Authors:  Bae J, Lee J-K, Lee K-T. Affiliation:  Dept. of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea. Journal:  Plastic and Reconstructive Surgery, December 2025. PMID:   40403284 . Key takeaways Pure skin perforator (PSP) flaps were harvested with loupes only (3.5×) using a distal-to-proximal technique and ultra high frequency ultrasound. In 71 flaps (55 SCIP, 10 ALT, 6 TDAP): mean thickness ~3.5 mm, harvest time ~37 minutes, and pedicle length ~4.8 cm; TDAP were thickest/longest, SCIP thinnest/shortest. Overall complications 25.4%; flap loss 8.5%  ( total 2.8%, partial 5.6% ). Delayed healing ( 19.7% ) predominated. Complication risk rose when flap size exceeded 25.4 cm² (40.5% vs 8.7%; ROC AUC 70.5%). Older age, active smoking, and larger flaps independently increased risk. Donor-site choice by indication: SCIP for digits/thin skin with nearby vessels; ALT/TDAP for thicker dermis or when a longer pedicle is needed. Background Thin, durable vascularized coverage is challenging for shallow but complex defects over bone or tendon, where conventional perforator flaps may be too bulky. PSP flaps leverage minute perforators and the subdermal plexus to deliver ultrathin skin paddles. Objective Evaluate PSP flaps’ harvesting feasibility without a microscope, optimal donor-site selection, and clinical outcomes across indications. Methods Design and setting:  Single-center retrospective series of consecutive PSP free flaps (April 2021–January 2024). Population:  71 patients; mean BMI ~24 kg/m². Donor sites: SCIP (n=55), ALT (n=10), TDAP (n=6). Indications and wound beds:  Oncologic resections 90.1%; chronic wounds 8.5%. Wound beds: cartilage/bone 59.2%, tendon 12.7%, subcutaneous 28.2%. Technique:  High-frequency ultrasound (22 MHz) used for perforator mapping; distal-to-proximal dissection under loupes (3.5×). A thin fat lobule was retained when contour was needed. Endpoints:  Harvest metrics (time, thickness, pedicle length), flap and donor complications, multivariable regression for risk factors; ROC-derived size cutoff; learning-curve (CUSUM) analysis. Results Harvest performance:  Mean harvest time 37 minutes. Median thickness 3.5 mm; most flaps based on a single PSP. Pedicle and geometry:  TDAP pedicles longest, SCIP shortest; TDAP thickest, SCIP thinnest. Operative time (overall case):  Mean 244 minutes (range 165–365). Complications (n=71):  Any flap-related 25.4%; flap loss 8.5% (total 2.8% [venous thromboses], partial 5.6%). Delayed healing 19.7%, infection 5.6%, hematoma 2.8%; flap-related reoperations 12.7%. Donor-site complications 11.3%. Rates did not differ by flap type. Risk factors:  On multivariable analysis, age  (adjusted OR 1.08 per year; P=0.041), active smoking  (adjusted OR 11.32; P=0.012), and larger flap  size independently predicted flap-site complications. Size threshold:  ROC AUC 70.5%; a 25.4 cm² cutoff yielded 40.5% complications above vs 8.7% below (P=0.003). Indication-based donor choice:  SCIP favored for digits/dorsal hand/toes; ALT/TDAP for plantar foot/lower leg or when longer pedicles are required. Learning curve:  Elevation time decreased from ~54 → 31 → 29 minutes across learning → proficiency → competency phases, with declining complications after ~15–31 cases. Conclusion PSP flaps provide ultrathin, reliable coverage for shallow but complex defects and can be safely harvested from multiple donor sites when surgeons apply indication-based selection and avoid oversized skin paddles. Strengths and limitations Strengths:  Largest PSP series to date (n=71); standardized loupes-only technique; identification of a practical size cutoff and independent risk factors; pragmatic donor-site algorithm. Limitations:  Single surgeon, retrospective design; relatively low BMI, predominantly Asian cohort; limited assessment of perforator caliber and preoperative imaging sensitivity for PSPs. Clinical relevance Consider PSP flaps when skin grafts are inadequate but flap bulk would impair function or aesthetics (digits, ankle, joints). Must be willing to accept higher flap failure and delayed wound healing rates Choose donor site by need: SCIP for thin skin and short reach; ALT/TDAP for thicker skin or longer reach. Keep paddles at or below ~25 cm² when feasible; if larger area is essential, consider multiple PSPs, staged coverage, or alternative flaps—especially in smokers or older patients. Critiques and questions Perfusion biology:  Failures likely relate to the PSP’s reliance on the subdermal/deep dermal plexus after superthin elevation, making outcomes sensitive to skin paddle size. Future work should quantify PSP flow (e.g., ICG angiography, speckle flowmetry) and correlate with outcomes. Generalizability:  Results come from one high-volume team with a learning curve flattening by roughly 30 cases. Centers new to PSP should anticipate higher early risk and adopt a proctored pathway with conservative case selection (SCIP for small digital defects first). Imaging:  High-frequency ultrasound aided perforator selection; current CTA protocols an pencil doppler are likely inadequate.

