refinement. Autologous fat grafting (AFG) is widely used, whereas injectable body fillers are used in selected cases despite concerns regarding durability and late complications. We performed a systematic review with quantitative synthesis of available outcome data on post-reconstructive breast remodelling using AFG and injectable fillers. PubMed/MEDLINE, Embase (Ovid), Cochrane CENTRAL, and Scopus were searched from inception to October 2025. The review protocol was prospectively registered in PROSPERO (CRD420251113092). Primary clinical studies reporting outcomes after reconstructive breast remodelling with AFG and/or injectable fillers were included; systematic reviews were screened for reference identification but were not included as primary studies. Where clinical and methodological heterogeneity allowed, quantitative synthesis was performed using random-effects models in Review Manager (RevMan) 5.4. Heterogeneity thresholds were predefined using the I² statistic, and publication-bias analyses were limited to outcomes with sufficient study numbers. Twenty-three primary studies met inclusion criteria. For AFG, pooled 12-month volume retention was 63.7% (95% CI 58.4-69.0; random-effects model; I² = 42%), with pooled retention of 56.2% (95% CI 51.1-61.3) at 24 months. Filler studies generally reported lower 12-month durability (approximately 31-45%), but were heterogeneous in product type, definitions, and follow-up, limiting formal pooling. Across reporting studies, AFG generally showed favourable aesthetic and patient-reported outcomes, while permanent and semi-permanent fillers were more frequently associated with clinically significant late complications including migration, chronic inflammatory reactions and secondary intervention. Current evidence supports AFG as a well-established option for post-reconstructive breast remodelling in appropriately selected patients, whereas evidence for permanent and semi-permanent fillers remains limited and heterogeneous due to less favourable risk-benefit profiles.

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Soft-tissue coverage of the forefoot, especially for irregular and extensive skin defects, is challenging for reconstructive surgeons because of the complex biomechanical properties and the high sensitivity of the plantar region. In this study, the efficacy of a combined approach utilizing a medial plantar artery perforator flap (MPAPF) and an anterolateral thigh perforator flap (ALTPF) for complex forefoot reconstruction was evaluated. A retrospective case series was conducted. From May 2018 to October 2023, six patients with complex forefoot defects underwent reconstruction using both an MPAPF and an ALTPF. The cohort comprised four males and two females aged 19-67 years. Data on patient demographics, injury etiology, flap size and survival, time to initial weight-bearing, and restoration of protective sensation were analyzed using descriptive statistics. All the flaps were free transplants, and no cases of vascular crisis were reported. MPAPF sizes ranged from 4.0 cm × 6.5 cm to 8.0 cm × 11.5 cm, whereas ALTPF sizes varied from 6.5 cm × 8.5 cm to 11.5 cm × 15.0 cm. During 8-27 months of follow-up, all patients achieved full weight-bearing within 3 months (mean 11.2 weeks). Protective sensation was restored in 83.3% (5/6) of the patients within 6 months and in the remaining 16.7% (1/6) of the patients within 8 months. The flaps exhibited good color and texture, and durable, sensitive coverage was observed in all the cases, with no recurrence of ulceration or major complications. The combined use of an MPAPF and ALTPF provides a feasible and promising strategy for complex forefoot reconstruction, resulting in reliable functional and sensory recovery with satisfactory aesthetic outcomes.

