Algorithm-Guided Treatment of Ulna Impaction Syndrome: A 10-Year Follow-Up Study of Ulna Shortening Osteotomy and Wafer Procedure.

Background: Ulnar impaction syndrome (UIS) is a common degenerative wrist condition which results from positive ulnar variance, leading to an overload on the ulnar carpus. Ulnar shortening osteotomy (USO) and the arthroscopic wafer procedure (AWP) are established therapies for UIS if conservative management fails. This study assessed an algorithm-guided treatment of UIS over a period of 10 years. Methods: This prospective observational study compared the outcome of 54 patients who underwent either USO or AWP for UIS based on a predefined treatment algorithm. The mean follow-up period was 10 years. Primary outcome parameters were the visual analogue scale (VAS) for pain and the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH), whereas secondary outcome parameters were grip and pinch strength and range of motion. Results: The median preoperative ulnar variance was 2.6 mm in the USO group and 2.0 mm in the AWP group. The postoperative average ulnar variance was 0 mm in both groups. The preoperative pain at rest was 3.4 in the USO group and 2.3 in the AWP group. One year after surgery, there was a significant reduction to VAS 0.7 and 0.2, respectively. These results persisted to the 10-year follow-up (VAS 0.9 and 0.2). The pain in motion also decreased significantly in the first year (from 6.8 and 6.7 to 2.2 and 2.1), as well as after 10 years (2.4 and 1.0). The preoperative DASH score averaged 31.3 in the USO group and 35.8 in the AWP group. At the 10-year follow-up, the DASH of both groups decreased significantly to 4.35 in the AWP group compared to 12.7 in the USO group. Conclusions: Our data show that, when using our algorithm, both USO and AWP, two common operative treatment options of UIS, reliably reduce pain and significantly reduce the DASH score over at least a period of ten years. The results after 10 years differ from short-term results in so far as after one year, the USO group showed to some degree similar outcome parameters compared to AWP, whereas at the 10-year follow-up, AWP reached slightly better primary outcome parameters. The algorithm presented, thus, produced excellent short- and long-term outcomes. Our findings and the applied algorithm can assist in decision-making and patient education.

A Gaze into the Eyebrow Standards of Asian Versus Caucasian Women.

BACKGROUND: Eyebrow position affects perceived facial expression and youthfulness, and its modification is a key component of facial rejuvenation. OBJECTIVE: This investigation aimed to assess the preferred vertical eyebrow position, apex location, and eyebrow shape in Caucasian and Asian individuals and to analyze gaze patterns during aesthetic judgment using eye-tracking technology. MATERIALS AND METHODS: The study included 76 Asian and Caucasian volunteers with no medical background. Eye movements were captured with a Tobii Pro Nano eye-tracker. Participants viewed AI-generated images of Caucasian and Asian females with varied eyebrow positions (ratios 1:1.3 to 1:2.5), shapes (angles 8° to 20°), and apex positions. Aesthetic preferences were rated on a 5-point Likert scale. Eye-tracking metrics and aesthetic ratings were statistically analyzed using ANOVA and bivariate correlations. RESULTS: Both genders across ethnicities preferred a moderate eyebrow position ratio of 1:1.6. For eyebrow shapes, a 12° angle received the highest ratings, while extremes were less favored, indicating a preference for moderately curved eyebrows. The most appealing apex position was above the lateral canthus for Asians, and halfway between the lateral limbus and lateral canthus for Caucasians. Eye-tracking revealed longer fixations on unattractive features, suggesting more complex cognitive processing, while attractive features were processed more efficiently. CONCLUSION: The study revealed that aesthetic preferences for eyebrow features are influenced by both ethnic background and gender, with a general preference toward moderately curved eyebrows and subtle variations in preferred positions. These findings suggest a need for culturally sensitive approaches in facial aesthetic procedures and highlight the potential of eye-tracking technology to enhance surgical planning. Surgeons are advised to adopt a conservative, patient-centered approach when modifying eyebrow features, considering individual and cultural aesthetics to maximize patient satisfaction. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[Ban on New year's Fireworks Reduces Severe Hand Injuries: A Nationwide Multicentre Study On The Prohibition Of Pyrotechnics Due To Covid-19 Restrictions]. / Verbot von Feuerwerkskörpern reduziert schwere Handverletzungen an Silvester: Eine deutschlandweite Multicenter-Studie des Pyrotechnikverbots im Rahmen der Covid-19-Maßnahmen.

