Research Appraisals
Evidence-based critical appraisals of the latest medical research, systematically evaluated using Oxford CEBM methodology.
Showing 11 appraisals
Lasers in medical science
Facial contour modulation and skin tightening using 40.68-MHz unipolar radiofrequency
To evaluate changes in facial contour and skin elasticity following full-face treatment with 40.68-MHz unipolar radiofrequency (RF), and to assess its safety and tolerability in adults with mild-to-moderate facial laxity. This prospective single-arm interventional clinical study evaluated adults with mild-to-moderate facial laxity who underwent three full-face 40.68-MHz unipolar RF treatment sessions at 4-week intervals. The primary endpoint was the change in VECTRA-derived three-dimensional facial volumetric parameters from baseline to Week 20. Secondary outcomes included Cutometer-derived skin elasticity parameters (R2 and R5), Global Aesthetic Improvement Scale (GAIS), FACE-Q satisfaction scores, visual analog scale (VAS) pain scores, and adverse event monitoring. Of the 30 enrolled participants, 26 completed follow-up and were included in the final analysis. By Week 20, VECTRA 3D analysis demonstrated modest volume reductions in the cheek (- 2.2 mL), jowl (- 1.7 mL), and submental region (- 2.9 mL). Skin elasticity parameters increased over time, with R2 increasing from 0.62 to 0.69 and R5 from 0.53 to 0.59. GAIS improvement was observed in 88.5% of participants, and the mean FACE-Q score increased to 72.4 ± 10.1. Treatment was well tolerated, with low mean pain scores (VAS 1.2 ± 0.9). Only transient erythema and mild edema were reported, with no serious adverse events observed. Three sessions of 40.68-MHz unipolar RF were associated with modest measurable improvements in facial contour and skin elasticity that were maintained during the 20-week observation period, with good tolerability and no serious adverse events. Because this was an uncontrolled single-arm study, these findings should be interpreted as preliminary and require confirmation in controlled studies with longer follow-up.
27 July 2026
Read appraisal →Breast cancer research and treatment
Extended applications of chest wall perforator flaps in breast surgery: case series and systematic literature review
PURPOSE: Chest wall perforator flaps (CWPFs) are integral to modern oncoplastic breast surgery, offering volume replacement without muscle sacrifice. While their role in partial breast reconstruction is established, data on extended and non-conventional applications remain limited. This study aims to synthesize current clinical experience and delineate the extended applications of chest wall perforator flaps beyond conventional oncoplastic contexts. METHODS: This study combined a prospective institutional case series from two tertiary centers (Singapore and UK) with a systematic literature review of PubMed, Embase, Web of Science, and Cochrane databases. Eligible studies described CWPF use for extended oncologic, reconstructive, or aesthetic indications. Data were synthesized descriptively according to PRISMA guidelines. RESULTS: Six women underwent LICAP-based reconstruction for complex indications including skin-replacing excisions, implant salvage, chronic sinus closure, and total autologous reconstruction with adjunct lipofilling. All flaps were fully viable with good contour restoration and symmetry, and adjuvant therapy proceeded without delay. The systematic review identified 38 studies (≈ 324 patients, 349 flaps). CWPFs, most commonly LICAP, LTAP, and TDAP, were used for defects following oncologic resection, radiotherapy injury, implant failure, or post-bariatric contour correction. Overall flap success exceeded 95%, with major complications under 5%. Donor-site morbidity was minimal, with high aesthetic satisfaction (> 90%). CONCLUSIONS: CWPFs represent muscle-sparing reconstructive options whose utility may extend beyond conventional oncoplastic indications; this descriptive series supports their feasibility and short-term outcomes across a range of selected clinical settings, suggesting that CWPFs warrant further consideration in the management of complex breast and chest wall defects.
