Authors:  Heron MJ, Zhu KJ, McVeigh AB, Rezwan SK, Cooney CM, Broderick KP Affiliation:  Dept. of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland Journal:  Journal of Reconstructive Microsurgery. March 2026 PMID:   40505695 Key takeaways This cross-sectional analysis of U.S. insurer policies found that, among the 53 insurers with explicit HBOT coverage policies, nearly half required prior authorization and many also required continuing authorization. Coverage variability was driven less by whether HBOT was recognized and more by how compromise, hyperbaric treatment, documentation, and reassessment thresholds were defined. To maximize coverage, clinicians should document medical necessity early, rule out or correct mechanical causes, include objective healing data when possible, and anticipate frequent reauthorization requests. Background HBOT is a recognized, covered indication for compromised skin grafts and flaps under Medicare, but the supporting clinical literature remains narrower than many surgeons assume. That combination likely explains why coverage often exists but authorization requirements remain stringent and heterogeneous. Objective To characterize HBOT coverage requirements among major U.S. insurers for acutely compromised flaps and grafts and to build a practical authorization and documentation algorithm for prescribing surgeons. Methods Design: Cross-sectional policy review with dual, blinded data extraction. Sampling frame:  The 60 largest health insurers by market share and enrollment, capturing approximately 80% of the market nationally and within each state. Policy collection:  Policies were gathered in August 2023 from public sources or directly from insurers when possible. Primary focus:  Documentation requirements for HBOT reimbursement in compromised flaps and grafts. Secondary focus:  Prior authorization, continuing authorization, treatment protocol requirements, credentialing, and pressure or session thresholds. Practical output:  A surgeon-facing reimbursement algorithm. Results Of 60 eligible insurers, 53 had explicit HBOT policies. 49 covered HBOT to varying extents. 3 labeled it investigational for compromised flaps or grafts. 1 explicitly did not cover it. 7 had no accessible confirmable policy. Prior authorization was required by 25 of 53 insurers. Only 15 insurers explicitly defined tissue compromise; most others relied on clinician judgment. Four policies required objective hypoxia with TcPO2 below 40 mmHg. Only 7 policies specified an actual treatment protocol, generally aligning with 2.0 to 2.5 ATA for 90 to 120 minutes, often twice daily initially. Documentation requirements were explicitly listed by 22 insurers. Most commonly requested items included medical records, evidence of healing, wound images, treatment goals, anticipated duration, and dive parameters. Many insurers wanted documentation of diagnosis, flap or graft type, surgeon name, exclusion or correction of mechanical causes, and failure of conservative therapy. Continuing authorization was a major operational issue. Session-based renewal thresholds clustered at 12, 15, 20, 30, and 40 sessions. Twenty sessions was the median among policies using a session threshold. When two dives were performed in one day, each dive generally needed to be documented and billed separately. Conclusion Most major U.S. insurers recognize HBOT for compromised flaps and grafts, but approval depends heavily on how well the surgeon demonstrates medical necessity and ongoing response to treatment. The paper’s main contribution is not proving HBOT works biologically, but showing surgeons how to navigate the payer process quickly enough for HBOT to remain clinically useful in an acute salvage setting. Strengths Addresses a highly practical coverage question that most HBOT papers do not. Broad insurer sampling designed to reflect the real U.S. market. Dual, blinded extraction improves reliability for a descriptive policy study. Provides an immediately usable reimbursement algorithm. Limitations Policies were collected in 2023, so some requirements may already have changed. Published policies may not reflect actual claims behavior or hidden payer requirements. It does not include a formal cost-effectiveness analysis. Clinical relevance Most large insurers recognize the indication, but reimbursement depends on rapid, comprehensive documentation. Rule out mechanical causes of flap or graft compromise and document that clearly. Frame requests as acute flap or graft compromise rather than vague poor healing. Include operative notes, current findings, treatment goals, dive details, serial photos, and measurable improvement. Expect early reauthorization and plan reassessment accordingly.

Authors: DeVito RG, Harlan D, Ke BG, Isaula DM, Park RH, Hollenbeck ST, Campbell CA, Stranix JT Affiliation:  Department of Plastic Surgery, University of Virginia Health System; School of Medicine, University of Virginia, Charlottesville, Virginia Journal:   Journal of Reconstructive Microsurgery , November 2025 PMID:   41197981   Key takeaways Immediate autologous reconstruction was associated with more blood loss and more transfusions than delayed reconstruction (unilateral and bilateral). Bilateral immediate cases had a 14.3% transfusion rate versus 2.0% for bilateral delayed; unilateral immediate cases had a 12.1% rate versus 0% for unilateral delayed. Postmastectomy radiation therapy requirement and vascular disease were the strongest independent predictors of transfusion; unilateral reconstruction and higher BMI were protective. Transfusion correlated with hematoma, but not with flap thrombosis or flap loss. Most useful for preoperative counseling and blood-management planning, not as proof that delayed reconstruction is universally better.   Background Autologous breast reconstruction is a durable mainstay of modern breast reconstruction with good patient satisfaction rates. There is limited data on whether reconstructive timing (immediate vs. delayed) meaningfully affects perioperative blood loss and transfusion risk from autologous breast reconstruction.   Objective To determine whether immediate versus delayed autologous breast reconstruction is associated with differences in postoperative hemoglobin drop and perioperative transfusion incidence, while also identifying predictors of transfusion.   Methods Retrospective single-institution cohort study. 264 consecutive patients undergoing free-flap breast reconstruction from July 2017 through June 2022 divided into 4 groups: Bilateral immediate autologous reconstruction: n = 77 Bilateral delayed autologous reconstruction: n = 50 Unilateral immediate autologous reconstruction: n = 99 Unilateral delayed autologous reconstruction: n = 38 Primary outcomes: Postoperative hemoglobin (Hgb), hemoglobin change, estimated blood loss (EBL), need for transfusion, and presence of hematoma Secondary outcomes: Flap thrombosis or loss, wound complications, infection, seroma, fat necrosis, hernia or bulge, deep venous thrombosis, and pulmonary embolism. Statistical analysis used unpaired t tests (for continuous variables) and Fisher exact tests (for categorical variables) to compare immediate and delayed populations, and multivariable regression to identify predictors of transfusion.   Results Primary outcomes Preoperative Hgb similar across groups ~12.6 g/dL Bilateral reconstruction Lower postoperative Hgb ( p=0.00001 ), larger Hgb drop ( p=0.0015 ), higher EBL ( p=0.00004 ), more transfusions ( p=0.0206 ), greater introp crystalloid ( p=0.002 ) and total fluid volume ( p=0.0019 ) given in immediate compared to delayed bilateral breast reconstruction No difference in hematoma incidence ( p=0.55 ) Mean follow-up 17.5 mo (bilateral immediate), 13.3 mo (bilateral delayed) Unilateral reconstruction Lower postoperative Hgb ( p=0.0015 ), larger Hgb drop ( p=0.0001 ), higher EBL ( p=0.013 ), more transfusions ( p=0.0246 ) given in immediate compared to delayed bilateral breast reconstruction No difference in hematoma incidence ( p=0.07 ) Mean follow-up 14.7 mo (unilateral immediate), 14.6 mo (unilateral delayed) Predictors of transfusion Increased risk of transfusion associated with: Postmastectomy radiation – OR 10.3 ( p=0.008 ) Vascular disease – OR 14.5 ( p=0.02 ) Decreased risk of transfusion associated with: Unilateral reconstruction – OR 0.20 ( p=0.04 ) By 12.3% by unit of BMI – ( p=0.04 ) Secondary outcomes Bilateral immediate cases had more mastectomy flap necrosis (16.9% vs. 4.0%, p=0.02801 ), while bilateral delayed cases had more donor site infections (26% vs. 9.1%, p=0.0103 ) Unilateral immediate cases had more minor breast wounds (30.3% vs. 13.2, p=0.04 ), while unilateral delayed cases had more major breast wounds (21.0% vs. 6.1%, p=0.03 ), minor donor site wounds (39.5% vs. 19.2%, p=0.0137 ), donor site infections (44.7% vs. 6.1%, p<0.001 ) Transfusion was associated with hematoma (OR 7.2, p=0.01 ) but not with flap thrombosis or loss   Conclusion Immediate autologous breast reconstruction was associated with greater blood loss and higher transfusion rates than delayed reconstruction in both unilateral and bilateral cases. Timing should be considered part of perioperative blood loss/transfusion risk stratification, especially in patients with plans for bilateral surgery, history of vascular disease, or anticipated radiation.   Strengths Consecutive real-world cohort with clinically relevant outcomes. Separates unilateral and bilateral cases. Multivariable analysis. Limitations Retrospective, single-center design. Groups were not fully matched, with meaningful differences in prior treatment history and operative factors. No standard deviations reported for data, just means (incomplete picture and makes it difficult to repeat/confirm statistics). Multiple comparisons made without discussion of appropriate correction factor (i.e. Holm-Bonferonni). Immediate case EBL/transfusion data captures effects of the combination of mastectomy and reconstruction, while delayed case EBL data captures only reconstruction. Limited number of flap thrombosis/loss events limits power to predict correlation between transfusions and these rare flap outcomes. Transfusion threshold and detailed flap-type breakdown not clearly provided.   Clinical relevance This paper supports more explicit counseling about transfusion risk when planning immediate free-flap breast reconstruction, especially for bilateral cases and patients likely to undergo radiation. This is not a definitive statement on ideal reconstructive timing, so this data should not be used to argue that delayed autologous reconstruction is universally preferable.   Editorial Notes The study likely captures the bleeding burden of the whole operative episode rather than isolated flap reconstruction alone. The null finding for flap thrombosis and loss should be interpreted in context.of limited power given small number of flap thrombosis/loss events. Need additional info about institution’s transfusion thresholds, use of tranexamic acid, anemia-management pathway, and whether mastectomy type or axillary surgery differed between groups. Consider further focused analysis of immediate cases to identify transfusion predictors.

