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.

Authors:  Crawford KL, Berman E, Whitney MA, Adams S, Orosco RK, Nguyen QT Affiliation:  Oregon Health & Science University; University of California–Berkeley; University of California–San Diego; University of New Mexico Journal:   Plastic and Reconstructive Surgery , January 2026 PMID:  40208969   Introduction Delayed facial nerve reconstruction is limited due to difficulty with identification of distal facial nerve segments with increasing time from injury. Producing a more reliable mechanism of identifying degenerated nerve segments is needed. Oxazine-4 has demonstrated to label nerves in a variety of experimental conditions, but its myelin-binding mechanism of action limits its ability to label chronically degenerated nerves. Bevonescein is hypothesized to be able to label degenerated facial nerve segments due to its extracellular matrix binding mechanism. Methods Sixteen mice underwent exploration of facial nerve. A 3 mm segment of the marginal mandibular branch was resected, ensuring that buccal branch was intact. Ten total mice were analyzed at 5 months post-transection. Mice tail vein injection of bevonescein and oxazine was done and imaging fluorescence of the facial nerve was completed. Results All marginal mandibular nerve segments were clearly visible with bevonescein under fluorescence microscopy. In contrast, only 4 of 10 mice had visible degenerated nerve segments. The mean signal-to-background ratio was significantly higher in the bevonescein cohort versus oxazine group for the degenerated segments (SBR 3.31 ± 1.11 vs 1.27 ± 0.54, P < 0.001. The fluorescence was similar for the intact buccal branch control nerve segment. Conclusion In a chronic murine facial nerve denervation model, bevonescein reliably labels degenerated nerves whereas the myelin-binding agent oxazine-4 does not meaningfully label chronically degenerated nerve segments. Editorial Notes Bevonescein (ALM 488, Alume Biosciences) is being evaluated in phase 2 clinical trials in head and neck surgery as an intraoperative fluorescent nerve imaging agent.

Authors:  Reimer T, Stachs A, Veselinovic K, Kühn T, Heil J, Polata S, Marmé F, Müller T, Hildebrandt G, Krug D, Ataseven B, Reitsamer R, Ruth S, Denkert C, Bekes I, Zahm D-M, Thill M, Golatta M, Holtschmidt J, Knauer M, Nekljudova V, Loibl S, Gerber B Affiliation:  Multicenter trial across Germany and Austria; the German Breast Group. Journal:  The New England Journal of Medicine, March 2025 PMID:  39665649.   Key takeaways Omitting sentinel lymph node biopsy in clinically node-negative patients undergoing breast-conserving therapy was noninferior for 5-year invasive disease–free survival in a mostly low-risk, HR-positive, HER2-negative population. Axillary recurrence was higher without axillary surgery, but absolute risk remained low at 5 years. Long-term lymphedema and arm morbidity were meaningfully lower when axillary surgery was omitted. External validity is narrow: most patients were older and had small, luminal tumors; higher-risk biology was underrepresented.   Background Sentinel lymph node biopsy is standard for axillary staging in early breast cancer, but even limited axillary surgery can cause lymphedema, pain, and long-term functional deficits. INSEMA examines whether staging can be safely omitted in carefully selected patients undergoing breast-conserving therapy with whole-breast irradiation.   Objective Determine whether omission of axillary surgery is noninferior to sentinel lymph node biopsy for invasive disease–free survival in clinically node-negative T1–T2 patients treated with breast-conserving surgery and whole-breast irradiation.   Methods Design:  Prospective, randomized noninferiority trial conducted at 151 centers in Germany and Austria; Therapeutic Level I. Sample size:  5,154 clinically node-negative patients undergoing breast-conserving surgery randomized 1:4 to omission vs SLNB. Key demographics:  Median age 62; 90% clinical T1; 79% pathologic T1; HR-positive/HER2-negative about 95%. Inclusion criteria:  Women 18 years or older; clinically node-negative by exam and imaging; T1–T2 (≤5 cm); planned upfront breast-conserving surgery. Axillary imaging rule:  Suspicious lymph nodes on preop axillary ultrasound triggered needle/core biopsy. Patients were eligible for randomization only if biopsy was negative; biopsy-proven nodal disease was excluded. Interventions & comparators:  Randomized 1:4 to omit axillary surgery vs sentinel lymph node biopsy. Radiation protocol:  Whole-breast irradiation for all; axilla not specifically targeted; Regional nodal irradiation was not performed except for 4 or more positive nodes in the surgery arm; partial breast irradiation was excluded. Primary endpoint:  Invasive disease–free survival in the per-protocol population. Noninferiority margin:  Required 5-year iDFS at least 85% in omission arm and upper 95% CI for HR less than 1.271. Statistics: Cox proportional hazards; noninferiority via CI for HR; multivariable adjustment for stratification factors (age, tumor size, grade).   