BACKGROUND: Injuries caused by explosions or pyrotechnic devices can lead to severe hand injuries with potential long-term consequences for both the affected individual and the healthcare system. The implementation of a nationwide ban on fireworks during the New Year festivities was only temporarily enforced as part of the protective measures during the Covid-19 pandemic. These two exceptional years provide an opportunity for evaluation as a model experiment to demonstrate the impact of a fireworks ban on the frequency of explosion-related hand injuries. MATERIALS AND METHODS: In a multicentre study, five German hand trauma centres retrospectively collected and analysed all pyrotechnic-related injuries that occurred within seven days around the New Year celebration between 2017 and 2023. RESULTS: Severe hand injuries from explosions were significantly less frequent at New Year celebrations during the pandemic period compared with data collected in the years before and after Covid-19. After the return to regular sales laws and celebrations in December 2022, a significant increase in injuries was observed, surpassing even the pre-Covid period. Epidemiological data confirmed a high proportion of minors and male victims. The highest number of injuries was observed on New Year's Eve and the first day of January, with adults mainly being injured during the festivities, while children and adolescents were mainly injured during the first days of January. CONCLUSIONS: A national ban proved to be an effective method to prevent severe hand injuries caused by explosive devices and their lifelong consequences. The data obtained in this multicentre study can serve as a basis for informed policy action.

Use of Acellular Matrices as Scaffolds in Cartilage Regeneration: A Systematic Review.

Significance: Cartilage regeneration remains a significant challenge in the field of regenerative medicine. Acellular matrix (AM)-based cartilage tissue regeneration offers an innovative approach to repairing cartilage defects by providing a scaffold for new tissue growth. Its significance lies in its potential to restore joint function, mitigate pain, and improve the quality of life for patients suffering from cartilage-related injuries and conditions. Recent Advances: Recent advances in AM-based cartilage regeneration have focused on enhancing scaffold properties for improved cell adhesion, proliferation, and differentiation. Moreover, several scaffold techniques such as combining acellular dermal matrix (ADM) and acellular cartilage matrix (ACM) with cartilage tissue, as well as biphasic scaffolding, enjoy rising research activity. Incorporating bioactive factors and advanced manufacturing techniques holds promise for producing more biomimetic scaffolds, advancing efficient cartilage repair and regeneration. Critical Issues: Obstacles in AM-based cartilage regeneration include achieving proper integration with the surrounding tissue and ensuring long-term durability of the regenerated cartilage. Furthermore, issues such as high costs and limited availability of suitable cells for scaffold seeding must be considered. The heterogeneity and limited regenerative capabilities of cartilage need to be addressed for successful clinical translation. Future Directions: Research should focus on exploring advanced biomaterials and developing new techniques, regarding easily reproducible scaffolds, ideally constructed from clinically validated and readily available commercial products. Findings underline the potential of AM-based approaches, especially the rising exploration of tissue-derived ADM and ACM. In future, the primary objective should not only be the regeneration of small cartilage defects but rather focus on fully regenerating a joint or larger cartilage defect.

Diagnostic power of ChatGPT 4 in distal radius fracture detection through wrist radiographs.

Distal radius fractures rank among the most prevalent fractures in humans, necessitating accurate radiological imaging and interpretation for optimal diagnosis and treatment. In addition to human radiologists, artificial intelligence systems are increasingly employed for radiological assessments. Since 2023, ChatGPT 4 has offered image analysis capabilities, which can also be used for the analysis of wrist radiographs. This study evaluates the diagnostic power of ChatGPT 4 in identifying distal radius fractures, comparing it with a board-certified radiologist, a hand surgery resident, a medical student, and the well-established AI Gleamer BoneView™. Results demonstrate ChatGPT 4's good diagnostic accuracy (sensitivity 0.88, specificity 0.98, diagnostic power (AUC) 0.93), surpassing the medical student (sensitivity 0.98, specificity 0.72, diagnostic power (AUC) 0.85; p = 0.04) significantly. Nevertheless, the diagnostic power of ChatGPT 4 lags behind the hand surgery resident (sensitivity 0.99, specificity 0.98, diagnostic power (AUC) 0.985; p = 0.014) and Gleamer BoneView™(sensitivity 1.00, specificity 0.98, diagnostic power (AUC) 0.99; p = 0.006). This study highlights the utility and potential applications of artificial intelligence in modern medicine, emphasizing ChatGPT 4 as a valuable tool for enhancing diagnostic capabilities in the field of medical imaging.

