Dr. Sophocles Voineskos, President/Président, GAM
ABSTRACTS / RÉSUMÉS Outcomes and management of self-inflicted penile amputations: A systematic review and case report
Valerie Steckle, Omar El-Sewify, Ammara Ghumman, Helene Retrouvey
Hamilton, ON
Purpose: Self-inflicted penile amputation is an extreme manifestation of genital self-mutilation closely linked to psychiatric disorders, gender dysphoria, and body integrity identity disorder, posing complex surgical, ethical, and psychosocial challenges. This study systematically reviews the management of self-inflicted penile amputations to evaluate management and outcomes, highlighting the need for individualized, multidisciplinary, and ethically sound approaches to care.
Methods: This systematic review followed PRISMA guidelines and Cochrane methodology, encompassing a comprehensive search of PubMed, Embase, and the Cochrane Library to identify studies on self-inflicted penile amputation that reported management strategies, functional, psychological, or cosmetic outcomes. Eligible data were descriptively analyzed to account for case heterogeneity, summarizing patient, surgical, and psychiatric variables to characterize management approaches and outcomes.
Results: A total of 90 cases from 73 publications were analyzed, predominantly involving young cisgender men (mean age 33 years) presenting after psychotic episodes with complete amputations caused by sharp instruments, most commonly at the penile base. Replantation was attempted in 80% of cases, primarily using microsurgical techniques. Successful reattachment occurred in 78%, with high rates of urinary (92%) and erectile (72%) function recovery among evaluable cases. Complications, particularly skin loss, were common and over half required reoperation; however, cosmetic outcomes were generally satisfactory. Persistent psychiatric morbidity remained frequent on follow-up. Five patients sustained repeated amputation attempts.
Conclusions: Self-inflicted penile amputation predominantly affects young men experiencing acute psychosis, and although microsurgical replantation offers high rates of functional recovery, persistent psychiatric illness and frequent postoperative complications emphasize the need for coordinated surgical and psychiatric management to achieve meaningful rehabilitation.
Depressor anguli oris branch to zygomaticus major branch nerve transfer: An anatomical study for facial synkinesis
Jane Zhu, Tiffany Tse, Hari Iyer, Ronald Zuker, Kevin Zuo, Heather Baltzer
Toronto, ON
Purpose: Facial synkinesis with depressor anguli oris (DAO) hypertonicity results in significant facial asymmetry with volitional smile. During selective neurectomy, transferring a nerve branch of the synkinetic DAO to a nerve branch of the zygomaticus major may improve commissure excursion by both weakening the antagonistic DAO and strengthening the desired zygomaticus major function. We present a cadaveric study to establish the anatomical feasibility of a DAO to zygomatic nerve transfer for treatment of synkinesis.
Methods: Ten embalmed hemi-faces were dissected. Facial nerve branches innervating DAO and zygomaticus major were identified. Measurements included number of sub-branches innervating each muscle, and swing distance from the zygomaticus major branch to masseter and DAO branch to the angle of the mandible. An end-to-end nerve transfer was then performed by transferring the nerve to DAO (donor nerve) to the nerve to zygomaticus major (recipient nerve). Descriptive statistics were used for data analysis.
Results: The number of sub-branches innervating zygomaticus major was 2.1 ± 0.5. Innervation to the DAO was found to be derived from the marginal mandibular branch, and sub-branches innervating DAO was 2.38 ± 0.86 for 8 specimens and could not be identified in 2 specimens. Swing distance was 4.09 ± 0.89 cm for the DAO branch, and 2.47 ± 0.59 cm for the zygomaticus major branch. Nerve transfer was successfully performed in all cadavers where a DAO nerve branch could be identified.
Conclusions: DAO to zygomaticus major nerve transfer for treatment of synkinesis is an anatomically feasible procedure. Future research should focus on the clinical outcomes of patients undergoing a DAO to zygomaticus major nerve transfer.
Standardizing Surgical Reconstruction Outcomes in Pediatric Sarcoma: Development and Implementation of a Hospital-Based Registry
Natasha Barone, Sevan Hopyan, Kristen Davidge, Karen Wong Riff
Toronto, ON
Purpose: Adult surgical sarcoma registries have shown how systematic, longitudinal outcome capture can convert rare, heterogeneous cases into actionable evidence, supporting benchmarking, practice standardization, and guideline development. In contrast, surgical pediatric sarcoma care lacks comparable infrastructure, which limits our ability to improve outcomes and support preference-sensitive decisions. The objective was to develop a hospital-based surgical registry to standardize the capture of reconstructive techniques, complications, function/aesthetics, and survival, and to establish a framework for a potential multicenter pediatric sarcoma reconstruction registry in the future.