Results Primary outcome, per-protocol:  5-year iDFS 91.9% omission vs 91.7% sentinel; HR 0.91 (95% CI, 0.73–1.14), meeting noninferiority. Event count and power:  Planned event-driven analysis for 851 events, but analysis performed with 525 events due to low event rate, reducing power versus plan. Overall survival, per-protocol:  5-year OS 98.2% omission vs 96.9% sentinel. Axillary recurrence:   1.0% omission vs 0.3% sentinel at 5 years . Other first events, per-protocol:  death 1.4% omission vs 2.4% sentinel; distant relapse 2.7% both; invasive ipsilateral breast recurrence 0.8% vs 1.1%. Safety and function at last follow-up:  lower persistent lymphedema (1.8% vs 5.7%), mobility restriction (2.0% vs 3.5%), and pain with movement (2.0% vs 4.2%) with omission.   Conclusion In clinically node-negative patients undergoing breast-conserving therapy, omission of surgical axillary staging was noninferior to sentinel lymph node biopsy for invasive disease–free survival after about 6 years, with less long-term arm morbidity.   Strengths Large randomized noninferiority design with mature median follow-up of 73.6 months. Radiotherapy quality controls and explicit constraints against deliberate axillary coverage improve interpretability of axillary omission. Captures patient-important endpoints: persistent lymphedema and arm symptoms.   Limitations Population is overwhelmingly low-risk: older, small tumors, luminal biology; higher-risk subtypes were underrepresented, limiting generalizability. Primary analysis occurred with 525 vs planned 851 events, decreasing statistical power and precision for uncommon but important failures like axillary relapse. Safety depends on preoperative axillary ultrasound and biopsy standards that vary widely across practice. Breast-conserving surgical technique was not granularly reported; the paper does not specify oncoplastic approaches or volume-replacement methods, limiting reconstruction-specific interpretation. Clinical relevance This trial supports de-escalating axillary surgery in carefully selected clinically node-negative patients having lumpectomy and whole-breast irradiation, with a clear reduction in long-term lymphedema and arm symptoms. It does not answer how to manage patients where nodal status would change systemic therapy or regional nodal irradiation decisions, because those higher-risk scenarios were uncommon in the enrolled cohort.   Additional considerations Whole-breast irradiation delivers incidental axillary dose; tangent design variability in real-world practice could change axillary control when surgery is omitted. The paper is surgically non-granular for the breast: it does not detail the reconstructive approach (i.e. oncoplastic mastopexy) which may further alter lymphatic drainage. The event shortfall reduces certainty about rare but consequential failures, and limits subgroup inference.

Authors:  Zona EE, Thornton SM, Via EC, Burkard ME, Michelotti BF, Poore SO, Lautner MA, Israel JS Affiliation:  University of Wisconsin School of Medicine and Public Health Journal:   Plastic and Reconstructive Surgery , February 2026 PMID:  40707174 Key takeaways Evidence base is limited and mixed; most perioperative recommendations are consensus-driven rather than trial-proven. For major reconstruction, hold tamoxifen  2 weeks preop and restart 2 weeks postop. Most other agents are continued; select drugs warrant CBC-based screening and targeted short holds. Minor revision procedures generally do not require holding anticancer medications unless thrombocytopenia is a concern. If ANC < 1000 cells/µL, involve oncology ± G-CSF and postpone if ANC remains low close to surgery. Background Breast reconstruction patients increasingly receive adjuvant endocrine, targeted, and immunotherapies, yet perioperative medication management is inconsistent. Objective To summarize evidence on how adjuvant anticancer agents affect reconstructive outcomes and to provide expert consensus recommendations on perioperative holding/continuation. Methods Design/setting/LOE: PRISMA-guided systematic review plus multidisciplinary expert consensus; available evidence predominantly observational. Databases/search: PubMed, Web of Science, Scopus; query included “breast reconstruction” AND “anticancer agent” plus individual drug names (initial query Dec 11, 2023). Selection: Dual-reviewer screening; excluded non–full text articles, case reports, editorials/commentary, and papers not linking agent exposure to reconstruction outcomes. Data extracted:  Study design, sample size, agent, reconstruction type, complications/adverse effects, and any perioperative recommendations. Consensus panel:  