Authors:  Jonis YMJ, Wolfs JAGN, Hummelink S, Tielemans HJP, Keuter XHA, van Kuijk S, Ulrich DJO, van der Hulst RRWJ, Qiu SS Affiliation:  Maastricht University Medical Center; Radboud University Medical Center - The Netherlands Journal:  Nature Scientific Reports, 2024 PMID:   38278856 Key takeaways LVA improved Lymph-ICF physical (−16.5 ± 18.5) and mental (−10.1 ± 29.5) domains at 6 months versus baseline. No between-group difference in total Lymph-ICF score at 6 months; both groups changed minimally. Limb volume and UEL index showed no sustained between-group differences through 6 months. 41–42% of LVA patients partially or completely stopped compression; 0% in CDT. Background Breast-cancer–related lymphedema (BCRL) impairs function and quality of life; complex decongestive therapy (CDT) is standard but lifelong. Supermicrosurgical LVA may improve symptoms. Objective Compare health-related quality of life (HrQoL) after LVA versus continued CDT in early-stage unilateral BCRL. Primary endpoint: Lymph-ICF total score. Methods Design/setting/LOE:  Prospective multicenter RCT; Netherlands. Participants:  Adult women, unilateral BCRL, ISL stage 1–2a with viable lymphatics by ICG (Narushima II–III). Planned n = 100; interim n = 46 per arm. Randomization:  1:1, block-stratified by site. Interventions: LVA:  1–5 end-to-end LVAs under microscope; patency confirmed; resume CDT maintenance after 2 weeks. CDT:  Standardized Verdonk method—skin care, MLD, exercise, compression; maintenance with elastic garment. Primary endpoint:  Lymph-ICF (lower better; ≥10-point decrease considered clinically meaningful). Secondary endpoints:  Water-displacement limb volume, UEL index, compression-garment use, adverse events/serious adverse events at 3 and 6 months. Results HrQoL (within-group):  LVA improved physical and mental domains at 6 months (−16.46 and −10.12; p < 0.05). HrQoL (between-group):  No significant difference in total Lymph-ICF between LVA and CDT at 6 months. Volume/circumference:  No significant intergroup differences in volume or UEL index at 6 months; transient UEL improvement at 3 months in LVA not sustained. Compression garments:  At 6 months, 21.3% stopped completely and 21.7% partially in LVA (≈42% any discontinuation); 0% stopped in CDT. Safety:  Comparable adverse events; erysipelas episodes in both groups; one breast-cancer recurrence reported as SAE in LVA arm (patient remained in study). Conclusion At 6 months, LVA improves physical and mental aspects of HrQoL versus baseline, without measurable early limb-volume advantage over CDT; many patients reduce or stop compression after LVA. Longer follow-up is required to determine durable superiority. Strengths & limitations Strengths:  First large multicenter RCT in BCRL assessing HrQoL after LVA; standardized CDT comparator; prespecified patient-centered outcomes. Limitations:  Interim 6-month readout; early-stage BCRL only; single LVA session; no mandated rationale for compression discontinuation; volume metrics may lag symptom change. Clinical relevance Offer LVA to appropriately imaged, early-stage BCRL patients primarily for symptom relief and HrQoL gains; set expectations that objective volume change may be modest by 6 months. Discuss a trial of relaxed compression in responders, with structured monitoring for recurrence of swelling. Critiques and questions Endpoint alignment:  The trial’s primary endpoint is total Lymph-ICF; yet benefits appeared in domain-specific scores (physical, mental). Timing of measurement:  Six months may be too early for structural changes in interstitial fibrosis to translate into measurable volume reduction; symptom relief (heaviness, tightness) often precedes volume change after LVA. Compression policy:  Compression discontinuation was frequent but not protocolized. Future analyses should correlate compression status with domain scores, infections, and rebound edema to guide tapering algorithms. Surgical dose and imaging:  One LVA session may under-treat selected patients; exploratory modeling showed no association between number of anastomoses and outcomes in this cohort, consistent with prior work. Detailing quality (ICG stage, vessel caliber) and patency over time may be more predictive than raw anastomosis count. Generalizability:  Early-stage, ICG-mappable BCRL was studied; applicability to advanced BCRL will remain uncertain until long-term data or separate trials address later stages.

Authors:  Watson JA, Knoedler S, von Reibnitz D, Zurfluh CE, Imholz C, Esposito G, Schreiner SJ, Gousopoulos E, Cai A, Kollarik S, Giovanoli P, Baumann C, Lindenblatt N. Affiliation:  University Hospital Zurich, Switzerland. Journal:  Plastic and Reconstructive Surgery – Global Open; October 2025. PMID:   41050965 Key takeaways Brain parenchyma lacks a traditional lymphatic system. Instead, the glymphatic system clears brain waste via CSF-interstitial exchange (sleep/AQP4) Meningeal lymphatics (true/traditional lymphatics) drain this resultant CSF and to deep cervical nodes. Deep cervical lymphovenous anastomosis (LVA) is proposed to augment CNS lymphatic outflow; early Alzheimer’s reports show feasibility and cognitive gains. Multiple prospective trials in Alzheimer’s and Parkinson’s are underway; robust validation remains needed. Robotic systems (e.g., Symani, MUSA) may improve precision for deep-neck lymphatic reconstruction. Background Modern research describes a two-component CNS clearance network composed of the glymphatic system  and meningeal lymphatic vessels . The brain generates substantial metabolic waste, including lactate, misfolded proteins, and byproducts of high neuronal activity, yet it lacks traditional lymphatic vessels within the parenchyma. To maintain homeostasis within the fixed intracranial space, it relies on a specialized mechanism in which cerebrospinal fluid (CSF) enters periarterial spaces, travels through astrocytic endfeet enriched with aquaporin 4 (AQP4) , and mixes with interstitial fluid through convective CSF and interstitial exchange. The resulting fluid then clears along perivenous pathways before draining into dural lymphatic vessels and ultimately to the deep cervical lymph nodes. Glymphatic activity increases during slow wave sleep, when reduced noradrenergic tone expands the interstitial space and facilitates AQP4 dependent flow. Arterial pulsatility, preserved astrocytic polarity, and intact meningeal lymphatics support efficient clearance. In contrast, aging, vascular comorbidity, trauma, and ischemia impair these pathways and reduce waste removal. Dysfunction of this system is increasingly associated with accumulation of beta amyloid, tau, and alpha synuclein, impaired neuroimmune surveillance, and worsened edema. These mechanisms link glymphatic and meningeal lymphatic impairment to Alzheimer and Parkinson disease, traumatic brain injury, and hemorrhagic conditions. Collectively, these insights provide the biologic rationale for augmenting cervical lymphatic outflow as a strategy to enhance CNS waste clearance, including the use of deep cervical lymphovenous anastomosis (LVA). Objective Review neurolymphatic physiology, synthesize early evidence for enhancing CNS lymphatic efflux via deep cervical LVA, and discuss how robotics may enable safe, precise translation. Methods Narrative review of