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Gynecomastia is the most common breast condition in pediatric and young adult males, yet large-scale studies evaluating its etiologies, risk factors, and management remain scarce. In adolescents, gynecomastia is most frequently idiopathic or obesity-related, while secondary causes are rarer. Persistent presentations may cause psychosocial distress and lead to surgical correction, though the optimal diagnostic approach remains controversial. We conducted a retrospective, population-based study of 19,640 males aged 10-25 years with documented gynecomastia diagnosis, extracting demographic and clinical variables including age, body mass index (BMI) Z-scores, family history, comorbidities, medication exposure, and surgical status. Reporting was in accordance with the STROBE guidelines. Most patients were idiopathic (74.3%), followed by medication-related (23.1%) and pathology-associated (3.4%). For patients with pathology-associated cases compared with other etiologies, the mean age and mean BMI Z-score were higher, and surgeries were more frequent (all p < 0.001). The prevalence of pathology increased with age, whereas obesity-related and familial cases predominated in younger children. Morbid obesity was significantly associated with higher surgical rates (5.2% vs. 2.1% in non-obese, p < 0.001). Independent associations with surgical intervention included older age (odds ratio (OR 1.20), higher BMI Z-score (OR 1.30), &#x2265;2 affected siblings (OR 8.35), and testicular tumors (OR 14.06). Model discrimination (area under the curve = 0.973) was excellent. In conclusion, gynecomastia in younger boys is primarily idiopathic or obesity-related, while older adolescents are more often diagnosed with secondary causes. Age- and risk-tailored diagnostic strategies, including early screening for obesity, family history, and medication exposure may optimize management and guide surgical decision-making.

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The Foucher flap, based on the first dorsal metacarpal artery, is an effective solution for thumb reconstruction following trauma or oncologic resections. This technique allows for the preservation of thumb length and volume while keeping sensitivity and functionality. The success of this surgical approach depends on meticulous planning and execution. This retrospective study analyzes five key aspects related to flap planning and harvesting: defect location, preoperative vascular pedicle identification, flap design, surgical dissection and pedicle insetting. A total of 24 patients who underwent Foucher flap thumb reconstruction between 2013 and 2023 were evaluated. The artery was preoperatively identified using Doppler imaging in all cases. Flap transfer was performed either through subcutaneous tunneling or skin incision, depending on the pedicle's characteristics. Functional and aesthetic outcomes were assessed through the Kapandji score, two-point discrimination and patient satisfaction surveys. At an average follow-up of six months, all flaps survived entirely. The mean Kapandji score was 8.17 and two-point discrimination in the skin paddle averaged 5.92 mm. Patient satisfaction was high, with 79 % rating their outcome as ``excellent'' and 21 % as ``satisfactory.'' Clinical evaluations confirmed favorable functional and aesthetic results. The literature review and clinical data support the Foucher flap as a reliable technique for thumb reconstruction. Careful preoperative planning and precise execution are essential to optimizing functional and aesthetic outcomes, minimizing complications and improving patients' quality of life.

Breast reconstruction following mastectomy is a critical aspect of oncologic care, and the choice of implant placement significantly impacts clinical outcomes. This study evaluates the safety and efficacy of prepectoral vs subpectoral positioning of polyurethane-coated Microthane&#x24c7; implants, focusing on complications and the necessity of additional devices. A retrospective cohort study was conducted of 93 consecutive patients (117 implants) treated between 2013 and 2019. The study analyzed outcomes over a median follow-up of 3.95 years, with a range reaching 7.2 years. Using statistical methods, demographic factors and complication rates, including the impact of radiotherapy, were compared. Prepectoral placement exhibited a lower overall complication rate than subpectoral placement with a high statistical significance: p-value = 0.0128. The data support the standalone use of Microthane&#x24c7; implants in the prepectoral position without adjunctive devices such as meshes or ADMs (acellular dermal matrices), enhancing recovery and minimizing costs. Despite the use of post-surgery radiotherapy on Microthane&#x24c7; implants, the incidence of overall capsular contracture (CC) remains consistently low, with a rate of 12%. Moreover, analyzing the complications in the case of radiotherapy (both pre- and post-surgery) in prepectoral and subpectoral positions, it was statistically defined that radiotherapy was not a confounding factor. Prepectoral positioning of Microthane&#x24c7; implants offers superior outcomes compared to subpectoral placement, challenging current norms in breast reconstruction practices. The use of Microthane&#x24c7; implants in the prepectoral position allows one to take all the advantages of the prepectoral position without additional costly devices as typically required for textured implants.