Medical oncology, surgical oncology, plastic surgery, advanced practice providers, and nurses. Procedure framework: Major: autologous free flaps, tissue expander placement, oncoplastic reduction. Minor: implant exchange, fat grafting, scar revision, fat necrosis excision, nipple reconstruction. Results Included evidence:  19 studies; 5793 patients. Agents with outcome data:  tamoxifen (18 studies), aromatase inhibitors (8), trastuzumab (2), pertuzumab (1). Evidence gaps:  No reconstruction-outcome studies identified for several commonly used agents (e.g., GnRH agonists, pembrolizumab, olaparib, abemaciclib, capecitabine), necessitating consensus-based guidance for many drugs. Medication-specific perioperative recommendations (major procedures) Tamoxifen Literature is mixed; some studies associate tamoxifen with microvascular complications, wound issues, and fat necrosis, while others do not. Consensus: Hold 2 weeks preop; restart 2 weeks postop. Aromatase inhibitors (e.g., anastrozole; extrapolated to letrozole/exemestane) Consensus: Do not hold; resume when tolerating oral intake. Trastuzumab / pertuzumab Consensus: Do not hold; resume near the usual every-3-week schedule after discharge. Note: One study suggested a small, non-significant signal toward wound breakdown requiring OR with dual HER2 therapy, limited by low event counts. Olaparib Consensus: Hold 48 hours preop; restart 1 week postop. Obtain CBC with differential within 7 days preop. Abemaciclib Consensus: Hold 1 week preop; restart 1 week postop. Obtain CBC with differential within 7 days preop. Pembrolizumab Consensus: Do not hold. Consider morning cortisol if not checked within prior ~3 weeks (rare adrenal insufficiency). Capecitabine Consensus: Do not hold. Obtain CBC with differential within 7 days due to thrombocytopenia risk; coordinate if platelets are low. General cytopenia guidance If ANC < 1000 , consult oncology ± G-CSF and postpone if ANC remains low close to surgery. Minor procedures Minor revisions generally do not require holding anticancer agents unless thrombocytopenia is a concern. Conclusion The authors propose a pragmatic perioperative framework: hold only a few higher-risk agents for major reconstruction (notably tamoxifen), continue most other anticancer therapies, and use targeted preoperative labs and oncology coordination to address cytopenias. Strengths Structured multi-database, PRISMA-guided review with dual-reviewer screening. Multidisciplinary consensus process and a clinically practical “major vs minor” procedural framework. Limitations Sparse reconstruction-specific outcomes data for many contemporary systemic therapies; numerous recommendations necessarily rely on expert opinion. Heterogeneous study designs, patient populations, and outcome definitions in the available literature. Clinical relevance For major breast reconstruction, this provides a straightforward medication-management playbook: hold tamoxifen around surgery, do not automatically stop most other agents, and incorporate CBC/ANC/platelet thresholds into readiness with early oncology involvement when cytopenias are present. Editorial notes The “major vs minor” framework is useful, but it can underweight patient-specific modifiers (Caprini score, prior VTE, bilateral microsurgery, operative time, radiation, obesity). A risk-stratified algorithm would further improve applicability. For dual HER2 blockade, what perioperative mitigation strategies (timing relative to infusion, nutrition, drain/antibiotic strategy) do the authors recommend in immediate reconstruction, where wound issues are most consequential? Research need: prospective, reconstruction-specific registries capturing agent timing/dose, hematologic indices, reconstruction type, and standardized complications to move practice from consensus to evidence.

Authors:  Moreira AA, Kozorosky E, Coopey SB Affiliation:  University of Pittsburgh School of Medicine; Allegheny Health Network; St. Joseph’s University Medical Center Journal:  Journal of Reconstructive Microsurgery, 2026;42:80–90 PMID:  39947639.   Key takeaways For macromastia and ptosis, the authors favor staging when feasible (mastopexy/reduction first, then NSM) to optimize nipple–areolar complex viability and shape control. They describe a selective one-stage approach for active-cancer patients using skin-only mastopexy/skin reduction with NSM, emphasizing perfusion assessment and a low threshold to abandon NAC preservation. Their “extreme NSM” cohort (specimens >600 g) reports nipple necrosis 4.7%, seroma 16.3%, and implant extrusion 7.0% (43 patients, 64 breasts) – comparable to their patient cohort who underwent NSM  with specimens < 600g.   Background Large, ptotic breasts have historically been considered higher risk for nipple-sparing mastectomy because long, thin mastectomy flaps and redundant skin can compromise perfusion and increase NAC necrosis.   