Authors:  Tanas Y, Harris P, Gasper G, Cato L, Cervantes Valadez S, Rashidi K, Nguyen P, Wang J, Swed S, Zak P Affiliation:  Houston Methodist Hospital Journal:   Plastic and Reconstructive Surgery Global Open , February 2026 PMID:  41710187 Key takeaways This is a PRISMA-based systematic review and meta-analysis of 5 comparative breast reconstruction studies including 1180 reconstructions in 1072 patients. No statistically significant clinical difference was found between AlloDerm and Cortiva for seroma, hematoma, infection, mastectomy-flap necrosis, reoperation, drain duration, or BREAST-Q physical well-being. The strongest signal is economic, not clinical: Cortiva was reported as 10% to 22% cheaper per sheet and, in the strongest cost studies, associated with 44% to 56% lower per-breast episode cost. Background AlloDerm and Cortiva are both human acellular dermal matrices used to support implant-based breast reconstruction. Brand-level comparative evidence has been limited despite widespread use and meaningful cost differences in real-world procurement. Objective To compare short-term complications, patient-reported physical well-being, and cost outcomes between AlloDerm and Cortiva in immediate and delayed prosthetic breast reconstruction. Methods Systematic review and meta-analysis, prospectively registered in PROSPERO and reported per PRISMA 2020. Databases searched: PubMed, Scopus, and Web of Science in 2025 for adult head-to-head comparative studies of AlloDerm versus Cortiva in implant-based breast reconstruction. Included designs: 1 blinded randomized trial, 1 interim randomized trial, and 3 observational comparative cohorts. Outcomes pooled with random-effects models: seroma, hematoma, infection, mastectomy-flap necrosis, unplanned reoperation, drain duration, BREAST-Q physical well-being, and cost. Operative settings were heterogeneous: mostly prepectoral in 3 studies, with mixed or subpectoral tissue-expander cases in the others. Follow-up ranged from 30 days to 42 months, and only 2 studies extended past 24 months. Results No significant difference in seroma: OR 1.50, 95% CI 0.56 to 4.06, P = 0.42. No significant difference in hematoma: OR 1.25, 95% CI 0.38 to 4.13, P = 0.71. No significant difference in infection: OR 1.06, 95% CI 0.66 to 1.69, P = 0.82. No significant difference in mastectomy-flap necrosis: OR 1.34, 95% CI 0.13 to 13.59, P = 0.80. Reoperation was similar: OR 0.89, 95% CI 0.35 to 2.30, P = 0.81. BREAST-Q physical well-being showed no significant difference: MD -1.61, 95% CI -4.53 to 1.30, P = 0.28. Drain duration was similar: MD -0.21 days, 95% CI -0.94 to 0.53, P = 0.58. The major distinction was cost. In the included economic analyses, Cortiva cost less per cm² and had substantially lower material and total per-breast episode cost in the strongest comparative cost study. The savings appear to come mostly from purchase price rather than fewer downstream complications. The highest-quality included randomized trial found Cortiva to be noninferior to AlloDerm, with directionally lower seroma and lower variable cost. The strongest comparative cohort similarly found comparable clinical outcomes but lower material and total episode cost with Cortiva. Conclusion AlloDerm and Cortiva appear clinically comparable in the short term, but Cortiva seems more economical. Strengths and limitations Best available brand-to-brand synthesis on this specific question, and it includes the highest-quality head-to-head randomized evidence currently available. Includes both clinical outcomes and cost, which is especially important when products appear functionally similar. The evidence base is still shallow: mostly nonrandomized data, moderate-to-high heterogeneity for some endpoints, and likely underpowering many variables. Long-term outcomes remain a major blind spot. The study cannot meaningfully answer questions about capsular contracture, aesthetic revision, fat grafting burden, or durable patient satisfaction. One indirect abdominal wall reconstruction study was used for cost context, which weakens breast-specific inference. Clinical relevance For practicing reconstructive surgeons, this paper supports a straightforward message: if you already use human ADM and your choice is AlloDerm versus Cortiva, you should not expect a meaningful short-term clinical difference based on current evidence. The practical differentiator is likely your local purchasing contract. Editorial Notes This study's biggest limitation is the lack of long-term outcomes that matter most to surgeons, including capsular contracture, implant positioning, revision rates, and aesthetic durability. Would these findings persist under stricter same-plane, same-stage, same-sheet-area, and same-thickness protocols?

