Sascha Wellenbrock

Merkel cell carcinoma (MCC)is a rare but aggressive cutaneous malignancy with increasing incidence and poor prognosis. Host immune status is a key determinant of MCCmerkel cell carcinoma development and outcome. While the AEIOU criteria are widely used to facilitate clinical recognition, their value for prognostic assessment remains unclear. To evaluate the association between individual AEIOU presentation features and disease progression in patients with merkel cell carcinoma, with particular emphasis on immunosuppression. We performed a retrospective single-centre cohort study including 400 patients diagnosed with merkel cell carcinoma. Disease progression, defined as local recurrence, nodal involvement or distant metastasis, served as the primary endpoint. AEIOU criteria were assessed at diagnosis and analysed using logistic regression. Complete follow-up data were available for 241 patients, of whom 81 (33.6%) experienced disease progression. Patients with progression were significantly older and more frequently male. Among the AEIOU components, immunosuppression was the only criterion significantly associated with disease progression, conferring an increased risk compared with immunocompetent patients (p<0.001). Other AEIOU features showed no consistent prognostic association. Complete follow-up data were available for 241 patients, of whom 81 (33.6%) experienced disease progression. Patients with progression were significantly older and more frequently male. Among the AEIOU components, immunosuppression was the only criterion significantly associated with disease progression, conferring an increased risk compared with immunocompetent patients (p<0.001). Other AEIOU features showed no consistent prognostic association.

Summary: Pectus excavatum (PE) is the most common congenital anterior chest wall anomaly, often requiring surgical correction due to both functional and aesthetic concerns. Gender-affirming surgery has seen a significant increase in recent decades, with mastectomy being the primary procedure for transgender men. For transmasculine patients with PE seeking chest masculinization, the possibility of addressing both conditions in a single surgery has not been well explored. We report the first known case of a 33-year-old transgender patient with PE undergoing a combined procedure of masculinization top surgery and chest wall reconstruction. A novel bilateral inferiorly pedicled adipocutaneous flap, supplied by vessels of the anterior intercostal artery perforators, was used to correct the sternal depression while performing a mastectomy. This technique provided an immediate, well-perfused autologous reconstruction, eliminating the need for foreign implants or multiple procedures. The patient had an uneventful recovery and, at 1-year follow-up, demonstrated a satisfactory chest contour with complete correction of the funnel chest deformity and a masculinized thorax. This approach offers a viable, single-stage solution for transgender patients with PE, avoiding complications associated with implants or fat grafting. By using autologous tissue and preserving vascular integrity, this method expands the surgical options for chest wall reconstruction in gender-affirming care.

Background: Cutaneous melanoma is a rising global health concern and identifying modifiable or associated risk factors remains essential for improving prognostic stratification. Hypothyroidism, affecting approximately 5.1% of the general population in Germany, has been associated with various malignancies. This study investigates the prevalence and potential prognostic implications of hypothyroidism in melanoma patients. Methods: We conducted a retrospective single‐centre study including 1553 patients with cutaneous melanoma (AJCC stages I–III). Patients were stratified based on thyroid function into hypothyroid and euthyroid groups. Data were collected via clinical records and standardized patient questionnaires. Results: Hypothyroidism was documented in 234 patients (15.1%), significantly higher than the national prevalence (5.1%, p < 0.001). Tumor site differed significantly between groups, with hypothyroid patients more frequently exhibiting melanomas on the lower extremities ( p < 0.001). These patients also showed a non‐significant trend toward lower Breslow thickness ( p = 0.09) and a significantly reduced number of metastatic lymph nodes ( p = 0.009). Conclusions: Our findings suggest that hypothyroidism is markedly more prevalent among patients with cutaneous melanoma and may be associated with clinical features linked to improved prognosis. These observations warrant further investigation to clarify whether hypothyroidism itself, or its underlying immunologic and hormonal milieu, plays a protective role in melanoma progression.