Objective Provide a practical algorithm and technical strategies to expand NAC preservation for patients with macromastia and ptosis undergoing NSM.   Methods Design: Narrative review with institutional algorithm and a retrospective outcome summary on patients who underwent NSM with >600g specimen Algorithm: Stage reduction or mastopexy first, then NSM performed 1–3 months later when oncologically feasible Primarily favored for prophylactic Or highly selected early-stage cancers where short delay is acceptable (DCIS) – patients underwent lumpectomy at time of mastopexy/reduction. RTX withheld due to second stage NSM performed in 1-3 months   In healthy, carefully selected patients with active cancer and grade 2 or 3 ptosis - consider one-stage NSM with immediate skin-only mastopexy/reduction. 1.      Breast surgeon performs NSM through an inferolateral incision to help preserve NAC perfusion via superficial branches of the 5th intercostal perforator. 2.      Intraoperative perfusion assessment of mastectomy flaps and NAC (clinical exam ± ICG); low threshold to excise the NAC or convert the plan if perfusion is marginal. 3.      If the NAC is well perfused, perform immediate skin-only mastopexy.  §  There were a variety of pedicle patterns discussed: superior dermal pedicle with limited transposition; McKissock-type or tripedicle dermal flaps; extended inferior dermal pedicle when IMF-to-nipple distance is short. Patients who are not candidates for single stage (active disease, with higher comorbidities, and grade 2 ptosis) should undergo NSM with implant or DIEP flap reconstruction – the redundant tissue is then excised as a mastopexy 3 months later as a second stage. Or 6 months later if they require radiation.     Results The author’s reviewed their results for their “Extreme NSM cohort” (>600 g specimen weight), and compared complication rates to their cohort tradition NSM (<600g specimen” n: 43 patients, 64 breasts; mean breast weight ~879 g (range 603–1658); mean BMI 31.5. Reconstruction mix:  direct-to-implant 53.5%, tissue expander 27.9%, DIEP 18.6%. Complications: seroma 16.3%, hematoma 7.0%, skin flap necrosis 7.0%, nipple necrosis 4.7%, implant extrusion 7.0%, major complications 27.9%. Author’s report no statistically significant increase in risk of NAC necrosis between groups.     Conclusion With careful patient selection, incision planning, and real-time perfusion assessment, the authors argue NSM can be extended to macromastia/ptosis using staged approaches and selected one-stage techniques.   Strengths Clear pragmatic algorithm reflecting real multidisciplinary decision-making. Emphasizes perfusion-driven “stop rules,” the correct safety posture for high-risk NSM. Provides complication rates in a population many surgeons consider outside traditional NSM candidacy.   Limitations Primarily an experience-driven review and algorithm; no comparative evidence that one pathway is superior. No statistical analysis No analysis of cohorts based on degree of ptosis and/or mastopexy design (e.g. amount of dermal preservation around the NAC) Operative detail capture is incomplete; mastopexy pattern was not consistently recorded, limiting reproducibility. Outcomes are confounded by mixed reconstruction types and treatment contexts without stratified risk modeling.   Clinical relevance This paper functions best as a technical and decision framework: stage when oncologically feasible; when one-stage is necessary, treat it as a perfusion-driven operation with a low threshold to convert plans (NAC sacrifice) based on intraoperative assessment.   Editorial notes The algorithm would be stronger with reproducible risk stratification (BMI, smoking, diabetes, prior radiation, breast size/measurements) tied to NAC loss and reconstructive failure rates. As well as the type of mastopexy designed and the degree of ptosis: 2 vs. 3. Perfusion assessment is emphasized, but quantitative ICG or other numeric thresholds were not provided; decisions are described qualitatively (clear ischemia vs borderline vs good perfusion).

Authors:  Momeni A, Yesantharao PS, Meyer S, Posternak V, Shefren K, Przybylo V, Januszyk M, Pannucci CJ Affiliation:  Stanford University School of Medicine; Plastic Surgery Northwest Journal:  Plastic and Reconstructive Surgery, November 2025 PMID:  40327806.   Key takeaways In high-risk free-flap breast reconstruction patients, inpatient apixaban 2.5 mg BID had the same observed bleeding rate after prophylaxis initiation as enoxaparin 40 mg daily. No symptomatic VTE occurred in either arm at 90 days, so efficacy comparisons are not possible from these data. Chemoprophylaxis duration was inpatient only, averaging about 2.4 days, so this trial does not address extended prophylaxis strategies. Practical value: fixed-dose oral prophylaxis avoids injections and anti–factor Xa monitoring, and this study supports short-course safety, not superiority.   