[Perioperative Use of Antibiotics as Infection Prophylaxis in Elective Wrist Arthroscopy: A Nationwide Survey]. / Einsatz von Antibiotikum zur perioperativen Infektprophylaxe in der elektiven Handgelenksarthroskopie: Eine deutschlandweite Befragung.

BACKGROUND: Wrist arthroscopy is a standard procedure in hand surgery for the diagnosis and treatment of wrist conditions. While perioperative antibiotic prophylaxis (PAP) is not generally recommended for elective hand surgery, there is no official standard for elective wrist arthroscopy. This study aimed to determine the actual clinical use of PAP in elective wrist arthroscopy in Germany and relate it to the structural conditions of clinics performing this procedure. MATERIAL AND METHODS: We conducted a systematic search of all facilities in Germany offering wrist arthroscopy. Among these, we performed an online survey using the SoSci Survey online tool via email. RESULTS: PAP is more frequently administered in cases involving simultaneous bone procedures. Cephalosporins are the most commonly used antibiotics in cases of PAP administration. Hospitals administer PAP more frequently than outpatient settings, with most surveyed institutions following facility-specific internal standards for antibiotic administration. The number of arthroscopies performed in the surveyed centres does not influence antibiotic administration. CONCLUSIONS: The use of PAP in wrist arthroscopies in Germany is inconsistent. The increased use in arthroscopies with bone involvement corresponds to AWMF guidelines, but a general recommendation for wrist arthroscopies, including soft tissue arthroscopies, is necessary to provide physicians with medical and legal certainty.

Microvascular Muscle vs. Fascio-Cutaneous Free Flaps for Reconstruction of Plantar Load-Bearing Foot Defects-An International Survey.

Background: The reconstruction of plantar load-bearing foot defects faces many plastic surgeons with a major challenge. The optimal patient- and defect-oriented reconstructive strategy must be selected. Methods: To analyze the current trends and recommendations in reconstruction of plantar load-bearing foot defects, we conducted an international survey among plastic surgeons querying them about their recommendations and experiences. Results: The survey revealed that the most common strategies for reconstruction of the foot sole are locoregional and microvascular free flaps, emphasizing the relevance of plastic surgery. Among microvascular free flaps, muscle and fascio-cutaneous free flaps are by far the most frequently used. The target qualities of the reconstructed tissue to be considered are manifold, with adherence being the most frequently mentioned. We observed a noteworthy correlation between the utilization of muscle flaps and a preference for adherence. In addition, we identified a substantial correlation between the usage of fascio-cutaneous free flaps and further target qualities, such as good skin quality and sensitivity. Conclusions: Our findings provide insights into the clinical reality and highlight important aspects that must be considered in reconstruction of the weight-bearing areas of the foot providing support in the selection of the appropriate therapy.

Postoperative Benefits of Soft Tissue Wrist Arthroscopy: Retro- and Prospective Analyses of Outcome Measures.

Background: Elective soft-tissue-only wrist arthroscopy is a standard procedure in hand surgery for the diagnosis and treatment of wrist pain. A number of pathologies can be treated arthroscopically, with the aim of pain reduction and improved wrist mobility. A postinterventional evaluation of the treatment using objective and patient-reported outcome measures (PROMs) allows for an evidence-based statement about the benefits of soft-tissue-only wrist arthroscopy. Methods: A dual-center study combining retro- and prospective clinical analyses of patient outcomes after soft-tissue-only wrist arthroscopies was performed. The data were collected at two hospitals with departments specializing in hand surgery. The outcome was measured by assessing the range of motion of the wrist and its manual strength, as well as PROMs, including Disabilities of the Arm, Shoulder and Hand (DASH) scores. Results: A total of 154 soft interventions met the study criteria and could be included. Seven months after the elective soft-tissue-only wrist arthroscopies, mobility improved significantly for active extension and flexion, as well as the ulnar and radial abduction of the wrist. The grip strength also improved significantly, by an average of 6 kg, during this period. The DASH score improved significantly, from 35 points to 14 points. Additionally, wrist pain at rest was reduced significantly. Conclusions: After elective soft-tissue-only wrist arthroscopy, patients showed an overall functional improvement in their wrist, with a significant reduction in pain and improvement of mobility and grip strength. This study emphasizes the importance of wrist arthroscopy as a successful treatment option for soft tissue pathologies of the wrist.