17 July 2026
Read appraisal →Hernia : the journal of hernias and abdominal wall surgery
Clinical outcomes in abdominal wall autologous flap reconstruction: a systematic review
PURPOSE: Complex abdominal wall defects present major reconstructive challenges when restoration of fascial continuity must be combined with durable soft-tissuecoverage, visceral protection, and, in selected cases, functional repair. Although autologous flap reconstruction is well established for selected indications, its overall role across defect types has yet to be established. METHODS: A systematic review was performed in accordance with PRISMA guidelines (PROSPERO: CRD42023491916). PubMed/MEDLINE, Embase, Scopus, Web of Science, Cochrane Library, and Google Scholar were searched from inception to April 2026 for studies reporting adult autologous flap-based abdominal wall reconstruction. Given substantial clinical and methodological heterogeneity, data were analysed descriptively. RESULTS: 172 studies comprising 4,421 patients were included. Pedicled flaps predominated (n=4,095, 92.6%), with free flaps used in 146 patients (3.3%) and mixed approaches in 180 (4.1%). Hernia-related pathology was the commonest indication (n=3751, 84.8%), followed by malignancy (n=470, 10.6%). Frequently used flap categories included anterolateral thigh, tensor fascia lata, rectus-based, and latissimus dorsi-based flaps. Flap selection was primarily defect-driven: fascia-bearing regional and turnover techniques were used mainly for structurally focused hernia repair, whereas composite flaps were used more often for oncologic, fistulating, traumatic, contaminated, or full-thickness defects. Common short-term complications include seroma, surgical site infection, and wound dehiscence. Flap failure and reported long term hernia recurrence were low. Free flaps were used more often for larger defects weighted mean 401 cm² vs 250 cm² for pedicled flaps), although size ranges overlapped. CONCLUSIONS: Autologous flap reconstruction is a durable and versatile option for selected complex abdominal wall defects. Reconstructive strategy should be guided primarily by defect composition.
10 July 2026
Read appraisal →European journal of trauma and emergency surgery : official publication of the European Trauma Society
Initial surgical management of injuries to the upper extremities for patients with multiple and/or severe injuries - a systematic review and clinical practice guideline update.
PURPOSE: Our objective was to update the evidence-based and consensus-based recommendations for the initial surgical management of upper extremity injuries in patients with suspected multiple and/or severe injuries based on current evidence. This guideline topic is part of the 2025 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries. METHODS: MEDLINE and Embase were systematically searched to September 2024. Further literature reports were obtained from clinical experts. Randomised controlled trials (RCTs) or observational studies reporting risk-adjusted outcomes were included if they compared early versus delayed surgical treatment for fractures, vascular injuries, or nerve injuries affecting the upper extremities in patients with multiple and/or severe injuries. Studies comparing limb salvage versus amputation or comparing amputation criteria for the upper extremities were also included. We considered patient-relevant outcomes such as mortality and limb salvage, as well as the sensitivity and specificity of scores for predicting upper extremity amputation. Risk of bias was assessed at the outcome level using ROBINS-I for observational studies and AMSTAR-2 for systematic reviews. We used available meta-analyses if possible; alternatively, we synthesised the evidence narratively. We used GRADE to rate the certainty of evidence. Expert consensus was used to develop recommendations and determine their strength. RESULTS: Among 2498 records screened for eligibility, four studies were included. Observational studies addressed the timing of humeral fixation, the timing of revascularisation, or compared limb salvage with amputation. A systematic review evaluated scoring systems for mangled upper limb salvage. Four recommendations were modified, and one consensus-based recommendation was added. All five recommendations achieved strong consensus. CONCLUSION: The timing of surgical intervention for upper extremity injuries in polytrauma patients should be individualized, based on the patient's physiological status, injury pattern, and the risks and benefits of early versus delayed surgery. Although early surgery may improve functional outcomes and reduce complications, adequate patient stabilization is essential before proceeding. Limb salvage should be attempted for patients with a MESS score of less than seven, provided the patient is sufficiently stable and depending on the condition of the amputated limb.Although the guideline addresses patients with multiple and/or severe injuries, the scarce evidence, heterogeneity of the included studies and the limited representation of true polytrauma cohorts may restrict the applicability of the findings to the broader critically injured trauma population.