Background Breakthrough VTE remains clinically meaningful in high-risk plastic surgery patients despite guideline-compliant enoxaparin (current gold-standard). Optimal LMWH dosing and adherence limited by and practical barriers including weight-based dosing, factor Xa monitoring, and subcutaneous injections.   Objective Primary - Test safety of apixaban vs enoxaparin looking at clinically significant bleeding after starting prophylaxis Secondary - Test efficacy of apixaban vs enoxaparin looking at symptomatic VTE in 90 days.   Methods Design:  Single-center, blinded, randomized controlled trial with 1:1 randomization between study arms; Level II. Population:  Adult women with breast cancer undergoing free abdominally-based freflap breast reconstruction and Caprini score 7 or higher. Key exclusions:  Contraindication to study drugs, active bleeding, bleeding disorder/coagulopathy, HIT, liver or kidney disease, uncontrolled HTN, recent neurosurgery/ophthalmologic surgery, alcohol/substance abuse, therapeutic anticoagulation, postoperative flap takeback requiring heparin drip Interventions: Apixaban 2.5 mg twice daily Enoxaparin 40 mg daily Timing and duration:  Started 12 hours after skin closure, continued inpatient until discharge. Co-interventions:  SCDs periop and in bed; early mobilization POD1 per ERAS pathway. Primary endpoint:  Clinically significant bleeding events after prophylaxis initiation through 90 days. Secondary endpoint:  Symptomatic VTE within 90 days. Statistics:  Intention-to-treat after exclusions, Chi-square and t-testing on normally distributed variables, nonparametric testing on non-normally distributed variables; odds determined using Fisher exact test with Firth penalized logistic regression with stepwise selection; noninferiority if the upper limit of 97.5% CI for apixaban event rate didn’t exceed 2% margin over enoxaparin event rate.   Results Enrollment:  86 screened; 79 enrolled; randomized – 37 to apixaban and 39 to enoxaparin after excluding 3 patients for takeback + heparin drip. Baseline and operative characteristics: Similar demographics, comorbidities (Caprini median 7 (in both arms), reconstruction characteristics; mean prophylaxis duration aligned with LOS (~ 2.4 days). Primary outcome, bleeding after starting prophylaxis: 1/37 (3%) apixaban vs 1/39 (3%) enoxaparin; OR (odds ratio) bleeding event 1 (99% CI 0.9-1.1, pseudo R 2 =0.91) Symptomatic VTE:  0 in both arms at 90 days. Other complications:  Any 90-day complication 16% apixaban vs 13% enoxaparin; OR (odds ratio) other complication 1.1 (99% CI 0.9-1.1, pseudo R 2 =0.86)   Conclusion In abdominally-based breast reconstruction high-risk (Caprini > 7) patients, short-course inpatient apixaban was noninferior to enoxaparin for post-initiation bleeding. No symptomatic VTE observed in either group.   Strengths Randomized clinical trial, with blinded assignment after surgery   Limitations This study does not answer the main clinical question: whether apixaban reduces VTE compared with enoxaparin. 0 symptomatic VTE events in both groups, trial not powered for VTE efficacy. Inpatient-only prophylaxis (2-3 d) limits generalizability to those using extended post-discharge prophylaxis. Single-center design and highly selected population excludes patients who declare themselves high-bleed-risk intraoperatively or early postoperatively, including those needing takeback with heparin infusion. Underpowered for bleeding detection, power justification references a high bleeding rate from a different oral Xa inhibitor experience with higher equivalent dose in patients also taking NSAIDs.   Clinical relevance This study supports apixaban 2.5 mg BID as a reasonable safety-equivalent alternative to enoxaparin 40 mg daily with the presumed advantage of improved compliance with an oral agent. No VTE events were reported, so this study cannot weigh in on efficacy of VTE prevention, but prior studies suggest 2.5 m BID is an appropriate prophylactic dose.    Editorial notes This trial shows short-course apixaban has similar bleeding rates to standard-dose enoxaparin after microsurgical breast reconstruction, but it was not able to compare VTE prevention. Apixaban 2.5 mg BID is a standard prophylactic regimen in other surgical fields (e.g., joint replacement). This study assumes comparable prophylactic-intensity anticoagulation versus enoxaparin 40 mg daily, but drug-specific anti–factor Xa levels were not measured to confirm equivalence. Apixaban may be an attractive outpatient prophylaxis option to avoid injections and potentially improve adherence. Outpatient safety, adherence, and VTE efficacy remain unproven in this study. Other specialties (notably ortho re: joint replacement) have evaluated apixaban 2.5 mg BID for post-discharge prophylaxis with acceptable outcomes.