Biocompatibility of Synechococcus sp. PCC 7002 with Human Dermal Cells In Vitro.

Being the green gold of the future, cyanobacteria have recently attracted considerable interest worldwide. This study investigates the adaptability and biocompatibility of the cyanobacterial strain Synechococcus sp. PCC 7002 with human dermal cells, focusing on its potential application in biomedical contexts. First, we investigated the adaptability of Synechococcus PCC 7002 bacteria to human cell culture conditions. Next, we evaluated the biocompatibility of cyanobacteria with common dermal cells, like 3T3 fibroblasts and HaCaT keratinocytes. Therefore, cells were directly and indirectly cocultured with the corresponding cells, and we measured metabolic activity (AlamarBlue assay) and proliferation (cell count and PicoGreen assay). The lactate dehydrogenase (LDH) assay was performed to determine the cytotoxic effect of cyanobacteria and their nutrition medium on human dermal cells. The cyanobacteria exhibited exponential growth under conventional human cell culture conditions, with the temperature and medium composition not affecting their viability. In addition, the effect of illumination on the proliferation capacity was investigated, showing a significant impact of light exposure on bacterial growth. The measured oxygen production under hypoxic conditions demonstrated a sufficient oxygen supply for further tissue engineering approaches depending on the number of bacteria. There were no significant adverse effects on human cell viability and growth under coculture conditions, whereas the LDH assay assessed signs of cytotoxicity regarding 3T3 fibroblasts after 2 days of coculturing. These negative effects were dismissed after 4 days. The findings highlight the potential of Synechococcus sp. PCC 7002 for integration into biomedical approaches. We found no cytotoxicity of cyanobacteria on 3T3 fibroblasts and HaCaT keratinocytes, thus paving the way for further in vivo studies to assess long-term effects and systemic reactions.

[Coverage of complex pararectal pelvic defects: role of the free myocutaneous musculus vastus lateralis flap]. / Deckung komplexer pararektaler Beckendefekte: Rolle der freien myokutanen Musculus vastus lateralis Lappenplastik.

BACKGROUND: In the event of an advanced rectal carcinoma, an evisceration with rectal amputation may become necessary. The resulting defects, due to their extent, depth, or local tissue damage from previous surgeries and radiation, can in many cases only be closed through free microvascular tissue transfer. In this case series, we demonstrate the successful combination of a musculocutaneous musculus vastus lateralis flap (MVL) with a direct connection to the superior gluteal artery. MATERIALS AND METHODS: Over a 47-month period, we retrospectively examined 11 cases of patients with dorsal pelvic defects after evisceration and rectal amputation that could not be closed using local or regional means. In cases of extensive defects with deep pararectal wound cavities, all these patients underwent defect coverage through a free myocutaneous MVL flap with a direct vascular anastomosis to the superior gluteal vessels. RESULTS: The mean defect size was 290.0 cm² (SD: 131.2; range: 200-600 cm²). The mean defect depth was 10.5 cm, necessitating MVL flap reconstruction with an average size of 336.3 cm². Three operative revisions were required due to postoperative bleeding. There were no arterial or venous thromboses, and no flap loss occurred. Only one necrosis of a distal flap tip was observed, which could be corrected secondarily by direct suturing. The case-mix evaluation yielded an average value of 24.251 (SD: 21.699; range: 7.036-65.748) points, emphasizing the complexity of the cases. CONCLUSIONS: Our results indicate that a free microvascular MVL flap is a viable therapeutic option for pararectal defects that cannot be closed by local or regional methods. The superior gluteal artery proves to be a safe and sufficient vascular connection. In combination, even extensive defects can be successfully closed.

[Robotic-assisted harvesting of a latissimus dorsi muscle flap: a case report]. / Roboter-assistierte Hebung der M. latissimus dorsi ­ Lappenplastik: Ein Fallbericht.

Having established itself in various other areas of surgery as well as in urology, robotics is increasingly gaining importance in plastic surgery. The case presented in this manuscript describes the first published robotic-assisted harvesting of a latissimus dorsi muscle free flap in the German-speaking world. The aim is to increase the knowledge of robotics in plastic surgery and to support the introduction of robotic-assisted plastic surgery in Germany.

ESPRAS Survey: National and European Societies for Plastic Surgeons.

