Scientific Abstract Presentations: Research & Technology Session 5 Saturday, October 17 Sat, Oct 17 10:30 a.m.-12:30 p.m. CDT

Background: Pressure injuries affect approximately 2.5 million individuals annually in the United States and represent a substantial economic burden, with costs exceeding $26 billion per year. Early identification and accurate staging are critical to prevent progression and reduce treatment costs. Recently, multimodal artificial intelligence (AI) chatbots, including large language models (LLMs), have gained growing image interpretation capabilities. Their potential role in assisting frontline clinicians with rapid pressure injury assessment needs to be elucidated. Methods: The National Pressure Injury Advisory Panel (NPIAP) staging system is widely used as a gold standard for evaluating the severity of pressure injury. In addition, the DESIGN-R classification is also used for the detailed evaluation developed in Japan. The DESIGN-R score ranges from 0 to 66, evaluating depth, exudate, size, inflammation/infection, granulation tissue, necrotic tissue, and undermining. Two leading AI chatbots-GPT-5.2 (OpenAI) and Grok 4.1 (xAI)-were prompted with: "Here is a suspected pressure injury on [location]. Can you evaluate the stage of this lesion according to (1) NPIAP classification and (2) DESIGN-R classification?" Each image was queried 10 times (total 440 responses) in February 2026. Accuracy was compared against clinician-established staging. For the second query, the AI-generated DESIGN-R score was considered correct if it was within 5 points of the clinician-assigned score. Statistical comparisons were performed using t-tests and chi-square analyses, with P < 0.05 considered significant. Results: A total of 44 clinical pressure injury images were used, including 8 Stage 1, 8 Stage 2, 4 Stage 3, 4 Stage 4, 12 Unstageable, and 8 suspected deep tissue injuries (sDTI). For NPIAP staging, GPT-5.2 demonstrated a mean accuracy of 98.2 ± 5.4%, significantly outperforming Grok 4.1 (62.7 ± 9.0%, p < 0.001). GPT-5.2 accurately identified Stages 1 (p < 0.001), 3 (p = 0.001), and 4 (p < 0.001) pressure injuries, and suspected deep tissue injuries (p < 0.001), whereas Grok 4.1 presented significantly lower accuracy across these stages. For DESIGN-R scoring, GPT-5.2 achieved 75.5 ± 7.48% accuracy, compared to 21.8 ± 6.35% for Grok 4.1 (p < 0.001).
Conclusions: This study showed that GPT-5.2 presented excellent performance in NPIAP staging and moderate performance in DESIGN-R scoring. These advanced multimodal LLMs demonstrated high accuracy in classifying pressure injury stages using clinical images alone. These findings suggest potential roles for AI chatbots in screening, triage, and remote wound assessment, particularly in resource-limited settings. However, further validation is necessary before integration into routine pressure injury management workflows.

Introduction: Lymphedema is a chronic condition caused by impaired lymphatic transport and is classified as primary (hereditary) or secondary (acquired). Population-level estimates remain limited because of heterogeneous etiologies, inconsistent diagnostic coding, and underrecognition. While breast cancer–related lymphedema has been well characterized, large-scale longitudinal studies capturing both primary and secondary lymphedema across diverse populations are scarce. We evaluated temporal trends in incidence, prevalence, and demographic disparities using multicenter real-world data.

Methods: We conducted a retrospective cohort study using the TriNetX Global Collaborative Network, including patients with at least one healthcare encounter between January 1, 2016, and December 31, 2025. Individuals with a prior diagnosis of lymphedema were excluded. Incident lymphedema was identified using ICD-10 codes for hereditary (Q82.0), postmastectomy (I97.2), and lymphedema not elsewhere classified (I89.0). Annual incidence and prevalence were estimated using TriNetX analytic tools, with cross-stratified incidence tables exported for external analysis. Incidence rates were calculated per person-year. Adjusted incidence rate ratios (IRRs) and 95% confidence intervals (CIs) were estimated using multivariable negative binomial regression with a log person-time offset, adjusting for calendar period, sex, age, race, ethnicity, and lymphedema subtype. Sensitivity analyses assessed the impact of masked small cell counts (<10) reported as 10.

Results: Among 136,675,514 patients across 166 healthcare organizations, 312,468 incident cases of lymphedema were identified. Annual incidence increased from approximately 50 to 168 cases per 100,000 person-years between 2016 and 2025, while prevalence rose from 134 to 536 per 100,000 persons (Figure 1). Incidence increased with age, peaking at 65–69 years, and was consistently higher among women. Ten-year cumulative incidence and prevalence per 100,000 persons were 5 and 9 for primary lymphedema, 13 and 29 for postmastectomy lymphedema, and 247 and 483 for secondary lymphedema not elsewhere classified. In adjusted analyses, incidence was higher in 2021–2025 compared with 2016–2020 (IRR 1.40, 95% CI 1.34–1.45; p<0.001), and female sex remained independently associated with increased risk (IRR 1.30, 95% CI 1.25–1.36; p<0.001). Compared with White individuals, adjusted incidence was higher among Black (IRR 1.71, 95% CI 1.60-1.82), Asian (IRR 1.48, 95% CI 1.36-1.57), and American Indian/Alaska Native or Native Hawaiian/Other Pacific Islander individuals (IRR 5.58, 95% CI 5.22–5.96), as well as among individuals of Hispanic ethnicity (IRR 1.71, 95% Cl 1.63-1.80); all p<0.001). Collapsing smaller racial strata improved estimate stability.

Conclusions: Lymphedema incidence increased markedly over the past decade and varied independently by sex, age, race, ethnicity, and disease subtype. Adjusted analyses uncovered substantial demographic disparities that were not evident in unadjusted comparisons, emphasizing the importance of risk-adjusted population estimates. Secondary lymphedema accounted for the majority of cases, reflecting substantial diagnostic heterogeneity. These findings highlight a rapidly growing and uneven population burden of lymphedema and support the need for improved epidemiologic surveillance, standardized diagnostic approaches, and targeted prevention and rehabilitation strategies to address inequities in care.

Background: Medical student research productivity has become a defining currency in plastic surgery residency selection. However, the magnitude, acceleration, and structural implications of student authorship within the specialty's literature remain undefined at scale. We applied AI-enabled large-scale authorship extraction to test the hypothesis that medical student authorship has undergone a measurable structural inflection over the past decade.

Methods: Using automated AI-based bibliometric scraping and credential-parsing algorithms, we analyzed all publications from January 2010 through December 2025 across three major journals: Annals of Plastic Surgery, Plastic and Reconstructive Surgery, and PRS Global Open. Authors were classified as medical students based on bachelor-level credentials (e.g., BS, BA, BSc, BEng) without concurrent MD-equivalent or doctoral degrees. Only U.S.-affiliated publications were included. Natural language processing pipelines extracted authorship position, institutional affiliation, and team size.