Fingertip injuries are a common yet significant subset of hand injuries, often resulting in functional impairment due to the intricate anatomy of the fingertip. These injuries can lead to substantial disability and financial burdens on healthcare systems. This study aims to analyze the epidemiology, injury patterns, and management strategies of fingertip injuries treated at North Medical Tower Hospital, Saudi Arabia, with the goal of informing clinical practice and prevention strategies. A retrospective review was conducted of 105 patients treated for fingertip injuries at North Medical Tower Hospital, Saudi Arabia between January 2023 and September 2024. De-identified medical records were reviewed for demographic, clinical, and treatment data. Statistical analysis was performed. Descriptive statistics were used to summarize demographic and clinical variables and to describe injury patterns and management strategies. A total of 105 patients were included, comprising 77 males (73.3%) and 28 females (26.7%), accounting for 138 fingertip injuries. Amputations were the most frequent injury type (n = 60, 43.5%), followed by fractures (n = 31, 22.5%) and lacerations (n = 19, 13.8%). Crush injuries represented the predominant mechanism of injury (n = 54, 50.9%), with door-related injuries being the second most common cause (n = 27, 25.5%). Among patients with fingertip amputations, management most commonly involved primary wound closure (n = 24) or flap-based reconstruction (n = 9), while remaining cases were managed with secondary healing or alternative approaches based on injury severity. Fractures were primarily treated with splint immobilization (n = 11) or K-wire fixation (n = 6). Fingertip injuries, particularly amputations and fractures, are common across both pediatric and adult populations and are predominantly related to crush and door-related mechanisms. These findings highlight the need for targeted preventive strategies in domestic and industrial settings. Future prospective studies incorporating standardized functional, sensory, and patient-reported outcome measures are required to refine injury-specific, evidence-based management algorithms for fingertip injuries.

Hidradenitis Suppurativa (HS) is a debilitating auto-inflammatory condition which typically occurs in the skin folds of the body such as the axilla, groin, gluteal and perianal regions. It is characterized by painful nodules which can develop fistulas and abscesses. Disease affecting the perianal region in particular requires multi-disciplinary input due to involvement of deeper structures. The HS multidisciplinary team (MDT) meetings held at Princess Alexandra Hospital (PAH) are held with the collaboration of dermatology, plastic surgery, colorectal surgery and radiology teams to manage complex HS cases across Queensland. Magnetic resonance imaging (MRI) is the modality of choice at this unit for patients with complex anogenital disease. An additional unique service that is offered at PAH is three-dimensional (3D) virtual modeling using these MRI scans. We believe that this provides a valuable tool for the MDT team in decision making and also for patients to better understand their disease. We aim to present a case series of eight patients with complex anogenital HS who received 3D virtual modeling of their MRI scans and outline our workflow for referrals. We believe that 3D virtual reconstructions of MRI scans for complex anogenital HS cases are valuable in assisting decision making for clinicians. We hope that with ongoing optimizations in MRI sequences and advancements in 3D technology, this can become a more readily available tool for clinicians involved in the treatment of HS.

Low-temperature dielectric-field heating has emerged as a non-ablative modality that selectively engages water-rich dermal and fibro-septal structures while sparing adipose tissue. Operating within a controlled thermal-shock window (&#x223c;42-45 &#xb0;C), the Dermis Layer Targeted Dielectric Heating System (DLTD) -when utilized at low-to-moderate intensity levels-induces reversible collagen recoil and early dermal tightening without high-temperature injury. Although conceptually suited for mid- and lower-face rhytids, clinical data remain limited. To evaluate the clinical efficacy, three-dimensional structural elevation, and safety of a single DLTD session, applied within a low-to-moderate energy range, for improving nasolabial folds and marionette lines in Asian women. Thirty-two women aged 35-65 years with visible nasolabial folds and marionette lines received one DLTD session delivered at low-to-moderate intensity levels along the midface-to-lower-face axis. Outcomes were evaluated at baseline, immediately after treatment, and at weeks 4 and 8. Wrinkle severity was assessed using WSRS and the Merz scale, and structural changes were quantified by 3D vector analysis of midface elevation and marionette descent. GAIS ratings were obtained at week 8, and pain and adverse events were documented. WSRS improved from 3.1 to 2.0 (35.5%), and Merz scores from 2.6 to 1.9 (26.9%) at week 8. Three-dimensional analysis showed progressive vertical elevation and improved perioral support, with midface elevation increasing from +0.6 mm to +1.9 mm and marionette descent improving from -0.4 mm to -1.2 mm. At week 8, 95% of investigator and 92% of patient GAIS ratings indicated improvement. Pain was minimal (0.4/10), and no serious adverse events occurred. A single DLTD session at low-to-moderate intensity produced consistent wrinkle reduction, measurable three-dimensional structural elevation, and high satisfaction with negligible discomfort and no downtime. These findings support DLTD as a promising non-ablative option for mid- and lower-face rejuvenation. Larger controlled studies are needed to establish long-term durability and comparative efficacy.