BACKGROUND: The European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS) comprises 40 national societies across Europe. In addition to ESPRAS, there are 8 different European Plastic Surgery societies representing Plastic Surgeons in Europe. The 4th European Leadership Forum (ELF) of ESPRAS, held under the motto "Stronger together in Europe" in Munich in 2023, aimed to collect and disseminate information regarding the national member societies of ESPRAS and European societies for Plastic Surgeons. The purpose was to identify synergies and redundancies and promote improved cooperation and exchange to enhance coordinated decision-making at the European level. MATERIAL AND METHODS: An online survey was conducted regarding the organisational structures, objectives and challenges of national and European societies for Plastic Surgeons in Europe. This survey was distributed to official representatives (Presidents, Vice Presidents and General Secretaries) and delegates of national and European societies at the ELF meeting. Missing information was completed using data obtained from the official websites of the respective European societies. Preliminary results were discussed during the 4th ELF meeting in Munich in March 2023. RESULTS: The ESPRAS survey included 22 national and 9 European Plastic Surgery societies representing more than 7000 Plastic Surgeons in Europe. Most national societies consist of less than 500 full members (median 182 members (interquartile range (IQR) 54-400); n=22). European societies, which covered the full spectrum or subspecialities, differed in membership types and congress cycles, with some requiring applications by individuals and others including national societies. The main purposes of the societies include research, representation against other disciplines, specialisation and education as well as more individual goals like patient care and policy regulation. CONCLUSION: This ESPRAS survey offers key insights into the structures, requirements and challenges of national and European societies for Plastic Surgeons, highlighting the relevance of ongoing close exchange between the societies to foster professional advancement and reduce redundancies. Future efforts of the ELF will continue to further explore strategies for enhancing collaboration and harmonisation within the European Plastic Surgery landscape.

Abdominoplasty in a Patient With Type 3 von Willebrand Disease: A Case Report.

ABSTRACT: von Willebrand disease (vWD) is an inherited bleeding disorder that is characterized by a quantitative or qualitative deficiency of the von Willebrand factor (vWF). Type 3 is the most severe form of vWD with a near-complete absence of vWF and a significantly increased risk of excessive bleeding and hematoma during a surgical procedure. To date, no data on surgical and hemostatic management of a type 3 vWD patient undergoing body-contouring surgery has been published. We report the case of a 47-year-old woman with type 3 vWD requiring medically indicated abdominoplasty after massive weight loss due to bariatric surgery. The case was successfully managed with individualized bodyweight-adapted substitution of recombinant vWF vonicog alfa and tranexamic acid under close monitoring of vWF and factor VIII activity. For further risk stratification, we propose the multidisciplinary treatment of patients with severe vWF undergoing elective plastic surgery in specialized centers providing around-the-clock laboratory testing and access to a blood bank. In addition, strict hemostasis during surgery and early postoperative mobilization with fitted compression garments are recommended to further reduce the risk of bleeding and thromboembolic complications.

The Influence of Scar Patterns After Reduction Mammoplasty on Eye Movement and Gaze Pattern: An Eye-Tracking Investigation.

BACKGROUND: Given that scars are acknowledged as the primary cause of postoperative dissatisfaction following reduction mammoplasty, it is imperative to comprehend the patient's visual perception of different scar patterns in order to enhance patient satisfaction. To achieve this, eye-tracking technology provides an unbiased method of evaluating how observers assess breast scars. METHODS: 58 participants (32 females and 26 males) between the ages of 19 and 82 years (mean age of 29.47 ± 10.98 years) were shown 18 color photographs, taken at 3 viewing angles (right 45° oblique, frontal and frontal view with arms raised), from 6 patients undergone reduction mammoplasty with the inverted T-scar technique (3 patients) or no-vertical-scar technique (3 patients). The images were presented to every participant for a fixed duration of 5 s each. Eye-tracking device was used to collect and analyze the gaze data of viewers. RESULTS: The nipple-areola complex (NAC) and the periareolar scar captured observers' gaze faster, had longer duration and more count of eye fixation than all other parts of breast scars, regardless of the viewing angle and scar pattern. Moreover, the scar region in the inverted T-scar pattern received greater and faster visual attraction of observer's gaze than the no-vertical-scar pattern. CONCLUSION: The NAC and the periareolar scar seem to be perceived as the most important regions for breast aesthetics. The findings can be helpful to assist plastic surgeons in determining the most appropriate technique for reduction mammoplasty, meanwhile underlining the importance of a fine periareolar scar and symmetric NAC for excellent aesthetic outcomes. This is to our best knowledge the first study using eye-tracking technology in evaluating reduction mammoplasty outcomes. This study explored the influence of different scar patterns after reduction mammoplasty on eye movements and gaze patterns among observers. The study have validated the significance of the NAC and the periareolar scar for breast aesthetics and revealed that the scar region in the inverted T-scar pattern may be judged less visually attractive than the no-vertical-scar pattern. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors  www.springer.com/00266 .