Temporal trends were evaluated using segmented (interrupted time-series) regression to detect slope changes between early (2010–2017) and late (2018–2025) eras. Annual proportions of medical student first authorship were modeled using linear regression with interaction terms to estimate differential slope coefficients across eras. Model assumptions were assessed through residual diagnostics. Differences in team size were compared using parametric testing with two-sided significance set at p < 0.05.

Results: A total of 13,723 U.S.-affiliated publications were included. Medical students appeared on 4,227 manuscripts (30.8%) and served as first author on 2,135 (15.6%). Segmented regression demonstrated a significant positive slope change in first-author medical student publications beginning in 2018 (interaction coefficient beta > 0, p < 0.001), corresponding to a 143% increase in mean annual first-authored output (77.8 vs. 189.1 publications per year). The proportional contribution of medical student first authors rose from 10.5% in the early era to 18.9% in the late era, peaking at 24.3% in 2022.

Authorship network expansion paralleled this rise. Publications with at least one medical student author had significantly larger author teams compared to those without medical students (mean 6.14 vs. 4.01 authors; mean difference 2.13; p < 0.001). Even when occupying first position, medical students were embedded within larger collaborative structures (mean 5.45 authors; p < 0.001). Institutional concentration analysis revealed disproportionate first-author output among a limited subset of academic centers, suggesting clustered mentorship and research infrastructure effects.

Conclusions: Medical student authorship in plastic surgery has not merely increased-it has undergone structural acceleration consistent with a redistribution of academic labor. In recent peak years, nearly one in four first authors has been a medical student. AI-enabled large-scale bibliometrics reveal a specialty increasingly shaped by early-career investigators operating within expanding collaborative networks. These findings suggest a paradigm shift in authorship dynamics within plastic surgery and raise important questions regarding mentorship structures, academic stratification, and the downstream implications for residency selection and workforce development.

Exosomes are nano-sized intercellular messengers that have been proposed as regenerative adjuncts for plastic surgery. Through their cell-free abilities to affect multiple modulatory pathways at once, exosomes have been suggested for use in flaps and skin grafts in order to improve survival. To evaluate their efficacy for this indication, this systematic review and meta analysis was registered on PROSPERO (CRD420251146650) and conducted according to PRISMA 2020. PubMed, OVID, Scopus, Web of Science, and Google Scholar were searched through September 2025 and 25 animal studies (19 flap; 6 skin graft) were included. To ensure statistical precision, meta-analysis was only performed on outcomes with studies k≥10, whereas secondary outcomes with k≤10 were synthesized narratively. Results were favourable for exosomes, though heterogeneity (I2 76-97%), funnel plot asymmetries, and Egger's test limit the significance of these findings. Random-effects determined that exosomes significantly increased flap survival (k=19; MD 35.54%; 95% CI 25.11–45.97; p<0.0001) and angiogenesis (k=19; SMD 3.60; 95%CI 2.66–4.54; p<0.00001). Notable improvements in flap perfusion, VEGF, and apoptosis were also observed. Exosome-treated skin grafts exhibited increased graft take by days 10 and 14 post-op. Subgroup exploration indicated that human-derived and ADSC-exosomes were more beneficial than animal-derived and BMSC-exosomes, respectively. SYRCLE determined 22/25 studies had overall low risk of bias, although allocation concealment, blinding, and random housing were unclear. These findings support the use of exosomes in high-risk aesthetic and reconstructive surgeries involving flaps and grafts. Whilst promising, there remain a number of barriers to widespread adoption, in particular, affordability, clinical access, and regulatory approval.

Background: Chronic diabetic wounds remain a major clinical challenge due to persistent inflammation, impaired angiogenesis, and delayed tissue regeneration. Recent studies showed stem cells- derived extracellular vesicles (EV) possess substantial therapeutic potential across various pathological conditions, including chronic wound healing In this study, the authors investigated that EV from adipose-derived stem cells (ADSC-EVs) with normoxic or hypoxic condition could accelerate wound closure through rescuing the function of keratinocytes and fibroblast in diabetic wound healing. Materials and Methods ADSC-EVs were isolated from adipose tissue, cultured under hypoxic conditions to induce the release of extracellular vesicles (h-EVs) and compared with normoxia-induced extracellular vesicles (n-EVs). We assessed the functions of h-EVs on human skin fibroblasts (HSFs) and human keratinocyte in vitro. In addition, in vivo a diabetic mouse wounding model (A round, 10x10mm-diameter, full-skin defect was performed on the back skin of each mouse) was established to assess the curative effect of h-EVs and n-EVs in diabetic wound healing. Mice aged 8 weeks were divided randomly into the normoxic (n-EV) -treated diabetes group, hypoxic-EV treated group, the phosphate-buffered saline (PBS)-treated diabetes group, and the PBS-treated normal group. EVs in each groups were administered topically at concentrations of 10⁷ and 10⁹ particles per wound, three times per week. The wound closure kinetics, average healing time, reepithelialization rate, and neovascularization were evaluated by histological staining. Immunohistochemistry revealed reduced CD45⁺ inflammatory infiltration, increased Ki67⁺ epithelial proliferation, and enhanced collagen deposition at days 10 and 17, confirming both anti-inflammatory and regenerative effects. Results ADSC isolated EVs exhibited characteristic morphology, particle size, and specific protein markers (CD9, CD81, and Alix), confirming their purity and identity. In vitro studies demonstrated that normoxic-EVs (n-EVs) and hypoxic-EVs (h-EVs) both significantly enhanced fibroblast and keratinocyte proliferation and migration in a dose-dependent manner without cytotoxicity. In vivo, a streptozotocin-induced diabetic wound mouse model was used. The results revealed both types of EV (n-EVs and h-EVs) accelerated wound closure. However, h-EVs showing superior regenerative efficacy. Histological and immunohistochemical analyses revealed that h-EVs reduced CD45⁺ inflammatory infiltration, increased Ki67 and VEGF expressions, and enhanced fibronectin deposition, indicating improved inflammation resolution, angiogenesis, and extracellular matrix remodeling. Conclusion: Our study findings demonstrate that Hypoxic-conditioned EVs exert multifaceted therapeutic effects, integrating anti-inflammatory, pro-angiogenic, and pro-regenerative mechanisms to accelerate diabetic wound healing. The high safety, scalability, and molecular efficacy highlight ADSC-EVs as a promising next-generation, cell-free therapy for chronic and ischemic wounds, offering a clinically translatable approach in regenerative medicine.

Introduction The American Board of Plastic Surgery's oral certifying examination is the capstone of plastic surgery training, requiring consistent demonstration of clinical judgment across complex, evolving clinical scenarios (1). Existing preparation is limited by scalability: high-quality mock oral examinations require expert faculty and are difficult to standardize. Artificial intelligence offers a new paradigm for surgical education by enabling adaptive, case-based dialogue with consistent delivery and rapid feedback (2). We developed an autonomous AI-powered oral board simulator tailored to plastic surgery and conducted a pilot evaluation to assess feasibility and validity.