Authors:  Lloyd K, Shern TP, Holt LR, Daly AE, Anderman KJ, Fell GG, Gadd MA, Verdial FC, Kwait RM, Tomczyk E, Ozmen T, Smith BL, Specht MC Affiliation:  Massachusetts General Hospital; Dana-Farber Cancer Institute, Boston, Massachusetts Journal:  Annals of Surgical Oncology, February 2026 PMID:   41708932 Key takeaways Same-day discharge was achieved in 88% of reconstructed mastectomy patients and in 100% of the ASC cohort. Older age, living more than 30 miles away, bilateral surgery, and afternoon PACU arrival predicted overnight admission. ASC cases had shorter PACU stays, fewer PACU issues, and similar 30-day complications versus HOPD cases. Estimated facility-fee savings were $1.79 million, or 61.2%, for 99 ASC cases compared with equivalent HOPD care. This is a strong systems and operations paper, but selection bias limits any claim that ASC location itself causes better outcomes. Background Same-day mastectomy pathways have expanded because they can reduce length of stay, opioid exposure, and hospital resource use without clearly worsening short-term outcomes. What remains less well defined is whether implant-based mastectomy with immediate reconstruction can be shifted safely from hospital outpatient departments to ambulatory surgery centers while preserving outcomes and lowering costs. Objective To identify predictors of overnight admission after same-day mastectomy with immediate implant or tissue expander reconstruction, and to evaluate the safety, feasibility, and cost profile of performing these cases at ambulatory surgery centers versus hospital outpatient departments. Methods Design: Retrospective cohort study within a single health system. Setting: Two hospital outpatient departments and two ambulatory surgery centers. Study period:  January 2023 to June 2024. Population: 559 consecutive women undergoing mastectomy with immediate implant-based or tissue expander reconstruction. Eligibility details:  ASC patients had to meet center-specific criteria including BMI less than 45 kg/m2 and ASA class 3 or less; patients with difficult airway history, severe untreated sleep apnea, or prior major anesthetic problems were not eligible for ASC surgery. Case mix: Median age 48 years. 85.3% White. 68.0% invasive cancer, 21.5% ductal carcinoma in situ, 10.5% prophylactic. 67.6% bilateral procedures. 58.7% direct-to-implant and 41.3% tissue expander reconstruction. Perioperative pathway:  Standardized same-day mastectomy protocol with regional blocks, multimodal analgesia, antiemetics, and postoperative support. Comparisons: Same-day discharge versus overnight stay. Planned versus unplanned overnight stay. ASC versus HOPD. Endpoints: PACU events, narcotic use, postoperative length of stay, 30-day complications, return to OR, readmission, and cost. Statistics: Multivariable binomial logistic regression for predictors of overnight admission; cost modeled using 2024 Medicare outpatient facility fees. Results Discharge success: 492 of 559 patients, or 88.0%, went home the same day. 67 patients, or 12.0%, stayed overnight. Of overnight stays, 35 were planned and 32 were unplanned. Independent predictors of any overnight admission: Age greater than 65 years: OR 2.48. Distance greater than 30 miles: OR 2.16. Bilateral surgery: OR 2.44. Afternoon PACU arrival: OR 2.01. Independent predictors of unplanned overnight admission: Distance greater than 30 miles: OR 2.32. Bilateral surgery: OR 3.02. Afternoon PACU arrival: OR 2.70. PACU findings tied to unplanned admission: Nausea and vomiting. Hypotension. Inadequate pain control. Safety: Thirty-day complications were similar between same-day discharge and overnight-stay patients: 84 of 492 (18.3%) versus 14 of 67 (20.9%). Hospital readmission within 30 days was also similar: 43 of 492 (8.7%) versus 9 of 67 (13.4%). Return to OR within 30 days was similar as well: 41 of 492 (8.3%) versus 9 of 67 (13.4%). Five hematomas requiring return to OR occurred within 24 hours; three had already been discharged and two were still in PACU. ASC versus HOPD: Same-day discharge: 100.0% at ASCs versus 85.4% at HOPDs. Median postoperative stay among same-day discharges: 2.27 versus 3.97 hours. PACU issues were lower at ASCs, including hypotension, nausea and vomiting, somnolence, and anxiety. PACU narcotic use was lower at ASCs. Thirty-day complications, readmissions, and return to OR were not significantly different. Cost: Estimated ASC facility fees for 99 patients: $1,132,380. Estimated HOPD facility fees for the same cases: $2,917,876. Estimated savings: $1,785,496, or 61.2%. Conclusion For selected patients undergoing implant-based immediate reconstruction, same-day mastectomy at an ambulatory surgery center appears feasible and short-term safe, with substantial facility-level cost savings. The clearest modifiable operational signal is timing: morning scheduling and avoidance of late PACU arrival may meaningfully reduce unexpected admission. Strengths and limitations Large contemporary cohort focused specifically on mastectomy with immediate implant or tissue expander reconstruction. Direct comparison of ASC and HOPD settings with real operational outcomes and modeled cost data. Retrospective, single-system design with important selection bias ; ASC patients were preselected and could not stay overnight at the center . Surgeons practiced across limited sites, so site effects may partly reflect surgeon or team behavior rather than facility type. Cost analysis used Medicare facility-fee estimates and excluded professional fees, downstream utilization, and transfer logistics. No patient-reported outcomes, satisfaction data, or longer-term reconstructive outcomes were assessed. Clinical relevance This paper supports a structured pathway with regional anesthesia, multimodal analgesia, aggressive antiemetic strategy, and deliberate morning scheduling. Patients who are older, live farther away, or are having bilateral surgery merit more careful site selection and stronger counseling about the chance of overnight admission. In practice, the paper supports moving selected direct-to-implant and tissue expander cases to ASCs, but only if the center has experienced breast and plastic surgery teams, reliable escalation pathways, and a culture optimized for same-day discharge. Context within the literature American Society of Breast Surgeons Working Group, 2022:  The specialty review supports home recovery after mastectomy when patient selection, education, analgesia, and rescue pathways are standardized. This current study fits that framework and provides a more granular site-of-care comparison. Specht et al., 2022:  In this same Massachusetts General Hospital program, implementation of a same-day reconstruction pathway reduced median stay from 24.6 to 5.5 hours without increasing 30-day readmissions. The current paper is the operational next step, showing further compression of stay and extension into ASCs. Vuong et al., 2021:  In a large integrated system, 64% of mastectomies were outpatient. Immediate reconstruction and ASA 3 to 4 decreased the odds of outpatient recovery, and 7% of outpatients had return-to-care within 7 days. Compared with that broader cohort, the present paper focuses only on reconstructed patients and highlights distance, bilateral surgery, and late-day recovery as the strongest practical barriers. Caminiti et al., 2024:  In a planned same-day mastectomy cohort, postoperative admission was predicted by preoperative opioid use, ASA status, longer PACU stay, and start time after noon, with higher costs for those admitted. The present study strongly confirms the timing signal and extends it to reconstructed patients. Brantley et al., 2023:  NSQIP analysis of more than 21,000 immediate implant-based reconstructions showed similar wound complications and lower readmission with same-day discharge versus admission. That national dataset supports the safety signal seen here. Schwartz et al., 2020:  Prepectoral reconstruction in an ASC had similar overall complications and lower major infectious complications than hospital-based care. The current paper did not reproduce a lower infection signal, but it did show equivalent short-term safety with faster recovery and lower estimated cost. Kauke-Navarro et al., 2025:  A 15-year NSQIP analysis of direct-to-implant reconstruction found same-day discharge was associated with lower adjusted odds of complications, reoperation, and readmission in selected patients. This newer national literature strengthens the argument that carefully selected implant-based mastectomy patients do not need routine overnight admission. Editorial Notes The most important limitation is confounding by selection and system design. ASC patients were preselected for lower anesthetic risk and all ASC cases were scheduled in the morning, so the paper cannot isolate whether the better PACU profile is due to the ASC itself or simply who and when the center operated. A 100% same-day discharge rate at ASCs is impressive, but it may partly reflect the fact that these centers have no overnight capability. That operational constraint may bias toward discharge rather than prove every discharge was equally appropriate. The paper evaluates 30-day surgical safety, but not patient-centered recovery. We still do not know whether pain control, sleep, drain management confidence, or satisfaction differed by site. Five hematomas required takeback within 24 hours, and three occurred after discharge. That number is not alarming, but it reinforces that outpatient pathways must be paired with excellent triage, patient education, and rapid access to re-evaluation. The cost analysis is useful for administrators, but it is based on Medicare facility-fee estimates and excludes physician reimbursement, caregiver burden, ambulance transfers from ASC to hospital, and indirect costs. In general, shifting cases to lower-acuity centers produces the greatest savings for payers/insurers, although professional fees may be somewhat higher in those settings.  Bottom line