Authors:  Clark A, Shauly O, Sherrer J, Losken A Affiliation:  Emory University, Atlanta, GA Journal:  Plastic and Reconstructive Surgery – Global Open, January 2026 PMID:  41541241   Key takeaways Capsular contracture (CC) reflects a chronic peri-implant inflammatory response; bacterial biofilm and radiation are consistent contributors. Reported CC rates are higher after reconstruction than augmentation (≈19–25% vs 5–19%). Prevention measures (skin/pocket antisepsis, no‑touch technique, nipple shields, implant/mesh selection) are associated with lower CC in observational studies. Management is stage‑based: early/mild CC may respond to medical therapy or capsulotomy; severe or recurrent CC generally needs partial/total capsulectomy with implant exchange. The evidence base is heterogeneous and largely nonrandomized; no RCTs define a single best protocol. Background Capsular contracture is among the most common reasons for reoperation after implant-based augmentation and reconstruction. It causes firmness, distortion, and pain. The review synthesizes recent literature (2020–2024) to guide prevention and treatment strategies. Objective To provide an updated narrative review of CC mechanisms, epidemiology, diagnosis, prevention, treatment options, and patient outcomes for augmentation and reconstruction patients. Methods Design / level of evidence:  Updated narrative review of PubMed and Embase (search performed September 21, 2024). Evidence predominantly retrospective and observational (OCEBM levels 2b–5); no randomized trials identified. Screening: 93 records (2020–2024) identified; 52 studies included after applying inclusion criteria focused on objective outcomes and explicit protocols/dosing/technique descriptions. Bias assessment:  Qualitative assessment across design, confounding/selection, and outcome ascertainment domains; most included studies had moderate-to-high risk of bias. Results Pathogenesis and risk factors CC arises from an amplified foreign-body response with fibrosis and myofibroblast activity. Biofilm is implicated but not singularly causal. Postmastectomy radiation is a major clinical risk factor for CC in reconstruction cohorts. Additional factors discussed include incision choice and implant characteristics; literature is mixed and confounded by era effects and patient selection. Diagnosis and grading Baker I–IV grading remains the clinical standard though subjective; ultrasound and MRI criteria are being explored as adjuncts but lack consensus replacement value. Prevention strategies Reduce microbial burden:  Chlorhexidine skin prep; pocket irrigation with antiseptics/antibiotics; adherence to no‑touch technique and use of nipple shields to limit contamination. Implant/material choices:  Thoughtful selection of implant characteristics; adjunct use of acellular dermal matrix (ADM) or synthetic mesh may support thinner, more compliant capsules. Comparative data are heterogeneous; recent series show low CC rates with both biologic and synthetic meshes. Pharmacologic adjuncts:  Off‑label leukotriene receptor antagonists and short steroid/NSAID regimens are reported; efficacy signals are variable across small, nonrandomized studies. Monitor for drug‑specific risks (e.g., hepatotoxicity with some leukotriene agents). Treatment algorithms Early or mild CC (Baker II–III):  Trial of medical therapy (e.g., leukotriene inhibitors) and close observation; proceed to surgical release if symptomatic or deforming. Surgical management: Capsulotomy is often favored for thin capsules and less severe disease due to shorter operative time and recovery. Partial or total capsulectomy  is reserved for severe, recurrent, calcified, or adherent capsules; pair with implant exchange and a renewed prevention bundle. Adjuncts: Consider fat grafting for pain/contour and soft-tissue quality; reapply antisepsis/irrigation and no‑touch principles at revision. Conclusion A patient‑specific, multimodal strategy—meticulous technique, contamination control, judicious use of materials, and targeted adjunctive medications—best prevents and treats CC. Stronger prospective studies are needed to define optimal protocols and long‑term outcomes. Strengths and limitations Strengths of the review:  Comprehensive, pragmatic synthesis spanning epidemiology to revision surgery; offers clinically usable bundles and algorithms. Limitations of the evidence base:  Predominance of observational designs, heterogeneity in implant types/planes/radiation exposure, subjective outcome grading (Baker), and inconsistent reporting; no RCTs. Clinical relevance Ensure standard preventative measures are in place for all implant cases: modern skin antisepsis, pocket irrigation, no‑touch/nipple shields, nicotine cessation counseling, and deliberate implant/plane/material choices—especially in radiated fields. For early Baker II–III , a brief trial of medical therapy with documented monitoring can be reasonable; escalate promptly to capsulotomy if symptoms or deformity persist. For severe or recurrent CC , plan partial/total capsulectomy with implant exchange, reinforce prevention measures, and set expectations about recurrence risk and the role of explantation. Editorial Notes Evidence quality and consistency:  The reliance on retrospective series and subjective grading limits causal inference and protocol standardization. The Baker's classification is a poor and subjective outcome measure. To truly tackle this problem, plastic surgeons desperately need an objective and reliable way to measure capsule biomechanics.  Biofilm vs inflammation:  The review appropriately treats biofilm as contributory within a broader inflammatory cascade; however, we lack prospective data isolating the incremental benefit of each prevention‑bundle element. Future work should test bundle components in factorial or pragmatic designs. Mesh and materials:  Observational series suggest low CC rates with both biologic and synthetic meshes, however, the data is far from robust and should be interpreted with caution. Note that most included studies were conducted in aesthetic augmentation populations rather than reconstructive cohorts. Management decisions:  Capsulotomy may suffice for thin capsules, but understand that this does not usually address the (presumed) inciting cause.