Methods A large language model-based oral board simulator was developed to deliver Socratic case-based dialogue across core plastic surgery topics (2,3). Two cases were deployed: macromastia/reduction mammaplasty and flexor tendon injury (4,5). The system conducted real-time interactive examination and generated structured, case-specific feedback upon completion. Fourteen plastic surgery residents (PGY3–6) completed the AI session. Following completion, residents completed a structured post-session survey evaluating case-specific content validity and global performance domains. Responses were recorded on a 5-point Likert scale (1 = Strongly Disagree, 5 = Strongly Agree).

Results In the macromastia case, 78.6% of residents agreed or strongly agreed that the AI appropriately tested key elements of evaluation, patient selection, preoperative planning, and complication management; 71.4% endorsed appropriate testing of perioperative considerations, and 64.3% rated the case feedback as appropriate. The flexor tendon injury case performed similarly, with 78.6% endorsing appropriate testing of perioperative considerations, 71.4% endorsing appropriate testing of focused examination, preoperative planning, and complication management, and 50.0% rating the case feedback as appropriate. Overall utility was favorable, with 92.9% of residents agreeing that the tool provided a psychologically safe practice environment, 64.3% endorsing the tool as an effective modality for oral board preparation and 64.3% indicating intent to use the tool going forward. 57.1% recommended the platform as an adjunct to faculty mock exams.

Conclusion An autonomous, AI-driven oral board simulator is feasible to implement in a plastic surgery training environment and demonstrates strong early evidence of educational value and acceptability, particularly as a standardized adjunct to faculty-led mock oral examinations. This represents a pathway to increase access to ABPS-style practice, enabling consistent case delivery and structured feedback independent of faculty availability. More broadly, it demonstrates the potential of generative AI to democratize and scale surgical education.

References 1. ABPlasticsurgery.org. Accessed February 25, 2026. https://www.abplasticsurgery.org/candidates/oral-examination/oral-examination-process-requirements/ 2. Rao AS, Prasad S, Lee RS, Farrell S, McKinley S, Succi MD. Development and evaluation of an artificial intelligence-powered surgical oral examination simulator: A pilot study. Mayo Clin Proc Digit Health. 2025;3(3):100241. 3. Rao AS, Lee RS, Bott E, et al. The digital standardized patient: An artificial intelligence coach for cultural dexterity in surgical care. J Am Coll Surg. 2025;241(5):887-894. 4. Perdikis G, Dillingham C, Boukovalas S, et al. American Society of Plastic Surgeons evidence-based clinical practice guideline revision: Reduction mammaplasty. Plast Reconstr Surg. 2022;149(3):392e - 409e. 5. Tang JB. Indications, methods, postoperative motion and outcome evaluation of primary flexor tendon repairs in Zone 2. J Hand Surg Eur Vol. 2007;32(2):118-129.

Purpose There is a growing market demand for treatments that enhance muscle tone, improve physical performance, which promote overall well-being. Electrical muscle stimulation (EMS) systems have been developed for aesthetic body contouring, and clinical studies have demonstrated their safety and efficacy for this purpose. However, evidence of functional improvement has been limited and often lacking objective measurements. A new EMS device, designed to deliver rhythmic electrical stimulation to strengthen, firm, and tone muscles, was recently introduced and evaluated in a post-marketing study using both subjective assessments and objective performance tests.

Methods Participants were enrolled at a single U.S. site and assigned to either a Treatment or Control group. Subjects in the Treatment group received six weekly EMS sessions targeting the abdomen, quadriceps, gluteal, and hamstring muscles, and were followed 4-week after last treatment. Control group subjects attended three visits: baseline, week 5, and week 9 - aligned with the timeline of the Treatment group's last treatment and follow-up visit. Functional performance was evaluated. Participants also provided self-assessments of perceived improvement, and safety aspects were recorded throughout the study.

Results A total of 38 subjects were enrolled (19 subjects in each group). Body weight remained stable across all time points in both groups (P>0.05). Exercise tests showed statistically significant increases in muscle strength in the Treatment group before the final treatment and at follow-up compared with baseline (P<0.05), while no significant changes were observed in the Control group at the follow-up visits compared to baseline (P>0.05). Improvements in the Treatment group were significantly greater than in the Control group at both time points (P<0.05). Average prone hip extension repetitions increased by 68% before the final treatment and by 64% at follow-up (vs. −3% and −8%, respectively, in the Control group). Paced curl-up repetitions increased by 42% and 33% (vs. 5% and 6% in Controls), while seated quadriceps extension repetitions improved by 53% and 45% (vs. 5% and 4% in Controls). Side plank endurance increased by 73% and 71% (vs. −13% and −8% in Controls). In addition, 68% of participants in the Treatment group reported that their muscles felt stronger and firmer at both final assessment visits. Treatments were well tolerated and considered pain-free, with a mean pain score of 1.20 ± 1.58 on a 0–10 scale. No adverse events were observed.

Conclusion EMS treatment demonstrated a favourable safety profile and effectively enhanced muscle tone and strength, supporting its role as a non-invasive option for improving muscle function and conditioning.

Background Didactic education is a core component of plastic surgery residency training and helps to prepare residents for both board certification and clinical practice. Despite its importance, there is no nationally standardized education curriculum, and contemporary data on educational practices are limited.

Methods A cross-sectional survey was distributed to program directors and coordinators of ACGME-accredited United States plastic surgery residency programs. Items assessed didactic structure, delivery format, curriculum design, exam preparation strategies, and perceived effectiveness. Descriptive statistics were performed.

Results Twenty-three programs responded (25.8% response rate). Programs reported a mean of 3.65 weekly didactic hours. All offered journal club, morbidity and mortality conference, and weekly teaching conferences, with variability in supplemental experiences such as simulation and cadaveric dissections. Most programs used hybrid in-person and virtual formats (60.9%), and none were exclusively virtual. Residents were protected from clinical obligations in most programs (78%). Curricula were typically guided by program leadership (73.9%) and national resources such as the Plastic Surgery Education Network (69.6%). Formal post-didactic assessments and humanities-based curricula were uncommon. Although nearly all programs expected advance preparation (95.7%), few provided structured preparatory materials (17.4%). Only two programs encouraged the use of artificial intelligence. Over half required a minimum PSITE score (54.5%), with a mean threshold of 32.5%. Few programs offered dedicated year-round time for PSITE preparation (28.6%). Perceptions of the PSITE's validity were mixed, with half of program directors believing the PSITE to be an accurate reflection of a resident's knowledge.