Authors:  Hoyos AE, Perez Pachon M, Borras Osorio M, Castiblanco MP, Leon-Machicado M Affiliation:  Private practice, Bogotá, Colombia Journal:  Plastic and Reconstructive Surgery, February 2026 PMID:  40674620 Key takeaways Adding TXA to tumescent solution (for arm liposuction) reduced postoperative day 1 pain and bruising versus placebo in a split-body randomized trial. There was no difference in edema (arm circumference) No TXA-related adverse events were reported, but the study was not powered to establish thromboembolic safety. Background Arm contouring with liposuction is increasing in popularity. TXA has attracted interest as an adjunct to reduce bleeding, bruising, and possibly inflammation. Prior liposuction studies suggested that TXA can reduce blood loss and ecchymosis, but route, dose, and procedure-specific benefit remain inconsistent. This trial asked: does adding TXA to tumescence fluid improve early postoperative recovery in patients undergoing arm liposuction? Objective To determine whether adding TXA to tumescent solution for arm liposuction reduces postoperative pain, ecchymosis, and edema compared with placebo. Methods Design: Single-center, double-blind, contralateral randomized clinical trial. Setting: Specialized plastic surgery institution in Bogotá, Colombia, May 2022 to February 2024. Population: 78 adults undergoing arm liposuction, either isolated or combined with other aesthetic procedures. Demographics: 78.2% female; mean age 37.6 years; mean BMI 24.7 kg/m². Inclusion criteria:  Age 18 to 60 years, no major comorbidities, planned arm liposuction. Exclusion criteria:  Follow-up of 1 month or less, incomplete data, or contraindication to TXA. Intervention: One arm randomized to TXA tumescent solution and the contralateral arm to placebo. TXA formulation:  250 mg TXA per 1 L of standard tumescent solution. Control formulation:  Standard tumescent solution only. Technique: High-definition liposculpture with infiltration, ultrasound-assisted emulsification, and suction-assisted extraction. Most cases used VASER and MicroAire. Many patients also underwent additional liposculpture and contouring procedures. Primary measured outcomes:  Day 1 pain by visual analog scale (VAS), arm circumference over time, and ecchymosis area from standardized photographs using ImageJ. Follow-up for study endpoints:  Pain on postoperative day 1; circumference on days 1, 7, 15, and 30; ecchymosis on days 1 and 8. Statistics: Fisher exact test for categorical pain scores; Kruskal-Wallis for nonparametric continuous outcomes; significance threshold 0.05. Post hoc power analysis was performed for day 1 pain. Results Sample analyzed:  78 patients overall, but endpoint completeness varied. Pain analysis: 62 patients. Ecchymosis analysis: 47 patients. Circumference analysis: 40 to 47 patients depending on time point. Operative profile:  Mean operative time 271 minutes; mean infiltration volume 5573 mL; mean suction volume 4121 mL; mean lipoaspirate 2803 mL. Concomitant procedures were common:  abdomen liposculpture in all patients, back in nearly all, thighs in most, with frequent intramuscular fat grafting and other adjunctive procedures. Primary and notable secondary outcomes Pain, postoperative day 1:  significantly lower in the TXA arm. Mean VAS: 3.37 ± 0.84  with TXA versus 5.58 ± 1.14  with placebo. Distribution favored TXA: most TXA arms were in the mild pain range, whereas most control arms were in the moderate pain range. P < 0.001 . Ecchymosis, postoperative day 1:  significantly lower in the TXA arm. Median ecchymosis area: 2.26%  versus 5.21% . P = 0.021 . Ecchymosis, postoperative day 8:  numerically lower with TXA but not statistically significant. Median ecchymosis area: 0.97%  versus 2.54% . P = 0.167 . Arm circumference:  no significant difference at baseline or postoperative days 1, 7, 15, or 30. This argues against a measurable edema benefit using this metric. Safety and satisfaction Overall complication rate:  8.9%. Reported complications:  abdominal seroma, anemia, cellulitis, umbilical hematoma, and infection/immune response. Important nuance:  none of the adverse events were attributed to the arm lipoplasty itself or to TXA in the tumescent solution. Patient-reported satisfaction:  among 73 respondents, 91.8% rated results 8 to 10 out of 10 on a Global Aesthetic Improvement Scale-based survey. Late issues:  with follow-up up to 6 months in most patients, no scar formation, fibrosis, or cording was reported. Conclusion In healthy patients undergoing arm liposuction, adding TXA to the tumescent solution improved early recovery by reducing postoperative day 1 pain and bruising without a detectable difference in arm circumference. The authors conclude that tumescent TXA is a safe and effective adjunct for body contouring recovery, although the strongest evidence here is for early pain and ecchymosis rather than edema. Strengths Randomized, double-blind, split-body design is a major strength and controls for many patient-level confounders. Objective bruise quantification with standardized photography and ImageJ is better than subject ratings. Clinically relevant outcomes for aesthetic patients: pain, bruising, and recovery experience. The signal size for day 1 pain was large. Limitations Single-center study in a healthy, selected population limits generalizability. Endpoint completion dropped substantially; not all 78 patients contributed to each outcome. Most patients had multiple simultaneous body contouring procedures, which can complicate interpretation of pain and recovery. Arm circumference is a crude edema surrogate and may be too insensitive to detect meaningful tissue swelling differences. The safety dataset is too small to define thromboembolic risk or rare TXA-related events. The paired, within-patient design is excellent, but the statistical approach was not as rigorous as a fully paired or mixed-effects analysis would have been. Clinical relevance Adding TXA appears to be a reasonable, low-friction strategy to decrease bruising and improve day 1 comfort in carefully selected patients. Literature context Earlier liposuction studies already suggested that TXA reduces blood loss and bruising, but most were small, heterogeneous, or not truly arm-specific. A 2018 liposuction study showed substantially lower blood loss per liter of lipoaspirate with TXA, supporting a blood-sparing effect. A 2021 split-site flank liposuction study found less bruising on the TXA-treated side at days 1 and 7, which aligns closely with the current paper’s ecchymosis findings. A 2021 retrospective donor-site study in fat-grafting patients also showed less ecchymosis with local TXA infiltration. A 2022 randomized liposuction trial found reduced blood loss with TXA in tumescent solution and no TXA-related adverse events. A 2022 multicenter randomized trial from the same research group suggested that intravenous TXA outperformed local/subcutaneous TXA for hemoglobin preservation , which is important: local TXA may help bruising, but IV TXA may still be superior if the main endpoint is blood conservation. A 2023 randomized study again supported TXA, reporting less blood loss and less bruising, with the largest reduction seen in the local TXA group. More recent liposuction-specific and aesthetic-surgery meta-analyses support an overall blood-sparing effect of TXA, but they consistently emphasize heterogeneity in dose, route, outcome reporting, and study quality. Editorial Notes Why did only 62 patients contribute pain data and only 47 contribute ecchymosis analysis? A fuller accounting of missingness by randomized side and by patient characteristics would strengthen confidence. The edema question remains largely unanswered because circumference is a blunt tool for detecting postoperative tissue swelling after liposuction. Ultrasound, 3-dimensional imaging, or tissue thickness measurements would have been more informative. Pain findings should be interpreted cautiously because most patients underwent concomitant procedures.  The dose was 250 mg/L, which is lower than some previously reported tumescent regimens. That raises an important practical question: is this near the minimum effective dose for bruising reduction, or could a higher dose produce more durable benefit?