Methods: With REB approval (REAS#3409), a retrospective-prospective observational registry was developed in REDCap at SickKids through an iterative process including orthopedic oncologists, plastic surgeons, physiotherapists, and medical oncologists. The registry collects data on pediatric patients undergoing operative management for primary, secondary and recurrent/relapsed bone and soft tissue sarcomas of the extremities or axial skeleton. Data included: demographics, medical history, medical and surgical treatment, intraoperative and postoperative complications, functional and aesthetic outcomes, and survival. This registry supports linkage to long-term health-service data through IC/ES, the repository of health administrative data in Ontario.
Results: The REDCap registry was successfully implemented and populated with 390 surgically managed pediatric sarcoma patients treated (2005-2025). Most common diagnoses were Osteosarcoma (49%), Ewing (22%) and Rhabdomyosarcoma (5.4%). Tumor location included: 252 lower-extremity, 73 upper-extremity, 9 spinal, 18 anterior-chest/torso and 42 pelvic. Implementation generated clinic and operative documentation templates and a standardized follow-up framework.
Conclusions: This is the first dedicated pediatric sarcoma registry focused on surgical management with an attention to reconstruction, addressing critical evidence gaps while creating scalable infrastructure for collaboration. The data captured will be integrated into developing surgical decision-tools for surgeons, patients and their families.
Phase-Locked Gaze Analysis in Microsurgery Using an Integrated Eyetracking Microscope: Implications for Objective Assessment and Training Curricula
Victoria Kulesza, Eric Fung, Bin Zheng, Yao Zhang, Hana Vrzakova
Edmonton, AB
Purpose: Microsurgical training currently relies on time-intensive supervision or post-hoc analysis, often lacking timely, specific feedback. Optimal/personalized simulation pathways remain undefined. We evaluated ocular-mounted eye tracking to characterize phase-specific gaze behaviors during simulation and determine how these metrics inform objective skill assessment.
Methods: Experts (fellowship-trained microsurgeons, senior residents) and trained novices performed standardized glove suturing using a microscope with integrated eye tracking. The procedure was decomposed into needle alignment, pull-through, and knot tying. We analyzed gaze metrics (fixation duration, stability) and pupil dynamics alongside validated UWOMSA scores (rated by 2 blinded experts) to identify teachable differences.
Results: Six experts and six novices completed 32 trials. Differences were noted in the knot-tying phase, where experts maintained gaze stability while novices exhibited increased visual workload. Novices demonstrated significantly higher mean fixation duration (0.18 s ± 0.13 vs 0.11 s ± 0.09, p (34.33 ± 33.31 vs 12.58 ± 10.13, p −0.502, p −0.541, p Conclusions
Conclusion: Microsurgical expertise is characterized by distinct, phase-dependent visual strategies, particularly during knot tying. Implementing ocular-based eye tracking allows educators to objectively identify phases where trainees struggle, supporting “phase-locked” simulation curricula where feedback is targeted to subtasks with highest cognitive and visual demand.
Clinical and Patient-Reported Outcomes in Immediate vs Delayed Targeted Muscle Reinnervation
Kathryn Uhlman, Alexandra D'Souza, Jana Dengler
Toronto, ON
Purpose: Targeted muscle reinnervation (TMR) is an effective surgical treatment for post-amputation nerve pain. The aim of this study was to compare clinical and patient-reported outcomes of TMR in individuals who underwent surgery at the time of amputation (immediate) or in delayed fashion.
Method: A retrospective chart review of patients who underwent TMR surgery for major limb amputation at a tertiary centre between January 2020 to April 2024 was conducted. The primary outcome of interest was rate of post-TMR pain (phantom limb pain (PLP) and residual limb pain (RLP)). Secondary outcomes included re-operation rate, complication rate, prothesis tolerance, and Patient-Reported Outcome Measurement Information System-29 (PROMIS-29) and EuroQol- 5 Dimension 5 Levels (EQ-5D-5L) scales.