Conclusions Didactic education in plastic surgery residency remains heterogenous nationwide. Greater standardization, incorporation of assessment strategies, and thoughtful integration of emerging technologies may enhance equity, enhance learning efficiency, and optimize resident preparation.

Citations 1. Wickenheisser VA, Sergesketter AR, Carlson AR, Phillips BT. A National Characterization of Integrated Plastic Surgery Resident Educational Curricula. Plast Reconstr Surg. 2020;146(6):844e. doi:10.1097/PRS.0000000000007391 2. Luce EA. The Future of Plastic Surgery Resident Education. Plast Reconstr Surg. 2016;137(3):1063. doi:10.1097/01.prs.0000479982.67922.8a 3. Genovese A, Borna S, Gomez-Cabello CA, et al. The Current Landscape of Artificial Intelligence in Plastic Surgery Education and Training: A Systematic Review. J Surg Educ. 2025;82(8):103519. doi:10.1016/j.jsurg.2025.103519 4. Khansa I, Janis JE. Maximizing Technological Resources in Plastic Surgery Resident Education. J Craniofac Surg. 2015;26(8):2264. doi:10.1097/SCS.0000000000002198 5. Ali K, Colchado D, Davis MJ, et al. Online Resources in Plastic Surgery Education: A Toolbox for Modern Trainees and Plastic Surgeons. Plast Reconstr Surg – Glob Open. 2020;8(7):e2894. doi:10.1097/GOX.0000000000002894

Introduction: The development of ex vivo normothermic machine perfusion (NMP) models is essential for advancing skin xenotransplantation research. Before evaluating genetically modified tissues, it is critical to establish a stable and reproducible perfusion platform. The porcine Superficial Inferior Epigastric Artery (SIEA) flap is an excellent candidate for this purpose due to its anatomical similarities to human perforator flaps used in reconstructive surgery. This study aims to validate a standardized ex vivo NMP model using wild-type porcine SIEA flaps to serve as a baseline for future genetically modified skin studies. Methods: Five initial experiments were performed using SIEA flaps harvested from wild-type domestic pigs. The SIEA flap was selected for its consistent vascular pedicle and clinical relevance in plastic surgery. Following meticulous surgical dissection and isolation of the SIEA artery and vein, the flaps were weighed and connected to a custom-designed NMP circuit. The system utilized a centrifugal pump, a membrane oxygenator, and a heat exchanger to maintain normothermia (37ºC). A cell-free, nutrient-enriched preservation solution was used as the perforate. Perfusion was maintained for 4 hours, during which arterial pressure, flow rates, and pH were continuously monitored. Tissue viability was assessed via macroscopic inspection, capillary refill, and temperature stability. Results: Successful anatomical dissection and vascular cannulation were achieved in 100% of the experiments (n=5). The wild-type SIEA flap demonstrated a robust and predictable vascular architecture, facilitating reliable microvascular access. During the 4-hour NMP period, the flaps remained physiologically stable, with mean arterial pressures maintained between 40-60 mmHg. Mean flow rates remained consistent with physiological skin perfusion, and no significant edema or weight gain was observed. Macroscopic evaluation confirmed excellent tissue color, turgor, and prompt capillary refill throughout the experiments. The ex vivo system successfully maintained the physical and structural integrity of the porcine skin, demonstrating that the NMP platform can effectively sustain flap viability outside the donor organism for the duration of the study. Conclusions: This study successfully established a feasible and reproducible ex vivo NMP platform using wild-type porcine SIEA flaps. The stability of the physiological parameters and the preservation of tissue integrity confirm that this model is a reliable baseline for translational research. By validating the technique in wild-type animals, we provide a standardized protocol that can now be applied to evaluate genetically modified porcine skin such as GalT-KO. This platform bridges the gap between in vitro assays and complex in vivo transplantation, offering a high-fidelity tool for the preclinical validation of skin xenografts in reconstructive surgery. References: Stoerzer S, et al. Evaluation of αGal-KO Porcine Livers Using Normothermic Machine Perfusion. Transpl Int. 2024. Wu D, et al. New Hope for Treatment of Severe Skin Injury: Genetically Engineered Porcine Skin Xenotransplantation. Xenotransplantation. 2025. Kumar R, et al. Ex vivo porcine organ perfusion models as a suitable platform for translational transplant research. Artif Organs. 2017. Hidaka Y, et al. Perfusion Storage of Pig Kidneys and Relevance to Clinical Xenotransplantation. Xenotransplantation. 2025. Stelcer E, et al. Genetically Modified Pigs With α1,3-Galactosyltransferase Knockout: A Comprehensive Review. Front Immunol. 2025.

Background: Financial relationships between physicians and industry are under increasing scrutiny. While consulting payments have been a major focus, other forms of compensation may also influence interactions between surgeons and industry partners. This study characterizes the full scope of industry payments to academic plastic surgeons over a seven-year period. Methods: Data from the Open Payments database (2017–2023) were analyzed to identify all general, research, and ownership payments made to academic plastic surgeons in the United States. Surgeon characteristics-including educational background, fellowship training, research productivity (H-index, G-index, publication count), and years of clinical experience-were extracted. Payments were categorized by type, and trends were analyzed using descriptive statistics, linear regression, Lorenz curves, and Gini coefficients. Logistic and linear regression models identified surgeon characteristics associated with industry engagement. Results: A total of 886 plastic surgeons across 95 academic institutions were included. Between 2017 and 2023, the mean general payment per surgeon was $6,467 annually (SD $37,183; range $2–$878,411), with consulting fees comprising an average of 26% of total general payments. Overall, 233 surgeons (26.3%) received at least one consulting payment. In univariate analyses, factors associated with consulting payments included higher publication count (p<0.001), H-index (p<0.001), G-index (p<0.001), time since training (p<0.001), and additional academic degrees (p=0.028). In multivariable logistic regression, publication count, G-index, and time since training remained independently associated with consulting relationships, whereas fellowship training (p=0.3) and type of additional degree were not. Among consultants, higher G-index (p<0.001) was the only independent predictor of increased payment amounts. Payment distribution was highly unequal (Gini coefficient 0.80), with a small subset of surgeons receiving the majority of funds. Research payments were received by 18 surgeons (2.0%). Recipients demonstrated significantly higher publication count (p<0.001), H-index (p=0.003), G-index (p=0.002), and longer time since graduation (p<0.001). Research payment recipients were also more likely to receive consulting payments (6% vs. 0.6%, p<0.001). Ownership payments were exceedingly rare, with only five surgeons listed as recipients. All had also received consulting payments at some point during the study period, though the small sample size precluded meaningful statistical analysis. Conclusions: Industry payments to academic plastic surgeons are relatively common, with more experienced and academically productive surgeons more likely to serve as consultants. However, payment distribution is highly unequal, with scholarly impact as measured by G-index being the strongest correlate of payment magnitude. Research payments were rare but closely tied to academic productivity and more frequent among consultants. Ownership payments were nearly absent. Overall, citation-based indices demonstrated stronger associations with industry engagement than traditional metrics such as total publication count or fellowship training. Understanding these trends is critical for guiding institutional policies and promoting transparency in academic medicine.