glymphatic/meningeal lymphatic literature and disease associations. Appraisal of initial clinical reports using deep cervical LVA for cognitive dysfunction. Summary of registered clinical trials and practical/ethical considerations for future studies. Results Physiology:  AQP4-dependent glymphatic flow clears neurotoxic proteins; human imaging (eg, DTI-ALPS, MRI-visible perivascular spaces) and animal models link impaired glymphatic/meningeal lymphatic function to β-amyloid, tau, and α-synuclein aggregation, neuroinflammation, and edema. Clinical signal (AD case reports):  Deep cervical LVA has been described in an elderly cognitive impairment case (Lu 2022) and a 2024 AD case using a supermicrosurgical cervical shunting technique (Li 2024), with reported postoperative cognitive improvement; controlled data are not yet available. Multiple prospective trials registered in Alzheimer’s and Parkinson’s; no published Parkinson’s LVA outcomes yet. Alzheimer’s disease NCT06448442 NCT06448975 ChiCTR2500095309 ChiCTR2400093030 ChiCTR2400089883 ChiCTR2400094603 ChiCTR2400084617 Parkinson’s disease ChiCTR2400091857 Robotics:  First-in-human robotic central lymphatic reconstructions and larger series show patent anastomoses and symptom improvement, supporting feasibility for cervical LVA. Conclusion Enhancing CNS lymphatic efflux via deep cervical LVA is promising but investigational; rigorous mechanistic and clinical validation is required before routine adoption. Strengths & limitations Strengths:  Clear synthesis of emerging neurolymphatic science; practical roadmap for surgical approaches and robotic facilitation. Limitations:  Evidence base is mainly case reports/early series; no randomized or controlled data; ethical considerations remain. Clinical relevance For reconstructive microsurgeons and neurology/neurosurgery teams, cervical LVA, potentially with robotic assistance, could become an adjunct to improve protein clearance and inflammation. Use only within trials or protocols.

Authors:  Malekzadeh H, Kluemper J, Elemosho A, Janis JE Affiliation:  Dept. of Plastic and Reconstructive Surgery, Ohio State University Wexner Medical Center Journal:  Journal of Reconstructive Microsurgery, Oct 2025 PMID:   41072483 Key takeaways Across 11 studies, postoperative anticoagulation increased rate of hematoma (≈5.0% vs 3.0%; OR ~2.4) without reducing complete flap failure or reoperation rates. Subgroup analyses showed that only unfractionated heparin (UFH) was associated with increased hematoma formation; low–molecular-weight heparin (LMWH) showed no significant effect on hematoma rate. Adding aspirin to LMWH increased rates of reoperations (≈17.5% vs 10.1%) with no flap-survival benefit compared to LMWH alone Empiric usage of routine anticoagulation may not benefit all patients, however, employing a risk-based approach to postoperative anticoagulant use is warranted especially in those patients at high risk for thrombosis. Background Anticoagulants are commonly used after microvascular reconstruction as a method to prevent microvascular thrombosis and ultimately improve flap survival, but their benefit for flap outcomes is unproven, leading to high variance in clinical practice among microsurgeons. Objective The review sought to determine whether prophylactic postoperative anticoagulant use improves flap outcomes. Methods Design/level of evidence:  Systematic review and meta-analysis (Level III evidence base). Search window:  1995–January 2025 (PRISMA-compliant). Inclusion Criteria:  Studies comparing postoperative prophylactic use of anticoagulants (UFH/LMWH/DOAC/Vit K antagonists) with a comparator group and reported at