Breast augmentation is the most frequently performed gender-affirming surgery (GAS) for transfeminine individuals. Because of anatomical differences between transfeminine and cisgender women, implant selection requires tailored planning. The “Number Y” is an established method for implant height selection in cisgender patients. Since its adoption for transfeminine patients at our institution in 2016, its reliability in this population has not been validated. The aim of this study was to validate the Number Y in transfeminine patients, identify anatomical factors influencing implant height prediction, and propose an adjusted “Number trans-Y” to improve surgical planning. This retrospective study included 21 transfeminine patients undergoing breast augmentation as part of GAS. Preoperative implant height predictions using the Number Y were compared with actual intraoperative implant choices. Implant shapes were categorized as vertical-elliptical, circular, or horizontal-elliptical. Patient and implant characteristics were analyzed for concordance. The mean patient age was 39.62 years, BMI of 25.42, and the mean Number Y of 4.31, higher than reported in cisgender cohorts. Implant height prediction was accurate in 16 patients (76.19%). Discordant cases (23.81%) had significantly smaller thoracic perimeters (9 cm difference, P = .01) and lower Number Y (3.96 ± 0.11 vs 4.42 ± 0.28; P < .001). Most concordant cases received low-height implants, whereas discordant cases were predicted to require middle-height implants but ultimately received low-height implants. The Number Y has limited predictive accuracy in transfeminine patients because of distinct thoracic anatomy and higher Y factors. An adjusted Number trans-Y is proposed to optimize implant selection and surgical outcomes in this population. Level of Evidence: 4 (Therapeutic)

Background: Acute postoperative pain after surgery may lead to significant complications including chronification of pain, impaired cardiopulmonary function, and increased healthcare costs. As a common and complex procedure, abdominoplasty is a key focus for pain management strategies. Although transversus abdominis plane blocks, which target the abdominal wall's sensory nerves to reduce postoperative pain by blocking nociceptive input, have shown promise in reducing postoperative pain in abdominal surgeries, their use in abdominoplasty remains underexplored. Methods: Outcomes for patients undergoing abdominoplasty between 2013 and 2024 were analysed, comparing those who received a transversus abdominis plane block with those who did not. Postoperative analgesia followed a standardized protocol using oral narcotics and piritramide. Pain outcomes were assessed in both groups via chart review. The primary outcome, length of hospital stay, was analysed by multivariable linear regression adjusted for patient and surgical factors. Secondary outcomes, including complications and revision rates, were assessed by logistic regression. Exploratory analyses examined how reductions in medication use affected length of hospital stay and discharge timing. Results: Overall, 192 patients who had an abdominoplasty were included in analyses: 93 had a transversus abdominis plane block and 99 did not. The transversus abdominis plane group had a significantly shorter hospital stay, with a reduction of 2.21 (95% confidence interval (c.i.) −3.07 to −1.36) days after adjusting for confounders (P < 0.001; effect size, Cohen's d 0.45). Surgical complications occurred in 46.9% of patients. The overall complication risk in the transversus abdominis plane block group was significantly reduced by 52% (adjusted odds ratio 0.44, 95% c.i. 0.23 to 0.84; P = 0.012; effect size 0.52), particularly the occurrence of haematoma (adjusted odds ratio 0.34; P = 0.031; effect size 0.66). Additionally, patients who had a transversus abdominis plane block required less postoperative medication, including lower tilidine (P = 0.038) and metamizole (P = 0.032) doses. Conclusion: Use of the transversus abdominis plane block in patients who had an abdominoplasty was associated with improved postoperative outcomes, highlighting its potential as an effective pain management strategy and supporting its broader clinical application.

Background: In recent years, the profunda artery perforator (PAP) flap has gained recognition as a viable technique in autologous breast reconstruction, demonstrating low donor site morbidity and favorable reconstructive outcomes. This study aims to highlight the recent refinements using the PAP flap for breast reconstruction focusing on preoperative volume prediction. Methods: A retrospective study was conducted to evaluate the outcomes of breast reconstruction surgeries using the PAP flap at our institution between May 2018 and December 2022. A total of 114 PAP flaps performed in 96 patients were included. Statistical analysis was performed to analyze flap volume in relation to body mass index (BMI). Surgical details, such as donor site-related complications and patient characteristics, were also collected. Results: BMI was identified as a statistically significant predictor (p < 0.001) for flap weight in the resulting model. The average BMI observed was 23.0, while the mean flap weight was 304.2 g. The predictive model for flap weight was determined as follows: flap weight (g) = (19.252 × BMI) − 143.572. This model underscores the relationship between BMI and flap weight, quantifying the influence of BMI on flap weight prediction. Conclusions: Our study indicates that it is feasible to harvest an adequate volume for breast reconstruction even in patients with a low BMI. To facilitate preoperative prediction of PAP flap volume, we developed an algorithm designed to enhance preoperative planning and estimate the need for supplementary procedures to achieve the desired volume.