Fibrin glue neurorrhaphy (FGN) has demonstrated functional improvements for traumatic peripheral nerve injuries (PNI) in preclinical studies; however, evidence regarding its clinical effectiveness in humans remains limited. Recent advances in regenerative medicine, particularly involving biologics such as platelet-rich plasma (PRP), represent an innovative therapeutic strategy that leverages its neuroprotective, anti-inflammatory, and immunomodulatory effects as well as trophic support for tissue regeneration. To assess the safety and effectiveness of these approaches, we conducted a systematic review comparing FGN and microsuture neurorrhaphy (MN), used either individually or in combination with biologics, for primary peripheral nerve repair. Systematic literature searches were conducted across multiple databases from 1990 to 2025 in accordance with PRISMA guidelines, and the protocol was registered with PROSPERO. The primary outcome of interest was motor and sensory functional recovery and safety. Other outcomes included neurophysiological examinations, pain or discomfort and operating time. The Revised Cochrane Risk of Bias Tool for Randomized Trials(RoB2) and Newcastle-Ottawa Scale(NOS) were used to assess the risk of bias. A total of 164 patients from six studies were included. The mean patient age was 31.43 years, and 61.6% were female. Compared with MN, FGN achieved comparable motor and sensory recovery while offering shorter operative times and simpler technical execution. When combined with PRP, faster functional recovery was observed, and no major complications were reported. FGN may represent a sutureless alternative to MN with comparable functional outcomes in selected patients for primary peripheral nerve repair. The adjunctive use of PRP may facilitate nerve regeneration and improve functional recovery without introducing major safety concerns. However, given the heterogeneity of nerve types and the high risk of bias among included studies, these findings should be interpreted with caution, and require confirmation in adequately powered future studies.

Keloidal scars are benign lesions, and treatment is primarily directed toward symptom relief and cosmetic implications. Given the risk factors, clinical appearance and high recurrence rate, there is no universally accepted treatment. Currently, radiotherapy after surgical excision is recognized as the most efficacious modality. The aim was to compare the efficacy, by means of recurrence rates, between surgical excision alone, electron beam radiotherapy performed after surgical excision, and brachytherapy performed after surgical excision. This retrospective observational study included 27 patients with overall 48 keloids. Patients were divided into three groups: Group 1 (8 patients, 15 keloids) underwent surgical excision alone; Group 2 (10 patients, 19 keloids) received excision plus brachytherapy; Group 3 (9 patients, 14 keloids) received excision plus electron beam radiotherapy. Follow-up evaluations were conducted at 6 months and 2 years. Surgery combined with radiotherapy showed significantly lower recurrence rates compared to surgery alone, confirming its superior efficacy. No significant difference was observed between brachytherapy and electron beam radiotherapy (p = 0.701 for patients, p = n/a for keloids), indicating both are effective options. In the subgroup of keloids &#x2265;5 cm, a trend toward lower recurrence was observed with brachytherapy compared to electron beam therapy. The present study confirms that surgical excision of keloids followed by radiotherapy can be an effective method of keloid treatment. Although no significance was found when comparing the two radiotherapeutic modalities, brachytherapy showed better clinical advantage when treating larger lesion as well as alleviating the symptoms caused by keloids.