least 1 primary outcome; Primary outcomes included hematoma formation, complete flap failure, need for reoperation. Exclusion Criteria: anticoagulation use for flap salvage, therapeutic dosing of anticoagulant, studies with <10 cases, or those with no control or comparator group. Studies: Included 11 in total; 7 “anticoagulation vs none” (≈4,858 cases), 4 “LMWH ± aspirin” (≈1,102 cases); flaps sampled: mixed head & neck, breast, and other free flaps. Statistical Analysis:  Mantel–Haenszel fixed effects model used in studies without substantial heterogeneity; In studies with substantial heterogeneity, a sensitivity analysis was performed and random effects model used. Heterogeneity calculated by using Q test and I 2  statistics (>50% considered substantial heterogeneity). Results reported as odds ratios with 95% confidence intervals; subgroup analysis by agent. Results Anticoagulation vs none: Sample size/events reported:  ~4,858 cases across 7 studies Flap failure:  pooled 3.2% (anticoag) vs 5.2% (control); OR 0.82 (95% CI 0.41–1.64; p=0.57; I²=6%). No significant difference overall. Bleeding: pooled 5.0% (anticoag) vs 3.0% (control); OR 2.44 (95% CI: 1.11-5.40; p=0.0.03; I²=65%). Hematoma rates higher with anticoagulation. Subgroup analysis by agent shows this was primarily driven by UFH; LMWH use was not significantly associated with increased hematoma formation. Reoperation: pooled 6.3% (anticoag) vs 4.9% (control); OR 2.90 (95% CI: 0.91 – 9.20; p = 0.07; I 2  = 77%). No significant difference overall. LMWH + aspirin vs LMWH alone: Sample size/events reported:  ~1,102 cases across 4 studies; flap failure reported in 3 studies, reoperation reported in 3 studies, hematoma reported in 4 studies (3 with LMWH) Hematoma:  pooled 6.8% (LMWH) vs 9.2% (LMWH+ASA); OR 0.64 (95% CI 0.37–1.11; p=0.11; I²=48%).   No significant differences between groups. Flap failure:  pooled 3.2% (LMWH) vs 2.3% (LMWH+ASA); OR 0.72 (95% CI 0.27–1.92; p=0.51; I²=0%). No significant differences between groups. Reoperation: pooled 10.1% (LMWH) vs 17.5% (LMWH+ASA); OR 0.39 (95% CI 0.19–0.79; p=0.01; I²=0%). Reoperation rates significantly higher in patients receiving LMWH+ASA vs LMWH alone. Power note for flap failure:  Failure events were infrequent (≈2–5%) and only 3–4 studies contributed to the failure analyses; confidence intervals were wide and crossed 1 → underpowered to detect modest differences . Conclusion Routine postoperative heparinization increases bleeding without improving flap survival; adding aspirin to LMWH raises reoperations. Adopt individualized, risk-stratified VTE prophylaxis rather than blanket anticoagulation for free flaps. Strengths & limitations Strengths: Contemporary focus on the postoperative window; agent-specific subgrouping (UFH vs LMWH); sensitivity analyses. Limitations: All studies were Level of Evidence III and mostly retrospective; regimen heterogeneity (dose/timing/duration); incomplete adjustment for baseline thrombotic risk and case complexity. Clinical relevance Routine postoperative anticoagulation in average-risk patients does not reduce rates of flap failure, although the results are likely not powered sufficiently.  Adding aspirin to LMWH may increase rates of takebacks without a flap survival gain. Risk-stratify: Use Caprini score and thrombophilia status to escalate intensity/duration (e.g., extended LMWH) while balancing bleeding risk. Bottom line:  For most free-flap patients, skip routine postoperative heparin (and avoid LMWH+aspirin combinations). Risk-stratify for VTE and reserve intensified anticoagulation for patients with elevated risk factors while closely monitoring for bleeding.