Purpose: A 3D-photogrammetry-based facial anatomy curriculum integrating 3D/VR technology was developed and validated [1]. Yet, the long-term educational outcomes have not been assessed. In this study, we evaluated the attitudes of participants on 3D/VR-platforms in facial anatomy learning for advanced aesthetic procedures. Methods: A prospective REDCap-based survey was distributed to participants attending the Mayo Advanced Facial Anatomy Course. The survey captured demographics, previous familiarity with 3D/VR, pre- and post-session confidence (5-point Likert scale) across six facial regions, and perceptions of the educational value of 3D/VR learning. Descriptive statistics and paired comparisons were performed. Results: Out of 70 participants, 59 completed the pre- and post-course surveys, comprising 31.1% residents/fellows, and 62.2% consultants/surgeons, with a mean of 15.6 (±10.3) years in practice. Most were aged 35-44 years (46.7%), and the majority were male (86.7%). Only 18% reported familiarity with 3D/VR tools, and 81.2% were very interested in incorporating such technology into surgical education. Post-course, self-assessed confidence improved significantly across all facial regions (mean Δ= +1 on the Likert-scale; p < 0.05). Overall, 67.6% agreed that 3D/VR improved their understanding of facial aesthetic procedures and offered superior benefit compared to textbook-learning, and 91% would recommend 3D/VR anatomy tools to other learners. Conclusion: Integration of 3D and VR facial anatomy platforms yields measurable improvements in anatomical confidence and was perceived positively by trainees and faculty alike. These findings validate the educational value of immersive 3D-visualization and support its broader adoption in Plastic Surgery teaching curricula.

[1] Hussein SM, Emanuels AF, Leonel LCPC, et al. Facial Anatomy Teaching for Aesthetic Surgery: Using 3-dimensional Photogrammetry and Immersive Virtual Reality. Plast Reconstr Surg Glob Open. 2025;13(7):e6972. Published 2025 Jul 9. doi:10.1097/GOX.0000000000006972

Background & Hypothesis Amputations of digits and limbs are common, life-altering injuries, emphasizing the need for therapies that improve healing or even restore lost tissues. Mouse digit tip (MDT) regeneration serves as a unique model of partial limb regrowth, exhibiting comparable anatomic stages to other species capable of complete limb regeneration. Gene expression during digit regeneration is regulated in part by tissue regeneration enhancer elements (TREEs), which can be used to direct therapeutic genes using adeno-associated viral (AAV) vectors. Identifying and harnessing TREE sequences holds great promise for understanding the regenerative process and for use as tools in enhancer-based gene therapy for limb regeneration.

Methods & Results To find regeneration-associated enhancers, we profiled chromatin accessibility in MDTs 14 days post-amputation (dpa) versus uninjured digits using ATAC-seq. ATAC-seq identified hundreds of noncoding loci with increased accessibility during regeneration, enriched near promoters and distal regulatory regions of injury-responsive genes. Integrating single-cell and spatial data yielded 568 TREE candidates associated with blastema, nail matrix, or regeneration epidermis. To test the 568 potential elements in vivo at once, we implemented an AAV-delivered STARR-seq–style MPRA: ~725-bp genomic fragments were cloned into the 3′ UTR of a self-transcribing reporter in a self-complementary AAV backbone (scAAV[Exp]-SCP1>EGFP), so active enhancers drive their own barcoded transcripts (Figure 1). The enhancer library was packaged into AAV, administered systemically at 10 dpa. Serotype screening indicated AAV9 provided the most effective in vivo enhancer activation. The regenerating digit tips were collected at 14 and 21 dpa. Total RNA and genomic DNA were co-isolated, the variable region PCR-amplified and sequenced, and enhancer activity quantified by modeling RNA output normalized to DNA input with multiple-testing correction. The in vivo AAV-MPRA resolved subsets of elements with robust activity and clear temporal specificity - distinct profiles at 14 dpa (blastema formation) versus 21 dpa (tissue remodeling) - with a set of elements active at both stages. Consistently active candidates were linked to genes implicated in appendage repair, including Ror2 and Alox5. Ongoing studies will validate the top enhancers in vivo, and the leading candidate will then be used to investigate how enhancer-guided delivery enhances or accelerates MDT regeneration.

Conclusions Our results to date demonstrate a novel screening method for TREEs during MDT regeneration that couples chromatin accessibility profiling, single-cell/spatial expression maps, and in vivo AAV-based MPRA to discover and functionally rank TREEs. The resulting catalog and top-ranked elements clarify enhancer-mediated regulation in mammalian appendage regeneration and provide a toolkit for precision gene therapy, laying a foundation for stage-targeted AAV therapeutics.

Background The pathway to independent practice in plastic and reconstructive surgery demonstrates significant global heterogeneity (1). Training paradigms vary across international health systems, encompassing diverse models such as integrated, independent, and apprenticeship-based structures (2). Consequently, the criteria defining a resident's readiness for autonomous practice remain fragmented. With substantial differences in selection metrics, curricula, case volume requirements, and competency assessments, there is no unified consensus on how different systems conceptualize and produce a "competent" plastic surgeon (3). Therefore, this study aims to define the core structural and educational components that cultivate surgical competency across five regions.

Methods This mixed-methods study involved a PRISMA-ScR–guided scoping review and qualitative survey. The Population, Concept, Context framework was used for the search strategy, with population as plastic surgery trainees/residents, concept as training or education, and context as international comparison. A comprehensive search of Embase, PubMed, and Scopus was performed. Medical Subject Headings and keywords included "plastic surgery", "residency", "curriculum", "education", and country-specific identifiers. Three independent reviewers screened titles and abstracts, followed by full-text review for eligibility. Included articles described resident selection, program structure and curriculum, or assessment prior to independent practice. After duplicate removal, 254 records were identified; 76 underwent full-text review; 33 met final inclusion criteria. Data were extracted on entry pathway, prerequisite training, duration, supervision model, operative exposure requirements, progression framework, and summative assessment. To contextualize structural findings and incorporate cultural and regulatory perspectives, program directors or equivalent senior educators from each included country were surveyed using a structured questionnaire. Responses were analyzed qualitatively to understand (1) selection admission into plastic surgery residency (2) residency structure and curriculum (3) graduation; findings were integrated with scoping review data to refine cross-national comparisons of safety and surgical readiness.