Results: Eighteen limbs from 15 patients were included in the chart review (immediate: n = 8; delayed: n = 10). Four months post TMR, the incidence of PLP was n = 4 (22.2%) (immediate: n = 1, 12.5%; delayed: n = 3, 30%) and RLP was n = 8 (44.4%) (immediate: n = 3, 37.5%; delayed: n = 5, 50%). Three patients (16.7%) described difficulty with wearing their prothesis (immediate: n = 1, 12.5%; delayed: n = 2, 20%). Post-operative infection occurred in 1 patient (5.6% complication rate; immediate TMR). The immediate TMR group had better PROMIS-29 physical function and pain interference scores compared to the delayed TMR group (mean difference = 2.6 and 7.3 points, respectively, P > 0.05).
Conclusions: Clinical and patient-reported outcomes are likely more favorable in the immediate TMR population. Health care systems should consider providing TMR surgery at the time of amputation.
Operative Time and Feasibility of Immediate Lymphaticovenous Anastomosis During Breast Cancer Surgery
Maria Laura Petersen, Ahmad Oneissi, Aguirre Auge-Zemmour, Julian Diaz-Abele, Arij El Khatib, Joseph Bou-Merhi, Peter Alam, Michel Alain Danino
Montreal, QC
Purpose: Secondary lymphedema remains a common and debilitating complication following axillary lymph node dissection and regional nodal irradiation in breast cancer patients. A growing body of clinical evidence supports immediate lymphaticovenous anastomosis (ILVA) as an effective strategy to significantly reduce the incidence and severity of postoperative lymphedema without compromising oncological safety. Despite these demonstrated benefits, hesitancy persists regarding its routine implementation, largely due to concerns about added operative time and operating room efficiency. The purpose of this study was to objectively quantify the operative time required for ILVA and to evaluate the predictability and reproducibility of its integration into standard breast cancer surgery.
Method: A retrospective case series included 12 consecutive patients who underwent ILVA over a six-month period at a single institution. Patient demographics, surgical characteristics, number of anastomoses, anastomotic techniques, and operative times were collected. Statistical analysis was performed using IBM SPSS Statistics, version 31 (IBM Corp., Armonk, NY, USA).
Results: ILVA accounted for a median of 17.4% of total operative time, corresponding to a median duration of 43 min (range: 23-69 min). Each additional lymphaticovenous anastomosis increased operative time by approximately 7 min. Mean anastomosis time varied by technique, ranging from 30 min for end-to-side intussusception to 55 min for coupler-assisted anastomoses.
Conclusions: ILVA can be performed in a predictable and reproducible manner with a limited and measurable impact on overall operative time. These findings support the feasibility of incorporating ILVA into routine breast cancer surgery in centers with microsurgical expertise.
Feedback and Assessment Methods in Microsurgery Education: A Scoping Review
Jessica Gormley, Justin Haas, Muhammad Abbas, Elena Huang, Victoria McKinnon, Christopher Coroneos, Anita Acai
Hamilton, ON
Purpose: Microsurgery requires unique skills, instrumentation, and training, necessitating structured feedback and assessment for trainees. The lack of standardized methods for assessment and feedback may affect trainee satisfaction and operative outcomes. This scoping review synthesizes available literature on feedback and assessment in microsurgical training.
Method: Medline, EMBASE, ERIC, and Web of Science were systematically searched for studies discussing feedback and/or assessment in microsurgery. Study characteristics, feedback and assessment methods, and other relevant data were extracted. The Medical Education Research Study Quality Instrument (MERSQI) was used to appraise the quality of quantitative studies.
Results: From 2440 screened articles, 99 were included. Most studies (65%) were published after 2015, with plastic surgery, neurosurgery, and ophthalmology being the most represented specialties. Studies discussing solely assessment methods dominated (90%), with just 10% discussing both assessment and feedback. The most common task was microvascular anastomosis (55%), performed on synthetic (20%), chicken (16%), or rat models (11%). Global Rating Scales (GRSs) were the most frequently used assessment tools (73%), followed by checklists (23%) and device-derived metrics (21%). Common assessment parameters included suture placement (53.5%), dexterity (50.5%), and tissue handling (48.5%). Among feedback methods, real-time verbal feedback was the most prevalent (80%), while delayed written video review was also utilized (20%). No structured feedback methods were identified.
Conclusions: Despite the growing use of structured assessment tools, feedback remains largely unstructured in microsurgical education. While GRSs are widely used, the increasing availability of device-derived metrics is shifting assessment practices. The absence of standardized feedback methods may hinder the effective implementation of feedback across microsurgical training.