Authors:  Haas EJ, Thurimella K, Baghshomali Y, Egan K, Kaoutzanis C, Irwin T, McCarter M, David EA, Mathes DW, Yu JW Affiliation:  University of Colorado Anschutz School of Medicine Journal:   Journal of Reconstructive Microsurgery , January 2026 PMID:   41534855 Key takeaways Adults had substantially higher leak and dysphagia rates than pediatric patients, but also exhibited higher rates of comorbidities. Prior radiation was associated with dumping, stricture, poor wound healing, and reoperation. Pediatric cases were longer and associated with longer hospital stays, but major healing-related complications were lower. Background Superchargd jejunum is a strong option for esophageal reconstruction when a gastric pull-up is not available because it offers a favorable caliber match and intrinsic peristalsis. Objective To compare perioperative characteristics and postoperative complications after SPJ in pediatric versus adult patients and to explore adult comorbid factors associated with complications. Methods PRISMA-guided systematic review and meta-analysis. Databases searched: PubMed, Embase, Ovid Medline, and Web of Science. Search window: January 2000 to April 2025. Included studies: 23. Total patients: 477. Adults: 415. Pediatric/young adult: 62. Adults were mostly reconstructed for malignancy. Pediatric patients were mainly reconstructed for long-gap esophageal atresia. Primary endpoint: postoperative complications. Additional adult-only exploratory Ridge regression examined study-level comorbid factors associated with complications. Results Mean age: 57.2 years in adults versus 8.0 years in pediatric patients. Mean operative time: 667 minutes in adults versus 1,039 minutes in pediatric patients. Mean length of stay: 28.0 days in adults versus 51.5 days in pediatric patients. Primary and notable outcomes Anastomotic leak:  18% in adults (73/399) versus 1.7% in pediatric patients (1/58). Dysphagia: 34% in adults (28/83 reported) versus 5.6% in pediatric patients (1 reported pediatric patient). Pulmonary complications:  32% in adults (117/366) versus 16% in pediatric patients (3/19 reported). Adult risk-factor signals Prior radiation had the strongest association with dumping symptoms. Prior radiation was also associated with stricture, poor wound healing, and reoperation. Cancer history correlated with leak. Prior surgery correlated strongly with surgical-site infection. A seemingly protective smoking signal was likely a model artifact rather than a biologically credible finding. Conclusion SPJ is a legitimate option for esophageal reconstruction across age groups, but adult and pediatric SPJ are very different clinical scenarios. Adults, who are often reconstructed after cancer, radiation, and prior operations, have more leaks and swallowing problems, while pediatric patients undergo longer and more technically complex operations but generally heal better. Strengths Focus on surgeon-relevant outcomes such as leak, dysphagia, pulmonary complications, and reoperation. Attempts to move beyond descriptive pooling by exploring adult risk factors. Limitations Nearly all included studies were retrospective. Pediatric patients made up a relatively small share of the total cohort. Adult-pediatric comparisons are heavily confounded by indication and are really two very different clinical scenarios. Outcome definitions and reporting denominators were inconsistent across studies. The regression analysis used aggregate study-level data and should be viewed as hypothesis-generating. Clinical relevance For reconstructive microsurgeons, this paper is most useful for preoperative risk framing. Adult SPJ candidates, especially post-cancer and post-radiation salvage patients, should be counseled as high-risk for leak, stricture, dysphagia, wound problems, and reintervention. Pediatric patients represent technically longer cases rather than biologically higher-risk cases. When the stomach is unavailable, jejunum remains a strong conduit option in experienced multidisciplinary centers. Editorial Notes The comparison between adult and pediatric cases is largely irrelevant. Instead, this study serves to highlight the complicated nature of this approach and identifies risk factors for early postoperative complications.  Long-term functional outcomes deserve more emphasis, including feeding tube dependence, aspiration risks, dilation burden, and swallowing quality. It would be helpful to see stratified analyses by indication, radiation exposure, reconstruction route, and level of anastomosis.

Authors:  Qin N, Gundlach C, Kochheiser M, McVeigh AB, Vaeth AM, Wei L, Zhang A, Arbuiso S, Chinta M, Wang ML, Huang H, Otterburn DM Affiliation:  Weill Cornell Medicine; Division of Plastic Surgery, New York Journal:  Journal of Plastic, Reconstructive & Aesthetic Surgery. 2025;109:160-170 PMID:   40882602   Key takeaways -Neurotized DIEP had better tactile recovery than alloplastic reconstruction. -Alloplastic reconstruction had better cold and heat perception at later time points than neurotized DIEP. Background Breast sensation is important for quality of life. Neurotization has been shown to improve sensory outcomes in autologous reconstruction in the past, but thermal recovery has been less studied. Methods Design: Prospective, single-surgeon, single-institution cohort study from 2019-2024. Cohorts: Immediate neurotized DIEP flap after mastectomy. Neurotization using thoracoabdominal nerve (T10/11/12) coapted to third intercostal nerve. Two-stage implant-based reconstruction after mastectomy Outcomes: Tactile sensation: pressure-specified device across 9 breast regions, converted to 0-100 scores. Thermal sensation: correct identification of hot 52°C and cold 12°C stimuli across 5 regions. Postoperative outcomes measured at 4 different time points (1-6 months, 6-12 months, 12-24 months, and 24-48 months). Exclusions: Preoperative or postoperative radiation, peripheral neuropathy, and complications causing flap or implant loss. Results 269 total patients: 123 patients in DIEP cohort, 146 patients in alloplastic cohort. Characteristics were similar between cohorts, but DIEP patients had higher BMI and larger preoperative cup size. Adjusted tactile sensation favored DIEP at 1-6 months, 6-12 months, and 12-24 months; the 24-48 month difference narrowed and was no longer statistically significant after adjustment. Thermal sensation: Cold perception: No early difference, but alloplastic outperformed DIEP later: 12-24 months: 65.0% vs 48.6%, P = 0.040 24-48 months: 83.3% vs 57.1%, P = 0.001 Heat perception:   No early difference, but alloplastic outperformed DIEP later: 12-24 months (77.3% vs 54.3%, P = 0.024) 24-48 month trend persisted but was not significant. Conclusion In uncomplicated, nonradiated patients undergoing immediate reconstruction, neurotized DIEP restored tactile sensation better than two-stage alloplastic reconstruction, whereas alloplastic reconstruction showed better temperature perception at later time points. Although these thermal findings were underpowered, they underscore how incompletely we understand the complex biology of sensory recovery.