Results An analysis was conducted of eight countries across five continents, namely, the United States, Brazil, Colombia, Kenya, Rwanda, the Netherlands, India, and Vietnam. Duration of post-medical school plastics training ranged from four to seven years. Admission thresholds varied and included national match systems with standardized eligibility criteria (United States, Netherlands), competitive super-specialty examinations following general surgery (India), and university-based selection after core surgical training (several Latin American and African systems). Training structures comprised both integrated direct-entry models for 3/8 systems and staged progression through general surgery prior to specialization for 5/8 systems. All programs incorporated graded operative autonomy, defined rotations across reconstructive and aesthetic domains, and perioperative decision-making. Mechanisms for competency verification differed, including milestone-based progression with operative minimums (United States, Netherlands), time-based progression with institutional logbook review, and national or university-administered exit examinations (India, multiple African and Latin American systems). Despite structural heterogeneity, all systems required formal summative assessment prior to independent certification.

Conclusion Across diverse global systems, while the form of assessment varies, each employs mechanisms of authorization of independent practice based on locally driven thresholds of safety. Readiness is not determined by a single universal metric, but rather training culture, societal expectations for surgeons accountability, and regulatory structure. These findings suggest that competency remains context-dependent and further investigation is warranted for cross-continent collaboration.

References: 1. Lindqvist EK, Noordzij N, Chopra S, Navia A, Cappuyns L, Khalaf A, Fernandez Diaz OF, Berner JE, Monshizadeh L, Murphy RX Jr. Plastic Surgery Training across Seven Continents: Results from the First Global Trainee Survey. Plast Reconstr Surg Glob Open. 2022 Oct 7;10(10):e4520. doi: 10.1097/GOX.0000000000004520. PMID: 36225841; PMCID: PMC9542936. 2. Zheng J, Zhang B, Yin Y, Fang T, Wei N, Lineaweaver WC, Zhang F. Comparison of Plastic Surgery Residency Training in United States and China. Ann Plast Surg. 2015 Dec;75(6):672-8. doi: 10.1097/SAP.0000000000000226. PMID: 25003423. 3. Courteau BC, Knox AD, Vassiliou MC, Warren RJ, Gilardino MS. The Development of Assessment Tools for Plastic Surgery Competencies. Aesthet Surg J. 2015 Jul;35(5):611-7. doi: 10.1093/asj/sju068. Epub 2015 Mar 26. PMID: 25818305.

Background: Achieving a symmetric and aesthetically pleasing scar is one of the primary determinants of success in abdominoplasty. Traditional marking methods using laser alignment tools rely on visual estimation and patient body habitus, which may lead to scar asymmetry. We propose a novel, low-cost surgical marking technique to enhance precision and reproducibility by using a commercially available laser device mounted on the central axis of the surgical light. This study aims to assess the efficacy of our novel surgical marking tool by comparing lipoabdominoplasty results with and without laser-guided cross-projection. Methods: A retrospective review of 25 female patients undergoing full lipoabdominoplasty with laser-guided preoperative markings was performed at a single outpatient center between April 2025 and June 2025. A commercially available cross laser device was mounted on the central axis of the surgical light, projecting perpendicular vertical and horizontal reference lines on the abdomen. The scar height discrepancy between lateral incision endpoints was measured postoperatively using digital calipers and standardized photographic analysis. Outcomes were compared to a historical cohort of 30 consecutive abdominoplasties performed by the same surgeon without laser guidance. Results: No marking-related or laser-associated complications were observed. The laser-guided group demonstrated significantly improved symmetry, with a mean lateral scar height discrepancy of 2.3 mm (range 0–4 mm) compared with 8.1 mm (range 4–14 mm) in the control group (p < 0.01).
Conclusions: Cross laser-guided marking significantly reduces scar asymmetry and also improves patient-reported satisfaction following abdominoplasty. This simple, cost-effective technique offers objective intraoperative alignment and may serve as a practical adjunct to enhance aesthetic precision, reproducibility, and surgeon confidence in body contouring surgery.

References 1. Wongkietkachorn A, et al. Laser-assisted abdominoplasty marking to achieve better design of abdominal scar. Plast Reconstr Surg Glob Open. 2024;12(8):e5611. 2. Horta R, Domingues J, et al. A ruler for abdominoplasty preoperative markings: The potential of best scar symmetry. Surgical Innovation. 2022;29(2):168–174. 3. Kyriazidis N, et al. A novel approach to incision marking in abdominoplasty using 3D printing technology. PRS Global Open. 2024;12:e4812. 4. Kelly MB, et al. Application of laser alignment to enhance nipple–areolar complex symmetry in breast surgery: A pilot technique. Aesthetic Plast Surg. 2016;40(5):682–688.

Background: Resident surgical preparedness is of the utmost importance in the setting of internal mammary (IM) vessel access for anastomosis in breast microsurgery. Our team previously developed an anatomical low-cost microsurgical platform for resident microsurgical skills training in the confines of the depressed cavity accessed during IM vessel anastomosis. Our previous model has been advanced to include an automatic cardiopulmonary simulation that increases the difficulty and realism to better prepare residents for the specific challenges of anastomosis of the deep inferior epigastric artery perforator (DIEP) flap.

Methods: Anatomic 3D models of the sternum and ribs were 3D-printed in poly-lactic acid (PLA) with a low-cost fused deposition modeling (FDM) 3D-printer (Ender 3). A platform was designed in Fusion 360 and 3D-printed, housing a solenoid-driven deflector to mimic the displacement of the ribcage during the cardiac cycle. A water bottle was equipped with an electrical air pump with pneumatic valves to control air flow. Circuits utilizing Arduino microprocessors were used to drive simulated respiratory and cardiac cycles, displacing the rib model according to realistic cardiac and pulmonary rates. The model was outfitted with a 3D-printed Richardson retractor, as well as replica mastectomy flaps and a DIEP flap made from medical supplies. Residents practice microsurgical anastomoses on the model during simulated cardiopulmonary cycles, evaluating the training platform with Likert scale questionnaires.

Results: The advanced cardiopulmonary model was found to be more challenging than earlier versions of the rib model, offering better training of hand positioning and improving subjective preparedness for IM vessel access during DIEP flap anastomosis. Specifically, the movement associated with the simulated cardiopulmonary cycle was found to encourage extra practice and promote better understanding of ergonomics unique to DIEP flap IM vessel access.

Conclusions: This advanced simulation model for microsurgical skills training provides new challenges for residents preparing for operative participation in the high-stakes setting of internal mammary vessel access in the third rib space. Residents noted that the training platform revealed new challenges, related to both general microsurgery skills and to the specifics of internal mammary vessel access. The model was produced at relatively low cost with a standardized protocol, facilitating reproduction by other teams worldwide.