Authors:  Veiga DF, Garcia ES, Veiga-Filho J, Fialho SV, Borges ASF, Dornelas GV, Machado AA, Arruda Felix GA, Ferreira LM Affiliation:  Universidade Federal de São Paulo, Brazil Journal:  Plastic and Reconstructive Surgery, September 2025 PMID:  40857697 Key takeaways In reduction mammaplasty, a single preoperative cefazolin dose was noninferior  to a 24-hour regimen for 30-day superficial surgical-site infection (SSI). SSI occurred in 5.5%  overall and did not differ  between single-dose and 24-hour groups (4/73 vs 4/73; all superficial). Wound dehiscence  rates were similar (16/73 vs 14/73; P = 0.682), suggesting no wound-healing benefit from extended prophylaxis. Findings support antimicrobial stewardship : avoid routine postoperative antibiotics beyond induction for straightforward reductions (Level of Evidence I). Background Reduction mammaplasty reliably improves symptoms of macromastia. Postoperative infections are uncommon but drive morbidity and reoperations. Practice varies widely regarding antibiotic duration; many surgeons extend prophylaxis for 24 hours or longer despite limited evidence of benefit. Objective To determine whether 24 hours of cefazolin prophylaxis  reduces 30-day SSI compared with a single induction dose  in patients undergoing reduction mammaplasty. Methods Design:  Randomized, noninferiority, parallel-arm clinical trial (1:1 allocation). Setting:  Academic centers in Brazil. Participants:  146 women undergoing bilateral reduction mammaplasty. Interventions: Single-dose group : cefazolin 1 g IV at anesthesia induction only. 24-hour group : cefazolin 1 g IV at induction, then every 6 hours for 24 hours. No antibiotics  were given after 24 hours in either arm. Endpoints: Primary:  30-day SSI per CDC definitions (assessed weekly by a surgeon blinded  to allocation). Secondary:  Wound dehiscence and other wound complications. Population profile:  median age 33  years; median BMI 25.2 kg/m² ; median excised tissue 925 g ; median operative time 220 minutes . Results Infections:  8/146 (5.5%) had SSI; 4/73 vs 4/73  (single-dose vs 24-hour), P = 1.000 ; all were superficial incisional . Dehiscence:  30/146 (20.5%); 16/73 vs 14/73 , P = 0.682 . Groups were similar  in baseline characteristics; no signal that extended prophylaxis improved any measured outcome. Conclusion For reduction mammaplasty, extending prophylaxis beyond a single preoperative dose offers no advantage  for preventing SSI or dehiscence. A single-dose regimen is sufficient for routine cases. Strengths Randomized design with blinded outcome assessment  and standardized CDC SSI definitions. Prospective weekly follow-up  to 30 days. Limitations Noninferiority margin and power calculations  not detailed in the text available; small absolute number of SSIs may limit precision for rare deep/organ-space infections. All infections were superficial ; study not powered for deep SSI or reoperation. Antibiotic regimen limited to cefazolin ; external validity may vary with different flora, MRSA prevalence, or beta-lactam allergies. Cohort skewed toward young, normal-weight patients  (median BMI 25.2), potentially limiting generalizability to higher-risk populations (obesity, diabetes, smokers, massive resections). Clinical relevance For healthy patients undergoing standard reduction mammaplasty, prescribe only a single preoperative cefazolin dose  (weight-based per institutional policy), with no routine postoperative antibiotics . Reserve extended coverage for specific indications  (e.g., gross contamination, prolonged unplanned re-entry, beta-lactam allergy with alternative agents, or institution-specific resistant organism risks) rather than as a blanket practice. Incorporate this into ERAS and stewardship pathways. Critiques and questions Risk stratification:  Outcomes are reported for the overall cohort. Were a priori subgroups  (e.g., smokers, BMI ≥30, resection weight >1 kg/breast, long operative time) examined for interaction? These are the patients for whom some surgeons still extend prophylaxis. Drain use and wound care protocols:  Did drain use or placement, resection weight, or T-junction management differ between groups? Such factors influence dehiscence  (20.5% here) and might overshadow any marginal antibiotic effect. Microbiology and rescue therapy:  What organisms were cultured from SSIs, and did resistance patterns differ? Time to diagnosis and response to standard oral therapy would contextualize the clinical impact of superficial SSI .