[German Translation and Validation of the Patient-Oriented Questionnaire "Thumb Disability Examination" (TDX) for Specific Diagnosis and Follow-Up of Thumb Carpometacarpal Joint Osteoarthritis]. / Deutsche Übersetzung und Validierung des patienten-orientierten Fragebogens "Thumb Disability Examination" (TDX) zur spezifischen Diagnostik und Verlaufskontrolle bei Rhizarthrose.

BACKGROUND: Patient-reported outcome measures (PROMs) are becoming increasingly important in today's patient care. Unfortunately, the most common PROMs in hand surgery are very time-consuming and usually do not cover the actual, diagnosis-specific complaints of the patients. For diagnosis and follow-up of thumb carpometacarpal joint osteoarthritis, Noback et al. developed and validated the Thumb Disability Examination (TDX) questionnaire. This 20-item questionnaire specifically assesses daily living limitations and pain as well as patient-reported satisfaction of thumb function. The aim of this study is to validate the German translation of the TDX, the Thumb Disability Examination - German (TDX-G), and to compare it with the German-language versions of the MHQ and qDASH, which are currently used as gold standard. MATERIAL UND METHODS: Translation and back-translation were performed in accordance with accepted guidelines. For statistical validation of the TDX-G, 30 consecutive patients with thumb carpometacarpal joint osteoarthritis were interviewed under standardised conditions. Internal consistency was calculated using Cronbach's alpha. Test-retest reliability was determined in 10 patients who completed the TDX-G twice at an interval of 2 weeks. The validity of the TDX-G was determined by calculating the correlation coefficients of the TDX-G with the MHQ and qDASH, subjective pain sensation (NRS), and hand strength levels (coarse and pinch strength). In addition, the time to collect each questionnaire was compared. RESULTS: The TDX-G has high internal consistency (Cronbach's alpha 0.932) and test-retest reliability (intraclass correlation coefficient 0.963 [0.850-0.991]). There is a significant correlation between TDX-G and MHQ (- 0.782; p<0.001) and qDASH (0.833; p<0.001). All questionnaires correlate significantly with pain on exertion and pinch force, with the TDX-G having the highest correlation in each case. Significantly less time is needed to record the TDX-G (110±28 s) than to record the MHQ (413±98 s). CONCLUSION: The TDX-G is a reliable tool for diagnosing and monitoring the progression of thumb carpometacarpal joint osteoarthritis. It can be used in both patient care and clinical research and accurately mirrors the symptoms.

Giant Penoscrotal Lymphedema-What to Do? Presentation of a Curative Treatment Algorithm.

BACKGROUND: While rare, penoscrotal lymphedema (PL) is accompanied with devastating effects on the quality of life of patients. Moreover, especially for patients with excessive (giant) PL, no standardized curative treatment has been defined. This article therefore retrospectively evaluates the authors' surgical treatment approach for giant PL, which includes resection alone or in combination with a free vascularized lymph node transfer (VLNT). METHODS: A total of ten patients met the inclusion criteria. One patient dropped out of the study before therapy commenced. Eight of the nine remaining patients presented with end-stage (giant) PL. One patient presented with manifest pitting edema. All patients were treated with penoscrotal resection and reconstruction. Additionally, five patients received VLNT into the groin or scrotum. RESULTS: The extent of the lymphedema was specified with a treatment-oriented classification system. The median follow-up was 49.0 months. No patient showed a recurrence. Patients who received VLNT into the scrotum displayed a significantly improved lymphatic transport of the scrotum. CONCLUSIONS: Advanced PL should be treated in a standardized surgical fashion as suggested by our proposed algorithm. VLNT from the lateral thoracic region into the scrotum must be considered. If treated correctly, surgical intervention of end-stage PL leads to good results with a low recurrence rate.