Background The introduction of the venous microvascular coupler has transformed microvascular surgery, allowing for reliable and rapid anastomosis that significantly reduces ischaemic time and complication rates compared with hand-sewn anastomosis. However, arterial anastomosis remains technically demanding and time-critical in microvascular surgery. Whilst veins are easily anastomosed with a venous coupler system, arteries are required to be hand-sewn as existing coupling systems are limited by rigidity and poor compliance mismatch with native arterial vessels. A collagen-based coupler biomaterial may overcome the challenges of rigid synthetic couplers and allow for the rapid and effective anastomosis of arterial vessels.

Purpose This project aims to design and evaluate a 3D-printed novel collagen arterial anastomotic coupler for microvascular surgery.

Method A collagen-based arterial coupler was developed with enhanced radial compliance and precise luminal alignment. Devices were assessed for burst pressure, compliance, deployment accuracy, and degradation metrics using bench-top arterial flow models.

Findings Following iterative prototyping, a series of 10 arterial couplers were fabricated and evaluated in an in-vitro setting replicating physiological flow conditions. Secure anastomosis was achieved with sustained patency under physiologic pressures and mechanical performance met arterial flow requirements while maintaining compliance comparable to native vessels. Degradation rate was modifiable through choice of collagen subtype and could be modulated to occurred gradually without luminal compromise.

Conclusion This study supports the feasibility of a 3D-printed collagen arterial coupler for microvascular surgery. This approach addresses challenges associated with rigid venous coupler systems whilst offering a biologically integrated alternative to permanent devices, with potential to mimic the impact of the introduction of venous coupler systems and further reduce ischaemic time in microvascular surgery.

PURPOSE: Postoperative complications remain a major source of morbidity and cost following surgical procedures. Traditional risk stratification relies heavily on demographic factors, comorbidities, and perioperative clinical variables (1). Physical activity and sedentary behavior are increasingly recognized as important determinants of cardiometabolic health, immune function, and wound healing, yet their role in predicting surgical outcomes remains poorly defined (2). Wearable devices such as Fitbit offer an opportunity to objectively quantify habitual physical activity in real-world settings. The National Institutes of Health All of Us (NIH AoU) Research Program integrates electronic health records with longitudinal Fitbit data (3). Using this, we sought to evaluate whether habitual activity patterns are associated with postoperative complication risk.

METHODS: We conducted a retrospective cohort study of 7,161 adults in the NIH AoU Registered Tier Dataset (Version 8) with available Fitbit data who underwent at least one surgical procedure. Six-month postoperative complications were identified using standardized SNOMED-OMOP codes. Primary activity measures included mean and median daily steps, mean daily sedentary minutes, and mean daily active minutes. The primary outcome was any postoperative complication within 6 months of the index procedure. Multivariable logistic regression assessed associations between activity metrics and complications, adjusting a priori for age at procedure, sex at birth, body mass index, diabetes, chronic kidney disease, heart failure, and chronic obstructive pulmonary disease. Unsupervised k-means clustering was used to identify activity phenotypes, with complication rates compared across clusters. Statistical significance was defined as a two-sided p<0.05. Analyses were performed at the procedure level.

RESULTS: Among 7,161 participants contributing 41,438 surgical procedures, the 6-month postoperative complication rate was 5.0%. Most of the procedures were on female patients (67.8%). The three most frequent 6-month complications were pulmonary embolism (1.42%), bleeding (1.32%), and wound dehiscence (1.18%). Greater preoperative sedentary time was associated with increased odds of postoperative complications (OR 1.24 per SD increase, 95% CI 1.11–1.39; p<0.001), and remained significant after multivariable adjustment (Q3 vs Q1: OR 1.66, 95% CI 1.00–2.74; p=0.049). Daily step counts and active minutes demonstrated nonlinear associations with complications and were not independently significant per SD increase. Unsupervised k-means clustering identified four distinct activity phenotypes with complication rates ranging from 4.2% to 6.6%, with the lowest risk observed among patients with balanced activity profiles.

CONCLUSION: Wearable-derived preoperative activity metrics provide clinically relevant information for postoperative risk assessment, with sedentary behavior emerging as a key predictor of complications. Activity phenotyping using unsupervised clustering identified distinct risk profiles, suggesting that digital biomarkers may enhance preoperative risk stratification beyond traditional clinical factors.

REFERENCES: 1. Douville NJ, Kertai MD, Sheetz KH. Expanding the All of Us Research Platform Into the Perioperative Domain. JAMA Surg. 2025;160(2):220-221. doi:10.1001/jamasurg.2024.2343 2. Cambriel A, Tsai A, Choisy B, et al. Immune Modulation by Personalized vs Standard Prehabilitation Before Major Surgery: A Randomized Clinical Trial. JAMA Surg. Published online November 12, 2025. doi:10.1001/jamasurg.2025.4917 3. Master H, Annis J, Huang S, et al. Association of step counts over time with the risk of chronic disease in the All of Us Research Program. Nat Med. 2022;28(11):2301-2308. doi:10.1038/s41591-022-02012-w

Introduction: Fatal embolic events following gluteal fat grafting have traditionally been interpreted through the framework of macroscopic (MAFE) and microscopic (MIFE) fat embolism, concepts extrapolated from trauma-associated Fat Embolism Syndrome (FES). However, these models have never been validated histopathologically in aesthetic surgery and are largely based on clinical inference and gross autopsy findings.

Methods: This retrospective pathological study analyzed 51 consecutive deaths secondary to embolism following gluteal fat grafting in Colombia between 2002 and 2024 . Complete autopsy reports, macroscopic examinations, and detailed pulmonary histopathologic specimens were systematically reviewed. Findings were compared against established histologic features of trauma-related FES to determine whether aesthetic surgery–related deaths truly correspond to classical fat embolism syndrome.

Results: All patients were women (mean age 39 ± 12.2 years) who underwent combined aesthetic procedures including liposuction and gluteal fat transfer. The mean time from fat injection to death was 3.78 ± 6.48 hours, demonstrating an abrupt and catastrophic clinical course. Notably, 56.9% of patients died intraoperatively, and only 25.5% survived beyond 6 hours, limiting the development of a classical inflammatory syndrome.

Histopathologic analysis revealed a consistent and reproducible pattern across all cases. Pulmonary emboli were not composed of dispersed lipid droplets, as seen in classical FES. Instead, embolic material consisted of cohesive stromal–adipose tissue fragments containing intact adipocytes, fibrous septa, and preserved lobular architecture. These emboli produced acute mechanical obstruction of pulmonary arteries and arterioles without evidence of diffuse alveolar damage, alveolar–capillary membrane thickening, interstitial inflammation, or lipid-laden macrophages.

Two morphological patterns were identified: • Massive FACTES (n=31): Large composite stromal–adipose emboli associated with rapid hemodynamic collapse (mean time to death 2.29 hours). • Microscopic FACTES (n=20): Smaller but structurally identical emboli associated with relatively delayed deterioration (mean 5.95 hours; p=0.04). When compared to classical trauma-related FES, the distinction was unequivocal. In FES, pulmonary microvasculature contains free lipid droplets accompanied by endothelial injury, interstitial edema, inflammatory infiltrates, and alveolar–capillary membrane damage. In contrast, FACTES lungs showed preserved pulmonary architecture and absence of inflammatory response, supporting a purely mechanical pathophysiological mechanism.