Background: Merkel cell carcinoma (MCC) is a rare and frequently fatal form of skin cancer. Apart from Programmed Cell Death Protein 1 (PD-1)/Programmed Death-Ligand 1 (PD-L1) signaling, there is a lack of knowledge regarding other immune checkpoint molecules. Recent studies have observed elevated glycoprotein CD200 (also known as OX-2) mRNA expression in in different types of tumors, with CD200R-expressing myeloid cells present in the tumor microenvironment. However, the potential role of the CD200/CD200 axis as an additional checkpoint modulator remains widely unexplored. The aim of this study was to determine the intratumoral protein expression of CD200 as well as CD200R in a larger cohort of MCC patients and to correlate the expression levels with patients’ outcomes. Methods: In this multicenter study, we investigated 68 patients with MCC (68 primary tumors and 15 corresponding metastases). Immunohistochemistry (IHC) was performed for CD200 as well as CD200R. Digital quantification and analysis of IHC were performed using QuPath-0.2.3. Results: CD200 and CD200R expression was observed in 100% of cases. Univariate analysis revealed that low CD200 expression in primary tumors (p = 0.0007, HR 9.35), male sex (p = 0.045, HR 2.41), and immunosuppression (p = 0.0031, HR 6.36) were significantly associated with MCC relapse. Low CD200 expression was also linked to prior immune checkpoint inhibitors (ICI) and/or chemotherapy treatment (p = 0.037). Multivariable analysis confirmed that low CD200 expression (p = 0.0012, HR 5.25) and immunosuppression (p = 0.0056, HR 4.11) were independent predictors of MCC relapse. Conclusions: Expression of CD200/CD200R proteins is very high in MCC and may thus be of diagnostic value. More importantly, low intratumoral CD200 protein expression in primary MCC represents a robust independent predictor of MCC relapse.

Background: Despite its estimated high prevalence among women and increasing awareness, lipedema remains under-investigated. Ignoring its debilitating nature, surgical treatment for this condition is frequently covered by health insurance only in advanced stages and after the exhaustion of conservative therapies. Methods: A total of 1015 patients with lipedema were recruited via social media platforms. Of these, 860 patients provided answers to at least one complete section of the modified Body-Q questionnaire (response rate 85%). The Mann–Whitney U and Kruskal–Wallis tests were utilized to assess the impact of the surgical treatment by means of patient-reported outcomes on the self-perception of various body areas. Results: The satisfaction scores among conservatively treated patients for abdominal appearance, arms, back, body, buttocks, and inner thighs showed a statistically significant decline with increasing stages of lipedema. The comparison of patient evaluation scores in the appearance domain demonstrated better patient self-perception scores in patients who received at least one session of the surgical treatment for the hips and thighs (p < 0.01), inner thighs (p < 0.01), and excess skin (0.01) scales. On the body scale, the patients who underwent liposuction again reported better satisfaction scores; however, this did not reach statistical significance (p < 0.081). In the health-related quality of life domain, the patients who received liposuction treatment reported a better outcome in the body image (p < 0.01), physical function (p = 0.05), physical symptoms (p = 0.04), and psychological function (p < 0.01) scales. Conclusions: The current study underscores the burden of lipedema of affected patients and its negative impact on self-perception. As the disease progresses, conservatively treated patients experience a decline in satisfaction with various aspects of their appearance. However, surgical interventions, particularly liposuction, does not address esthetic concerns but significantly improve health-related quality of life across multiple domains, emphasizing the comprehensive benefits of surgical intervention in the management of lipedema.