Authors:  Speck NE, Rodriguez M, Lunger A, Pfister P, Schaefer DJ, Burger M, Shuck JW, Largo RD, Ismail T, Muller L. Affiliation:  Dept of Plastic Surgery & Head and Neck Surgery, University Hospital Basel, Basel, Switzerland; University of Texas MD Anderson Cancer Center, Houston, Texas Journal:   Plastic and Reconstructive Surgery Global Open , February 2026. PMID:  41635721. Key takeaways This is a clever pedicle-routing refinement for TORS reconstruction. The main innovation is a 1- to 2-cm nerve- and vessel-sparing mini-pharyngotomy that allows “inside-out” pedicle transfer while avoiding mandibulotomy and traditional lateral pharyngotomy. For practicing plastic surgeons, this is best viewed as a niche technique for experienced TORS/free-flap teams, not a standard approach to adopt broadly tomorrow. Background TORS is now a mature ablative platform for selected head and neck tumors, but reconstruction remains the bottleneck when defects are too large for secondary healing or local options. Reviews of post-TORS reconstruction note that larger, irradiated, or more complex defects increasingly require vascularized tissue, yet data on robotic-assisted inset remain limited. Objective To describe a minimally invasive method for transoral robotic free-flap inset and pedicle positioning in oro- and hypopharyngeal defects using a small transcervical mini-pharyngotomy designed to spare major nerves and vessels. Methods Design: Technical case series from 2017 to 2024; no comparator group. Patients: 4 patients, all ASA 3, ages 44 to 67 years. Indications included osteoradionecrosis, chronic osteomyelitis after prior cancer treatment, synovial sarcoma, and tonsillar SCC. Flaps: All 4 reconstructions used a radial forearm free flap; pedicle lengths were 6, 6, 10, and 12 cm. Technique: Posterior/lateral pharyngeal defects: lateral mini-pharyngotomy between the caudolateral resection edge and the neck. Anterior oropharyngeal defects: submandibular approach with hyoid retraction and a vallecular-level mini-pharyngotomy. Incision size was 1 to 2 cm, oriented along constrictor fibers, and just large enough to avoid pedicle compression. The pedicle was passed “inside-out” through a Penrose drain filled with irrigation fluid. Inset/anastomosis: Manual suturing where accessible, robotic suturing for deep or poorly exposed portions, arterial anastomosis to the superior thyroid artery, venous anastomosis to the internal jugular system. Perioperative pathway:  Oral intake began after leak testing at about 10 days in nonirradiated patients and 3 weeks in irradiated patients. Results Median defect size was 23.4 ± 9.7 cm²; recorded defects ranged from 12.25 to 30 cm². Operative times were 420, 452, 463, and 487 minutes; the authors report a mean of 455.5 ± 27.8 minutes. No flap loss, leak, fistula, or infection occurred. All patients were decannulated by discharge. Follow-up ranged from 9 to 70 months. Two patients required reoperation: 1 postoperative hematoma managed with arterial clipping, flap salvaged. 1 delayed tracheal bleed on postoperative day 16 requiring neck exploration and sternotomy; no arteria lusoria was found. Put plainly, the series achieved its technical end point, but half the cohort still returned to the OR. Conclusion The authors conclude that robotic-assisted inset using a mini-pharyngotomy is a safe, effective, minimally invasive alternative to conventional access for selected complex oro- and hypopharyngeal reconstructions. That conclusion is reasonable as a technical feasibility statement, but it is stronger than the data support if interpreted as evidence of superiority. Strengths Clear technical description with practical anatomy-based modification for pedicle transfer. Challenging real-world cases, including previously irradiated and infected fields. Reasonable follow-up window for a technical note, up to 70 months in one patient. Limitations n = 4, single-center, highly selected patients; this is strictly hypothesis-generating. No control group against standard transcervical pedicle routing, lateral pharyngotomy, or nonrobotic inset. All flaps were radial forearm flaps, so generalizability to bulkier ALT or perforator flaps is uncertain.

Authors:  Liu C, Han J, Fu R, Li T, Margonis GA, Wang JJ, Ma K, Wang W, Lin C Affiliation:  Peking Union Medical College Hospital (CAMS/PUMC) + collaborators (MSKCC, UCSF, etc.) Journal:   eClinicalMedicine  (The Lancet group), July 2025 PMID:   40727015 Key takeaways Postop IV iron reduced transfusion versus control ( RR 0.80, 95% CI 0.68–0.94; I²=0% ). Preop IV iron did not  reduce transfusion versus control ( RR 0.91, 0.72–1.15; I²=0% ). Hemoglobin (Hb) recovery: no clear benefit by POD7; by POD30 both strategies improved Hb versus control, with preop > postop  (preop vs postop MD 6.67 , 1.61–11.72). Postop IV iron increased early iron indices (POD7 ferritin/TSAT), but this did not translate into earlier Hb rise at POD7. No signal that IV iron timing changes length of stay, complications, mortality, or drug-related adverse events in pooled analyses. Background Perioperative anemia is common and is associated with worse surgical recovery and higher transfusion exposure. Intravenous (IV) iron is widely used in patient blood management, but the optimal timing, preoperative “prehabilitation” versus postoperative “rescue”, remains uncertain. Objective Compare preoperative (7–30 days before)  versus postoperative (0–30 days after)  IV iron in surgical patients for transfusion, Hb recovery, safety, and related outcomes. Methods Design: Systematic review + meta-analysis  of randomized controlled trials (RCTs) of patients receiving IV iron Search: PubMed/EMBASE/Cochrane/Web of Science through May 1, 2025; English only. Included studies/patients:  22 RCTs; 3026 patients; mean age 65.8; ~54% women; cardiac, abdominal, orthopedic and other surgeries. Interventions: IV iron (various dosages from 300 mg–3 g); multiple formulations (iron sucrose, ferric carboxymaltose, ferric derisomaltose, iron polymaltose). Comparators: placebo/standard care/oral iron (varied across trials). Primary endpoints:  (1) proportion transfused; (2) Hb change from baseline to POD7 and POD30. Secondary endpoints:  POD7 ferritin/TSAT; length of stay; complications; adverse events; mortality; quality of life. Results Transfusion (19 studies; n=2847): Postop IV iron vs control: RR 0.80 (0.68–0.94), I²=0% . Preop IV iron vs control: RR 0.91 (0.72–1.15), I²=0% . Indirect preop vs postop: RR 0.88 (0.66–1.17)  (no significant difference). Subgroup signal: postop transfusion reduction was largely driven by cardiac surgery trials*. Hb change POD7 (6 studies; n=586): Preop vs control: MD 4.64 (−4.49 to 13.78)  (not significant). Postop vs control: MD −4.51 (−9.75 to 0.72)  (not significant; high heterogeneity). Hb change POD30 (7 studies; n=905): Preop vs control: MD 12.11 (7.88–16.35) . Postop vs control: MD 5.45 (2.70–8.20) . Preop vs postop: MD 6.67 (1.61–11.72)  (preop better at ~1 month). Iron indices POD7: Ferritin: postop vs control increased (large MD); preop vs control not significant. TSAT: postop vs control increased; preop vs control not significant. LOS/complications/adverse events/mortality:  no significant differences across strategies. Conclusion Postoperative IV iron is associated with lower transfusion rates, while preoperative IV iron yields better hemoglobin recovery by POD30; either approach can be selected based on patient goals and context, recognizing heterogeneity and lack of direct head-to-head trials. Strengths Clinically meaningful timing windows (preop 7–30 days; postop 0–30 days). RCT-only inclusion with formal risk-of-bias assessment. Network meta-analysis enables an indirect timing comparison despite absent head-to-head trials. Limitations No direct preop vs postop RCTs; indirect comparisons are vulnerable to differences in surgery type, transfusion protocols, and trial era. “Timing” may be confounded by phenotype: preop trials often enroll preop anemia (often iron deficiency anemia), whereas postop trials often enroll postoperative anemia/functional iron deficiency. Control arms vary (placebo vs oral iron vs usual care); transfusion triggers are inconsistent across trials. Early Hb (POD7) is biologically and clinically noisy; heterogeneity is high in postop POD7 Hb. Clinical relevance Early postoperative IV iron shows the clearest signal for reducing transfusion exposure (notably in cardiac surgery–heavy datasets), whereas IV iron given 1–4 weeks preop is associated with a better hemoglobin trajectory by ~1 month. In practical terms, preop iron “optimizes the runway,” postop iron “rescues the crash,” and neither strategy should be expected to meaningfully raise Hb by POD7.