10 July 2026
Read appraisal →World journal of surgical oncology
Robotic-assisted versus conventional nipple-sparing mastectomy with immediate implant-based breast reconstruction: a GRADE-assessed systematic review and meta-analysis of prospective studies
BACKGROUND: Robotic nipple-sparing mastectomy with immediate implant-based reconstruction is increasingly adopted to improve cosmetic outcomes and patient experience; however, its comparative perioperative value against conventional or open nipple-sparing mastectomy remains uncertain when restricted to prospective evidence. METHODS: We performed a PRISMA-aligned systematic review and random-effects meta-analysis of prospective comparative studies and randomized trials comparing robotic versus conventional or open nipple-sparing mastectomy with immediate implant-based reconstruction. The primary outcome was the total operative time, and the secondary outcomes were major complications, nipple-areolar complex ischemia or necrosis, and length of hospital stay. The risk of bias was assessed using RoB 2 for randomized data and ROBINS-I for nonrandomized data. Leave-one-out sensitivity analyses were conducted for outcomes with substantial heterogeneity, and the certainty of the evidence was graded using GRADE. RESULTS: Three prospective studies were included. Robotic surgery was associated with a significantly longer total operative time (mean difference 64.01 min, 95% confidence interval 8.54-119.47). Major complications did not differ between the approaches (risk ratio 0.63, 95% confidence interval 0.27-1.47), nor did nipple areolar complex ischemia or necrosis (risk ratio 0.56, 95% confidence interval 0.28-1.11) or length of hospital stay (mean difference 0.22 days, 95% confidence interval - 0.26 to 0.70). Heterogeneity was high for operative time and moderate to substantial for length of stay. The certainty of the evidence was low overall, driven by imprecision, heterogeneity, and limitations of the non-randomized design. CONCLUSIONS: Robotic nipple-sparing mastectomy is associated with a longer operative time than conventional or open approaches. No statistically significant differences were observed in major complications or nipple-areolar complex viability; however, the current prospective evidence base is limited, heterogeneous, and imprecise, and clinically important differences cannot be excluded. In experienced centers, robotic nipple-sparing mastectomy may be considered for carefully selected patients who prioritize scar concealment and minimally invasive access; however, its broader role in routine practice remains uncertain pending stronger prospective data on safety, patient-reported outcomes, and resource use.
26 June 2026
Read appraisal →Physics in medicine and biology
Interlayer-aware postoperative facial appearance prediction in orthognathic surgery with bio-geometric guidance
Objective.Accurate prediction of postoperative facial appearance is essential for orthognathic surgical planning, yet remains challenging due to the nonlinear biomechanical coupling between bone and soft tissue. While deep learning methods offer a faster alternative to traditional biomechanical simulation, they typically map bony displacements directly to facial surface deformation, overlooking the intervening soft-tissue layers with distinct biomechanical properties through which displacement is progressively transmitted. Moreover, the many-to-one effect of regional bony movements on each soft-tissue point remains insufficiently captured.Approach.We propose a novel network that introduces an interlayer mixture-of-experts mechanism to decouple bone-to-surface deformation propagation into three biomechanically inspired proxy representations at different tissue depth levels. Since the contribution of each depth level varies across individuals and facial regions, a gated routing network adaptively weights each layer's contribution, providing a data-driven approximation of spatially heterogeneous, patient-specific deformation transmission. Additionally, a bio-geometric convolution module captures regional bony influences through elastic-weighted neighborhood aggregation.Main results.Evaluations on 88 orthognathic surgery patients demonstrate that the proposed method achieves a mean whole-face error of 1.39 mm, below the 2 mm clinical threshold, with statistically significant improvements over all baselines (p<0.05) and the highest clinician acceptance rate (94%).Significance.By incorporating bio-geometric priors into a deep learning framework, our approach enables a more physically grounded and interpretable prediction paradigm, supporting efficient and clinically reliable surgical planning.