Wide Awake Local Anesthesia No Tourniquet (WALANT) for hand surgery in children and adolescents remains limited due to concerns regarding patient cooperation. This systematic review aims to synthesize the existing evidence on WALANT in the pediatric population to guide future directives. This systematic review was performed in accordance with PRISMA guidelines. In June 2025, a comprehensive search of MEDLINE, Embase, Web of Science, and CENTRAL was conducted. All studies reporting on WALANT in patients <18 years old were retrieved without date restrictions. For those meeting inclusion criteria, study and patient characteristics, interventions, and outcomes were extracted and analyzed. In addition, study quality was assessed based on the Oxford Centre for Evidence-Based Medicine Levels of Evidence. Eleven studies were identified, including 441 patients and 507 procedures. No major complications were documented, and conversion to sedation or general anesthesia was required in only 0.6% of patients. Overall, the procedures were successful, as shown by consistent improvements in hand function. Patient feedback suggested high levels of satisfaction and minimal perioperative pain. Additionally, certain studies observed marked reductions in operative time, room time, recovery time, hospital stay, and costs. Although the literature is limited, our findings demonstrate that WALANT is a safe, feasible and effective alternative to systemic anesthesia in children and adolescents. Key considerations include appropriate patient selection, child-centered communication strategies, distraction techniques, and supportive environments. This supports the broader integration of WALANT into pediatric practice. However, further research is warranted to optimize patient experience and assess institutional benefits.

There is very little published data on the epidemiology of breast cancer related lymphoedema (BCRL) in the Scottish population. In Scotland, BCRL is treated by a variety of practitioners across the country and there is no national system to audit outcomes. With recent advances in lymphatic surgery and new guidance from NICE, there is a group of patients who could benefit from prophylactic lymphatic surgery at the time of their primary breast cancer excision. In this short communication we review 5 years of referrals to the lymphoedema unit attached to the Edinburgh Breast Unit. We show the rate of upper limb lymphoedema was 14.6% after oncological breast cancer surgery, and patients undergoing sentinel node biopsy and breast conserving surgery had a 3.3% risk of breast oedema. Importantly, during the process of data collection, we noted how patient records are often fragmented across several electronic and paper record systems. There is a clear need here for a national managed audit network which would enable accurate data collection across health boards and could be used to monitor outcomes of lymphoedema therapy and lymphatic surgery. We suggest, to begin with lymphoedema data could be added to the cancer audit network QPI's (quality performance indicators). This would allow annual assessment of patient outcomes in a rapidly changing surgical field.

To summarize and contextualize current and future perspectives in the surgical treatment of lymphedema, exploring new techniques and technologies, integrated treatment modalities, and their real-time clinical applications. Lymphedema is a debilitating condition caused by impaired lymphatic flow. It diminishes quality of life (QoL) and often leads to other sequential comorbidities. There is no established cure, and the optimal treatment option remains debated. Understanding current and future surgical approaches, especially the preventive and curative role at early stages, would be valuable. A literature review was conducted using PubMed, Cochrane, and Google Scholar, including only high-impact systematic reviews, meta-analyses, and randomized controlled trials from the past 10 years. Lymphovenous anastomosis, vascularized lymph node transfer, and liposuction were among the most discussed surgical treatment options. Benefits include speedy volume reduction, greater QoL, and better wound healing. Microsurgical techniques greatly aided early-stage lymphedema. Fibrotic, irreversible lymphedema cases were better treated with reductive procedures and improved QoL. On the flip side, we are encountering limitations in standardization, resources, and the need for adjunctive conservative therapy while trying to make surgical treatment the mainstay. Technological advances like imaging and robotics, and future innovations like regenerative medicine show potential, but further high-quality, long-term studies are necessary for standardized, cost-effective, and widely accessible care. Modern surgical treatment for lymphedema offers safer, more effective, and more individualized solutions. To make these procedures a part of mainstream, multidisciplinary care, further development must go into training, standardizing protocols, and making them accessible.

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