Title : Hypothermia during microsurgical head and neck reconstruction and incidence of venous thromboembolism Authors : Saadoun R, Guerrero DT, Bengur FB, Moroni EA, Surucu Y, Smith RE, Esper SA, Whitehurst SL, Artman J, Veit JA, Kubik M, Sridharan S, Solari MG Journal : JAMA Otolaryngology–Head & Neck Surgery. February 2025 PMID : 39636654   Key takeaways Venous thromboembolism (VTE) occurred in 3.2% (35/1078); free-flap pedicle thrombosis occurred in 2.2% (24/1078). Intraoperative hypothermia (core temperature <36°C) was common (76.5%) and associated with higher 30-day VTE odds when sustained beyond 30 minutes. Adjusted VTE odds were higher with sustained hypothermia versus no hypothermia: 30 to <120 minutes aOR 3.82 (95% CI 0.99–14.07); ≥120 minutes aOR 3.55 (1.05–11.95) (*not a strict dose-response; estimates are similar with wide CIs.) Hypothermia was not associated with free-flap pedicle thrombosis (overall OR 0.61, 95% CI 0.26–1.43).   Background Head and neck free tissue transfer involves long operations and substantial thrombotic risk. Intraoperative temperature is modifiable, yet hypothermia remains common.   Objective Assess whether intraoperative hypothermia (core temperature <36°C) is associated with 30-day VTE and/or free-flap pedicle thrombosis requiring revision after head and neck free tissue transfer.   Methods Design and setting: Retrospective cohort study; tertiary academic center. Study period: January 1, 2012 to August 31, 2023. Sample size: 1078 analyzed. Demographics (overall): Mean age 61.3 years; 67.2% male; mean Caprini score approximately 6.4 to 6.6. Inclusion criteria: Head and neck free tissue transfer cases within the study period. Key exclusions: Cases with postoperative hematoma requiring revision (to reduce confounding of venous compromise). Exposure definition (temperature): Core temperature recorded every minute. Temperatures harmonized to a “bladder-equivalent” core temperature using published offsets. Data binned into consecutive 30-minute blocks using the median of minute-level values. Hypothermia episode defined as any 30-minute block with median <36°C. Duration groups based on continuous hypothermia: No Hypothermia (<30 min) 30 to 120 minutes of hypothermia ≥120 minutes All patients warmed under institutional warming protocol during surgery: Systemic warming with warmed IV fluids and convective warming from pre-induction through PACU handoff. Outcomes (30 days): VTE: deep vein thrombosis and/or pulmonary embolism. Pedicle thrombosis: clot in pedicle artery or vein confirmed at revision surgery. Statistics: Univariable and multivariable logistic regression. Covariates highlighted in primary VTE model included Caprini score, chemoprophylaxis regimen, and surgery duration. Alpha 0.05; no multiplicity adjustment.   Results Hypothermia: 76.5% (825/1078) had at least one 30 minute period with median core temperature below 36°C. VTE Incidence: 3.2% (35/1078). Timing: median postoperative day 5 (IQR 4.0–10.5). Univariable associations: Any hypothermia episode: OR 3.36 (95% CI 1.02–11.1). Heparin prophylaxis vs enoxaparin: OR 3.16 (1.33–7.55). Multivariable model (adjusted for Caprini score, chemoprophylaxis, surgery duration): Hypothermia >30 to <120 minutes: aOR 3.82 (0.99–14.07). Hypothermia ≥120 minutes: aOR 3.55 (1.05–11.95). Heparin 5000 IU three times daily vs enoxaparin 30 mg twice daily: aOR ~3.01 (1.24–7.30). Free-flap pedicle thrombosis Incidence: 2.2% (24/1078). Timing: median postoperative day 2 (IQR 1.0–3.0). Arterial thrombosis: 0.5% (5/1078). Association with hypothermia: none detected (overall OR 0.61, 95% CI 0.26–1.43).   Conclusion Intraoperative hypothermia during head and neck free tissue transfer was associated with higher 30-day VTE risk, without an observed association with free-flap pedicle thrombosis.   Strengths Large, procedure-specific cohort with granular minute-level temperature data. Clinically important outcomes with pedicle thrombosis and VTE examined Predefined exposure processing that emphasized sustained, continuous hypothermia.   Limitations Retrospective design limits causal inference. Residual confounding likely (case complexity, transfusion, vasopressor exposure, fluid balance, and unmeasured illness severity may track with hypothermia). Exposure captured uninterrupted hypothermia duration; intermittent hypothermia burden (overall time spent under 36°C ) was not the primary metric. Chemoprophylaxis findings are vulnerable to confounding by indication (e.g., renal dysfunction, bleeding risk, or protocol drift).   Clinical relevance Hypothermia is already associated with worse perioperative outcomes (bleeding/transfusion, surgical site infection, and cardiac complications in other surgical populations). This study is another reminder that in long head and neck free-flap cases, teams should actively avoid prolonged hypothermia to improve outcomes. Target core temperature ≥36°C, minimize donor-site and skin exposure, employ multi-team approach to reduce operative time, and consider sterile forced-air warming over exposed regions when feasible.   Editorial Notes Hypothermia may be a marker rather than a mediator: even with adjustment for case duration and Caprini score, unmeasured factors (transfusion, vasopressors, tumor factors, nuances in comorbidities, etc.) may explain part of the VTE signal. Does intermittent hypothermia (repeated dips) confer similar risk as continuous hypothermia? Does duration or degree of hypothermia matter more? Would an area-under-the-curve metric below 36°C correlate more strongly with VTE? Chemoprophylaxis signal could use deeper context: What were the institutional criteria for selecting heparin versus enoxaparin? How often were doses delayed, held, or changed due to bleeding, reoperation, renal dysfunction, or epidural use? At first glance, the lack of association with pedicle thrombosis seems counterintuitive, but systemic VTE and pedicle thrombosis often arise from different mechanisms and time courses (early local/technical vs later systemic). Other studies on VTE have similarly found that systemic VTE and flap VTE do not always correlate.

Authors:  Bercz A, Alvarez J, Rosen R, Drescher M, Sonoda H, Karagkounis G, Wei I, Widmar M, Nash GM, Weiser MR, Paty PB, Allen RJ, Nelson JA, Coriddi M, Dayan JH, McCarthy C, Shahzad F, Matros E, Disa JJ, Cordeiro PG, Mehrara BJ, Garcia-Aguilar J, Smith JJ, Pappou EP  Affiliation:  Memorial Sloan Kettering Cancer Center, Colorectal Surgery Service and Plastic Surgery Service, New York, NY  Journal:  BJS Open, May 2025  PMID:  40503607     Key takeaways   Tissue flap reconstruction (TFR) was used in more complex resections and showed higher unadjusted 90-day dehiscence and infection than primary closure (PC).  In subgroup analysis, dehiscence was significantly higher in patients who underwent APR. There was no significant difference between TFR and PC in cases of total pelvic exenteration (TPE).  Flap type (VRAM, gluteal and gracilis) was not associated with the extent of resection, and there were no differences in wound infection, dehiscence or reintervention within 90 days between flap subtypes  Omental flaps in PC did not change wound outcomes  Independent predictors of dehiscence were anal cancer and extralevator abdominoperineal resection.   Pelvic exenteration independently predicted wound infection    Background   Perineal wound complications after abdominoperineal resection and pelvic exenteration remain common, particularly in irradiated fields and large dead-space defects, delaying recovery and adjuvant therapy.    Objective   Assess postoperative morbidity and identify predictors of wound complications across perineal closure strategies after radical anorectal oncologic resection.  Methods   Design:  Retrospective cohort at a comprehensive cancer center, January 2012–December 2020; STROBE-adherent; Therapeutic Level III.  Population:  414 patients with rectal (364) or anal (50) malignancy undergoing abdominoperineal resection (including extralevator abdominoperineal resection) or pelvic exenteration.  Interventions and comparators:   Tissue flap reconstruction: 150 patients, including VRAM (101), gluteal V-Y advancement (37), gracilis (12).  Primary closure: 264 patients, with pedicled omental flap in 81.  Endpoints:   90-day outcomes: wound dehiscence, wound infection, transfusion, readmission, invasive reintervention, Clavien–Dindo complications, flap loss. Definitions were explicitly provided.  Long-term outcomes: chronic hernia and non-healing wound beyond 6 months.  