21 June 2026
Read appraisal →Journal of robotic surgery
Robot-assisted peritoneal flap vaginoplasty in gender-affirming genital reconstruction: a systematic review and single-arm meta-analysis
Robot-assisted peritoneal flap vaginoplasty has emerged as an evolving reconstructive option in gender-affirming genital surgery. This systematic review and single-arm meta-analysis aimed to synthesize the available evidence regarding its perioperative, functional canal, and postoperative safety outcomes. This study was conducted according to PRISMA guidelines and prospectively registered in PROSPERO. PubMed, Cochrane Library, Embase, and Web of Science were searched from database inception to May 2026. Eligible studies included transfeminine or gender-diverse individuals undergoing robot-assisted peritoneal flap-based vaginoplasty with extractable clinical outcomes. Continuous outcomes were synthesized as weighted mean estimates with 95% confidence intervals (CIs), and overall postoperative complications were pooled using Stata version 18.0. Heterogeneity was assessed using the I² statistic, and leave-one-out sensitivity analyses were performed. Ten studies involving 974 patients were included. The pooled mean operative time was 305.37 min (95% CI 244.62, 366.12), and the pooled length of hospital stay was 5.80 days (95% CI 4.72, 6.87). At the last available follow-up, pooled neovaginal depth was 13.41 cm (95% CI 12.86, 13.96), and pooled neovaginal width was 3.61 cm (95% CI 3.55, 3.67). The pooled overall postoperative complication rate was approximately 30.1%. Sensitivity analyses suggested that the pooled estimates were not driven by any single study. Robot-assisted peritoneal flap vaginoplasty appears feasible and may achieve neovaginal dimensions broadly comparable to those reported for other full-depth vaginoplasty approaches. However, predominantly retrospective single-arm evidence precludes conclusions regarding superiority and highlights the need for standardized prospective studies with longer follow-up and patient-reported outcomes.
20 June 2026
Read appraisal →Journal of orthopaedics and traumatology : official journal of the Italian Society of Orthopaedics and Traumatology
Vascularized versus nonvascularized free fibular grafts in reconstruction of post-traumatic critical long bone defects, a comparative study
BACKGROUND: Reconstruction of critical-sized long bone defects is a complex orthopedic challenge. Free fibular grafts, vascularized (FVFG) and nonvascularized (NVFG), are established reconstructive options, but comparative clinical outcomes remain uncertain. PURPOSE: To compare clinical and radiological outcomes of FVFG and NVFG in patients with post-traumatic critical bone defects more than 10 cm. METHODS: A randomized controlled trial was conducted with 50 patients assigned equally to FVFG or NVFG groups. The primary outcome was time to union, while secondary outcomes included graft hypertrophy, functional scores (DASH and LEFS), complication rates, and donor site morbidity. RESULTS: The mean time to union was 5.78 months in the FVFG group and 6.17 months in the NVFG group, showing no statistically significant difference (p = 0.447). Rates of graft hypertrophy, functional recovery, and complications were comparable between the groups. CONCLUSIONS: Both FVFG and NVFG provide effective reconstruction for critical bone defects, with nearly similar healing times and functional outcomes. NVFG may represent a less complex alternative in selected cases.
26 May 2026
Read appraisal →Journal of investigative surgery : the official journal of the Academy of Surgical Research
Vascular and Wound-Healing Implications of Single-Stage Versus Multistage Repair of Anorectal Malformations: A Systematic Review and Meta-Analysis
BACKGROUND: Anorectal malformations (ARMs) are managed using either single-stage or multistage surgical repair. However, concerns persist regarding wound-related complications and long-term functional outcomes, which remain inconsistently reported across surgical approaches. OBJECTIVE: To compare wound-related complications and long-term functional outcomes following single-stage versus multistage repair of ARMs, with emphasis on wound perfusion, dehiscence, and vascular healing dynamics. METHODS: A systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD420251006245). PubMed and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched for studies published between 2000 and 2024 comparing single-stage and staged ARM repair in neonates and infants. Outcomes included wound dehiscence, surgical site infection (SSI), stenosis, prolapse, redo surgery, constipation, soiling, and voluntary bowel movements. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random-effects model. Study quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS). RESULTS: Nineteen studies involving 1,972 patients were included. Single-stage repair was associated with a significantly higher risk of wound dehiscence (OR 3.31; 95% CI 1.90-5.79; p < 0.0001), while no significant differences were observed for SSI, stenosis, prolapse, redo surgery, constipation, soiling, or voluntary bowel movements. Moderate to high heterogeneity was noted for selected outcomes. CONCLUSIONS: Single-stage repair provides comparable infection rates and long-term functional outcomes to multistage surgery but carries an increased risk of wound dehiscence. Optimizing tissue perfusion and minimizing tension are essential to improve outcomes. This study highlights the important role of vascular and wound-healing mechanisms in determining outcomes after anorectal malformation (ARM) repair. While single-stage surgery reduces the burden of multiple procedures, it exposes perineal tissues to fecal contamination and potential microvascular stress, which may increase the risk of wound complications.An understanding of tissue perfusion, venous drainage, and local tissue tension is critical during neonatal reconstructive surgery. Incorporating techniques that preserve vascular integrity, minimize tension, and protect the surgical site can help optimize postoperative healing and reduce the risk of wound dehiscence.