Discussion: These findings demonstrate that post–gluteal fat grafting deaths are not a variant of trauma-induced FES, nor do they represent a size-based continuum (macro vs micro). Instead, they constitute a distinct pathological entity characterized by embolization of adipose–connective tissue complexes. We therefore propose the term Fat and Connective Tissue Embolism Syndrome (FACTES) to accurately define this mechanism.

The clinical implications are profound. Conventional management strategies derived from FES (anti-inflammatory measures, supportive oxygenation, corticosteroids) are unlikely to reverse FACTES because the emboli are solid, structurally intact tissue fragments that cannot be emulsified or metabolically degraded. Instead, management must address acute mechanical pulmonary obstruction. Early aggressive resuscitation, extracorporeal membrane oxygenation (ECMO), and consideration of surgical or endovascular embolectomy may represent more rational rescue strategies.

From a preventive standpoint, the cohesive nature of the embolic substrate underscores the importance of injection plane, intramuscular pressure, cannula trajectory, and real-time ultrasound guidance. The data support strict subcutaneous injection techniques and continuous attention to venous anatomy, including secondary perforating veins.

In conclusion, this study provides the first large-scale histopathological validation that fatal embolism following gluteal fat grafting is not explained by the MAFE/MIFE paradigm. Instead, it represents a distinct mechanical vascular syndrome - FACTES - requiring a conceptual shift in diagnosis, prevention, and management. Recognizing FACTES as a separate pathological entity establishes a new foundation for future translational research aimed at reducing mortality in aesthetic surgery.

Background: Optical loupes remain the standard magnification tool in plastic and craniofacial surgery, but prolonged use can contribute to ergonomic strain and visual fatigue during fine-motor tasks. Emerging digital loupe and near-eye visualization platforms aim to preserve magnified precision while expanding functionality through software features such as hands-free controls, augmented overlays, and AI-assisted capabilities. However, hands-on data are limited. We conducted an initial pilot evaluation of the NuLoupes digital loupes system and the NuEyes Pro 4 platform to characterize usability, perceived workload, and tolerability. Methods: A hands-on benchtop pilot session was conducted by one experienced craniofacial pediatric plastic surgeon, who evaluated two head-mounted systems: NuLoupes digital loupes and NuEyes Pro 4 smart glasses. NuLoupes provides stereoscopic near-eye visualization with adjustable digital magnification and working-view parameters for fine tasks. NuEyes Pro 4 is a lightweight binocular headset that serves as a USB-C-tethered external display driven by a compatible smart device. Standard device fit and clarity adjustments were performed prior to assessment. Using NuLoupes, the surgeon performed a fine-suturing task on a pre-marked 3D-printed infant cleft palate model, placing two 4-0 Vicryl sutures to assess technical feasibility under digital loupe visualization. After each device exposure, the surgeon completed validated human-factors instruments: the System Usability Scale (SUS; 0–100) and a modified NASA Task Load Index (NASA-TLX; mental demand, physical demand, temporal demand, performance satisfaction, effort, and frustration; each 0–10). Tolerability was assessed using symptom severity ratings (0–10; 0 = none, 10 = extreme) for neck strain, eye strain, and head/face pressure or discomfort. Outcomes were summarized descriptively. Results: The surgeon successfully placed two 4-0 Vicryl sutures on a pre-marked 3D-printed infant cleft palate model using NuLoupes, demonstrating technical feasibility for fine suturing on an anatomical model. NuLoupes demonstrated acceptable usability (SUS 70/100). Item-level responses indicated the system was perceived as easy to use, well integrated, confidence-inspiring, and appropriate for frequent use, with neutral perceived complexity and a perceived need for some technical support. NASA-TLX ratings (0–10) showed low mental demand and frustration (2/10 each), moderate temporal demand (6/10) and effort (5/10), high physical demand (8/10), and high performance satisfaction (9/10). Tolerability ratings indicated moderate neck strain (6/10) and eye strain (7/10) with severe head/face pressure or discomfort (9/10). In contrast, NuEyes Pro 4 demonstrated very high usability (SUS > 90/100) and was perceived as easy to use and learn. NASA-TLX for NuEyes Pro 4 showed low physical demand (3/10) and moderate mental demand (4/10) but higher temporal demand, effort, and frustration (7/10, 7/10, 8/10, respectively), with performance satisfaction of 8/10. Tolerability was markedly improved with NuEyes Pro 4 (neck 1/10, eye 2/10, head/face 1/10). Conclusion: In this pilot, NuLoupes supported technically feasible fine suturing with acceptable usability but was limited by substantial discomfort and high perceived physical demand. NuEyes Pro 4 demonstrated high usability and markedly better tolerability, albeit with higher perceived time pressure, effort, and frustration. These findings establish baseline human-factors performance and support larger multi-user studies and iterative design optimization to improve ergonomics and workflow for next-generation digital visualization platforms.

Aims In 2024, the UK experienced national shortages of Technetium-99m (Tc99), which compromised access to the established dual-tracer mapping technique for sentinel lymph node biopsy in melanoma. Emerging evidence has demonstrated that indocyanine green (ICG) is a reliable alternative in gynaecological, breast, and head and neck skin malignancies. To avoid treatment delays, our unit adopted ICG as a single-modality technique and evaluated its performance in limb melanoma.

Method A prospective analysis was conducted in a specialist skin cancer centre between April 2024 and October 2024 by a multi-consultant team. Patients underwent either dual-tracer mapping (Tc99/blue dye) or ICG alone during this period. Outcomes included sentinel lymph node (SLN) detection rate, nodal metastasis rate, and procedural failure.

Results A total of 129 SLNs were identified in 95 patients (mean age 63.6 ± 14.9 years). Sixty-two patients underwent ICG alone, while 33 received dual-tracer mapping. ICG identified a mean of 1.15 nodes per patient (±0.54), compared with 1.35 (±0.72) in the dual-tracer group. SLN identification failed in three groin cases using ICG and in one axillary case using dual-tracer mapping.

Both groups detected eight melanoma-positive SLNs. ICG identified metastases in seven patients (11.3% of patients; 11.3% of nodes), while dual-tracer mapping detected metastases in five patients (15.2% of patients; 13.8% of nodes).

Conclusion ICG alone demonstrated comparable detection rates and metastatic yield to dual-tracer mapping in limb melanoma. It provided a safe and effective alternative when Tc99 was unavailable, without compromising oncological outcomes. Extended follow-up will be required to assess false-negative rates and to enable evaluation of diagnostic sensitivity and specificity.