Statistics:  Fisher exact and Wilcoxon rank-sum for group comparisons; multivariable logistic regression for independent predictors; significance threshold P < 0.05.    Results   Cohort characteristics: Median age 61 years; median follow-up 34.3 months.  Case-mix differences: Tissue flap reconstruction preferentially used in higher-complexity scenarios including exenteration, sacrectomy, vaginectomy, and intraoperative radiation.  Unadjusted 90-day morbidity (tissue flap reconstruction vs primary closure):  Wound dehiscence: 27% vs 11%.  Wound infection: 25% vs 14%.  Grade 3 or higher Clavien–Dindo: 32% vs 17%.  Flap loss: 1% overall in tissue flap reconstruction (2 patients).  Flap subtype comparisons: No differences in wound infection, wound dehiscence, readmission, or reintervention among VRAM, gluteal, and gracilis; VRAM associated with higher transfusion requirement.  Primary closure with omental flap vs without: No differences in wound infection, dehiscence, readmission, reinterventions, or long-term hernia/non-healing wound.  Independent predictors (multivariable):  Wound dehiscence: anal cancer (OR 5.24) and extralevator resection (OR 3.09).  Wound infection: pelvic exenteration (OR 17.8).  Closure method and intraoperative radiation were not independent predictors of dehiscence or infection in the full cohort.    Conclusion   In this cohort, higher raw wound morbidity tracked with reconstructive flap use because flaps were used in more complex resections; after adjustment, closure method did not independently predict dehiscence or infection, while anal cancer, extralevator resection, and pelvic exenteration predicted complications.    Strengths   Large, detailed single-institution dataset with standardized definitions of wound outcomes and 90-day morbidity.  Includes multiple flap options and an omental-flap primary-closure subgroup, allowing clinically relevant comparisons.    Limitations   Strong selection bias and confounding by indication: flap reconstruction was preferentially used for exenteration, sacrectomy, vaginectomy, and intraoperative radiation, which inflates unadjusted morbidity comparisons.  Key reconstructive drivers like defect size and dead-space volume were not captured, limiting mechanistic inference about technique choice and outcomes.  Functional recovery and patient-reported outcomes were not consistently available, leaving the most patient-important differences unanswered.    Clinical relevance   For reconstructive planning after abdominoperineal resection or exenteration, this paper reinforces that the patient’s oncologic context and extent of extirpation drive wound risk more than the type of flap or method of closure. It does not directly answer the operative question of how a given defect should be closed; it retrospectively reports outcomes based on how surgeons elected to close defects in practice. In straightforward abdominoperineal resection, primary closure appears reasonable when tension and dead space are controlled; in anal cancer salvage and extralevator resections, anticipate higher dehiscence risk and plan resources accordingly.    Editorial Notes   The unadjusted comparison is expected to favor primary closure because flaps were reserved for larger, higher-risk defects. The multivariable analysis is the clinically actionable message.  The regression model cannot correct for unmeasured confounders that dominate reconstructive decision-making: defect size, pelvic dead-space volume, levator geometry, tissue quality, and prior perineal wound history.  The flap subtype analysis is likely underpowered for meaningful comparisons, especially for gracilis. Grouping abdominal based muscle flaps and fasciocutaneous V-Y flaps confounds comparisons as these are generally chosen for differing reasons.   The anal cancer predictor has a wide confidence interval, suggesting limited events and potential model instability.  What was the institutional algorithm for selecting VRAM versus gluteal versus gracilis, and did it

Authors : Ahmed S, Crabtree J, Fallah KN, Rinne EJ, Hulsman L, Fisher CS, Ludwig KK, Danforth RM, Lester ME, Hassanein AH Affiliation : Indiana University School of Medicine Journal : Journal of Reconstructive Microsurgery , 2026 PMI D : 40068867   Key takeaways: Immediate DIEP had higher mastectomy skin necrosis than delayed-immediate DIEP (11.3% vs 2.2%; p  = 0.025). Necrosis needing operative debridement was higher with immediate DIEP (7.5% vs 1.1%; p  = 0.0499). Absolute risk reduction for mastectomy skin necrosis with delayed-immediate approach: 9.1%; NNT ≈ 11 flaps to prevent one necrosis event. Background : Mastectomy skin necrosis (MSN) remains a meaningful complication after autologous reconstruction, and internal mammary harvest/anastomosis requires prolonged skin-flap retraction that may worsen ischemia in fresh mastectomy flaps. Objective : Determine whether timing of DIEP reconstruction (immediate vs delayed-immediate) affects mastectomy MSN. Methods : Design: Single-center retrospective comparative study. Timeframe: 2013–2016. Cohorts: Group I: Immediate DIEP (49 patients, 80 flaps; 31 bilateral). Group II: Delayed-immediate DIEP (57 patients, 93 flaps; 36 bilateral). Key exclusions: “Delayed DIEP” with no  immediate reconstruction. Endpoints: Primary: MSN and management (local care, wound clinic referral, operative debridement). Secondary: DIEP flap skin necrosis, takeback, flap loss, and wound healing complications. Results: Baseline differences: Diabetes mellitus: 13.8% immediate vs 31.2% delayed-immediate ( p  = 0.001). Adjuvant radiation: 0% immediate vs 64.9% delayed-immediate ( p  = 0.0001). Periareolar incision more common in delayed-immediate (38.8% vs 61.4%; p  = 0.0027). Primary outcome (mastectomy skin flap necrosis): 11.3% (9/80) immediate vs 2.2% (2/93) delayed-immediate; p  = 0.025. Absolute risk reduction 9.1%; NNT ≈ 11 flaps. Management of MSN: Local wound care only: 3.8% (3/80) immediate vs 1.2% (1/93) delayed-immediate; p  = 0.3369. Operative debridement/reclosure: 7.5% (6/80) immediate vs 1.1% (1/93) delayed-immediate; p  = 0.0499. Other flap outcomes (not statistically significant): DIEP flap partial skin necrosis: 5.0% immediate vs 1.1% delayed-immediate; p  = 0.183. Takeback: 6.3% immediate vs 4.3% delayed-immediate; p  = 0.467. Flap loss: 5.0% immediate vs 1.1% delayed-immediate; p  = 0.167. Follow-up: Mean 472 days (range 99–1,381). Conclusion : Immediate DIEP performed on the day of mastectomy had a significantly higher risk of MSN than a delayed-immediate approach, so timing can be used in counseling as a modifiable risk factor. Strengths : Clear, clinically actionable endpoint (MSN and escalation of care). Homogenized comparison by excluding “true delayed” DIEP cases with skin deficiency. Limitations : Retrospective, single-center design with modest sample size and few events (risk of residual confounding). Cohorts differ meaningfully (e.g., diabetes and adjuvant radiation), and no multivariable adjustment is reported in the methods/statistics section. Uses flaps as units for some analyses (possible non-independence in bilateral cases). Clinical relevance : For patients at higher wound-risk (e.g., diabetes), this paper supports considering a delayed-immediate pathway (TE first, DIEP later) to reduce MSN and the need for operative debridement, at the cost of an additional operation. Editorial notes: The headline finding (MSN reduction) is compelling, but the absence of risk-adjusted modeling is the major weakness. Given major baseline differences (diabetes, incision type, radiation exposure), I’d want: A patient-level multivariable model (or propensity approach) accounting for diabetes, BMI, smoking, mastectomy type/incision, mastectomy weight, prior radiation, and surgeon. Clarification of the definition and adjudication of “mastectomy skin necrosis” (clinical vs imaging, threshold for calling it, standardized follow-up interval). The proposed mechanism, retraction stress on acutely ischemic skin in immediate DIEP vs “vascular delay” in delayed-immediate, is plausible and essentially echoes the delay phenomenon, but could’ve directly tested through SPY/ICG perfusion assessment in both cohorts. The “NNT ≈ 11 flaps” is clinically useful, but the event count is small. Confidence intervals for ARR/NNT would be helpful. Finally, delayed-immediate carries its own hazards (TE infection/removal, expander complications), and those outcomes weren’t quantified here, yet they materially affect counseling.