13 May 2026
Read appraisal →Biofabrication
Resolving the multiscale design trade-off in bone tissue engineering: from generative design to digital twins
The clinical translation of bone tissue engineering is constrained by a severe multiscale design trade-off: the requirement for load-bearing mechanical strength competes directly with the need for vascular-permissive porosity. Conventional approaches address scaffold geometry, material formulation, and fabrication in a sequential, decoupled manner and therefore fail to navigate this multi-objective conflict. To overcome this limitation, we propose an 'AI-Driven Holistic Intelligence' framework. It spans the entire pipeline from generative inverse design to digital twin (DT)-based predictive maturation. The framework integrates gradient scaffold optimization, closed-loop adaptive manufacturing, and virtual clinical trial within a unified workflow. This architecture is designed to co-optimize the boundary conditions of stiffness and perfusion simultaneously, rather than in isolation. Nonetheless, realizing this vision as a clinically viable autonomous regeneration pathway will require bridging persistent translational gaps in data standardization, algorithm interpretability, and regulatory alignment. Importantly, the core innovation of this framework is not merely to navigate the empirical 'trade-off' along a fixed Pareto front, but to resolve it through multiscale co-optimization that expands the accessible design space, enabling simultaneous improvements in mechanical strength and vascular perfusion beyond the limits achievable by conventional single-objective approaches.
13 May 2026
Read appraisal →Journal of special operations medicine : a peer reviewed journal for SOF medical professionals
Combat-Related Orthopedic Trauma in the Russo-Ukrainian War: A Systematic Review
INTRODUCTION: The Russo-Ukrainian conflict has produced large numbers of military and civilian casualties, with orthopedic and musculoskeletal trauma representing a major proportion of combat injuries. Explosions, gunshots, and blast mechanisms frequently generate complex wounds that demand specialized surgical and rehabilitative management. This review summarizes injury types, mechanisms, severity, clinical responses, and gaps in current knowledge. METHODS: Following PRISMA guidelines, a comprehensive search of PubMed, Scopus, Web of Science, and MEDLINE via WoS was conducted in February 2025. Eligible studies published from 2014 to 2024 included case reports, case series, cohort studies, and observational research describing orthopedic injuries in military or civilian populations affected by the conflict. Two reviewers independently screened studies, performed quality assessments using Joanna Briggs Institute tools and STROBE criteria, and synthesized data qualitatively with descriptive statistics when available. RESULTS: Thirty-one studies were included, primarily case reports and retrospective analyses from Ukrainian military hospitals and frontline facilities. Explosive and ballistic trauma produced high-energy fractures, traumatic amputations, severe soft-tissue loss, and neurovascular damage. Management strategies included external and internal fixation, bone grafting, microsurgical reconstruction, distraction osteogenesis, and the progressive use of 3D-printed implants to support limb salvage. Rehabilitation, including pain control, physiotherapy, and prosthetic training, was essential for functional recovery. Long-term complications included neuromas, phantom pain, stump morbidity, and psychological trauma. Telemedicine enabled remote consultation and continuity of care under resource-limited conditions. CONCLUSIONS: Combat-related orthopedic injuries in this conflict require advanced surgical techniques, coordinated multidisciplinary support, and prolonged rehabilitation. Expanded data collection, standardized reporting, and long-term follow-up are essential to improve functional outcomes and reintegration.
4 Apr 2026
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