Authors : Allen RJ Jr, Zhang KK, Cohen Z, Shahzad F, Nelson JA, McCarthy CM, Patel SG, Boyle JO, Shah JP, Disa JJ, Cordeiro PG, Mehrara BJ, Matros E Affiliation : Memorial Sloan Kettering Cancer Center, New York, NY Journal : Plastic and Reconstructive Surgery PMID : 41159801 Key takeaways 401 patients/413 fibula free flaps over 21 years; flap success 97.8% ; total flap loss 2.2% . CAD/CAM adoption  (40.7% of cases) was associated with shorter OR time (~50 min)  and shorter LOS , without reducing major complications. Immediate dental implant placement (IDIP)  in 23.7%  increased over time alongside CAD/CAM and was linked to higher dental rehabilitation rates. Fixation shifted from mini-plates  to custom reconstruction bars  beginning 2016–2019, aligning with virtual planning. Despite workflow gains, recipient-site complications remained common ( 54.7%  overall; 29.5%  reoperation). Background Fibula free flap (FFF) is the workhorse for segmental mandibular reconstruction. Advances in virtual surgical planning (VSP/CAD‑CAM), custom fixation, and IDIP have changed workflow and rehabilitation, but the effect on outcomes is unclear. Objective Describe evolving trends and techniques (CAD/CAM, dental implants, fixation) and characterize operative metrics and complications after FFF‑based mandibular reconstruction at a single high‑volume cancer center. Methods Design/setting/LOE:  Retrospective review, single comprehensive cancer center, 2000–2021 . Sample: 401 patients, 413 FFFs ; median follow‑up 2.9 years . Demographics, comorbidities, treatments abstracted. Defects:  Lateral (45.0%), hemimandible (32.7%), anterior (14.3%); composite oral cavity soft‑tissue defects 23.2%; external skin defect 19.9%. Techniques:  Mini‑plates vs reconstruction bars; use of CAD/CAM  (from 2010 → 100% by 2021) and IDIP  (from 2017). Endpoints:  Recipient and donor site complications (major = return to OR); flap loss; osteoradionecrosis; operative time; LOS; dental rehabilitation; temporal trends. Statistics:  Descriptive statistics and year‑over‑year trend plots; subgroup comparisons (e.g., CAD/CAM vs no CAD/CAM); α = 0.05. Results Cohort:  Mean age 58.0 ; male 63.9% ; prior radiation 77.2% ; procedure length mean 675.6 ± 132.5  min; LOS median 14  days. Flap characteristics:  Two‑segment (47.0%) and three‑segment (34.6%) constructs most common; skin paddle used in 79.2% ; systemic heparin 77.2% . Trends:  Case volume increased over time. Reconstruction bars  supplanted mini‑plates beginning in 2019 . CAD/CAM  use rose to 100% by 2021 ; IDIP  increased after 2017 ; dental rehabilitation rose in parallel (later dip during COVID‑era). CAD/CAM vs no CAD/CAM: OR time: 646.4 ± 116.3 vs 695.7 ± 132.5 min; P = 0.0002 . LOS: 14.3 ± 5.7 vs 17.9 ± 9.2 days; P < 0.0001 . Major complications: 31.5% vs 32.7%; P = 0.813 . Recipient‑site complications: 54.7%  overall; major 29.5% ; infection/cellulitis 15.3% ; dehiscence 15.0% ; fistula 12.4% ; exposed hardware 13.1% ; osteoradionecrosis 11.9% . Year‑to‑year major complication rates showed no clear trend . Flap outcomes: Total loss 2.2% (9/413) ; partial loss 1.5% ; additional flap‑related complication 3.9% . Donor‑site complications: 32.9%  overall, driven by delayed wound healing 28.3% . Conclusion Institutional adoption of CAD/CAM, IDIP, and custom reconstruction bars improved workflow (shorter OR time and LOS) and enabled dental rehabilitation but did not  reduce major complication rates. Mandibular FFF reconstruction remains morbid yet reliable, with high flap success. Strengths:  Large contemporary cohort; long observation window; detailed operative/complication definitions; practical metrics (OR time, LOS, dental rehab); granular technique trends. Limitations:  Retrospective single‑center design; evolving protocols over decades; limited adjustment for confounding; lack of standardized functional outcomes or quality‑of‑life measures; potential survivorship and documentation bias. Clinical Relevance The free fibula flap remains the gold standard  for segmental mandibular reconstruction, with reliable union and high flap survival. However, despite adoption of CAD/CAM planning, custom reconstruction bars, and immediate dental implants, major recipient-site complications have not declined . Critiques/Questions Signal vs causation:  CAD/CAM association with shorter OR time/LOS may reflect workflow optimization and learning‑curve effects rather than technology alone. Data gaps:  Functional outcomes (speech, diet), bony union, and plate/bar exposure over time would sharpen conclusions.