Authors:  Su S, Menon A, Taillon C, Saad O, Merceron T, Ghareeb P Affiliation:  Emory University/Grady Memorial Hospital Journal:  Journal of Reconstructive Microsurgery, January 2025 PMID:   39750583 Key takeaways Initiating dangle by POD ≤5  was safe  and associated with shortened postoperative length of stay  (LOS 12.3 vs 18.8 days , p =0.0018); total hospital LOS also shorter ( 24.0 vs 35.3 days , p =0.0067). On multivariable analysis, each 1-day delay  in starting dangle was linked to a 13% lower discharge probability  (Cox model) and higher odds of flap loss  (OR 1.31  per day; p =0.019). Background Lower-extremity flaps face high venous pressures in dependency; “dangling” conditions the flap but timing varies widely (POD <2 to >14). Objective Evaluate safety and LOS impact of earlier  (≤POD5) versus later  (>POD5) initiation of a dangle protocol after lower-extremity free-flap reconstruction. Methods Design/setting: Retrospective cohort, single institution (2012–2022). Cohort: 83  patients included (Early dangle n=22 ; Late n=61 ; 99 screened). A priori power reported (0.95). Protocol: Start at 5 minutes dangling three times daily; escalate by 5 minutes per dangle for each subsequent day if flap exam stable. Outcomes: Postop LOS (primary), hospital LOS, wound complications, flap failure, amputation, time to ambulation. Results Safety: No significant differences in wound complications, flap failure (9.1% early vs 9.8% late) , or amputation between groups; time to ambulation similar. Length of stay:  Postop LOS 12.3 vs 18.8 days  ( p =0.0018); hospital LOS 24.0 vs 35.3 days  ( p =0.0067) favoring early dangle. Multivariable findings: Each day’s delay in dangle → lower discharge probability  (~13% per day; model p =0.00016). Flap loss:  later dangle associated with higher odds ( OR 1.31 per day delay , p =0.019). Smoking trended but NS. Operative details:  Two-vein anastomoses more common in the late group; flap types mixed (ALT predominant). Conclusion Early dangle initiation (≤POD5)  is safe  and reduces LOS . Delaying dangle correlates with higher flap-loss odds  and slower discharge . Adopt an earlier, monitored dangle protocol  in standardized postoperative care. Strengths & limitations Strengths: Explicit power analysis; multivariable modeling; effect estimates for discharge and flap loss. Limitations: Retrospective single-center study with significant concern for selection bias by surgeon preference determining early vs. late dangle, single vs. dual venous anastomosis, and heterogeneity in flap donor selection; small early cohort; imbalance in number of venous anastomoses between the early and late dangle groups; discharge influenced potentially by unmeasured variables, such as nonclinical factors.

Authors:  Pai AA, Chen AC-Y, Loh CYY, Hung S-Y, Tsao C-K, Kao H-K Affiliation:  Chang Gung Memorial Hospital, Taoyuan, Taiwan Journal:  Journal of Reconstructive Microsurgery, online March 7, 2025 PMID:   39961360 Key takeaways Plate exposure occurred in 28.8% (74/292) after fibula free flap (FFF) mandibular reconstruction for primary oral cancer. Most exposures required surgery; ~50% underwent plate removal alone. 13.5% were treated with plate removal and regional flap 10.9% were treated with plate removal and free flap (6.8% ALT, 4.1% second fibula) Postoperative radiotherapy independently increased exposure risk (adjusted OR ≈3.7; p≈0.01) Three-year plate exposure–free probability: 65.9% with radiotherapy vs 92.5% without; 55.3% with infection vs 91.2 Postoperative wound infection was the strongest predictor (adjusted OR ≈10.7; p<0.001). Three-year plate exposure–free probability: 55.3% with infection vs 91.2% without. Neither incision placement nor the need for external skin replacement was reported Background Hardware complications, particularly plate exposure, remain common after oromandibular reconstruction despite advances in computer-aided design/manufacturing (CAD-CAM) and virtual planning. Objective Identify perioperative risk factors for plate exposure after FFF mandibular reconstruction for primary oral cancers. Methods Design/setting/level of evidence:  Single-center retrospective cohort (2015–2019); Level III. Population: 292 consecutive primary oral cancer patients undergoing segmental mandibulectomy and immediate fibula osteocutaneous reconstruction. Exclusions: Non–head and neck cases, repeats/previous failures, missing radiotherapy records, inadequate follow-up or imaging. Follow-up: Standardized clinic schedule; study follow-up reported as 2 years. Variables: Demographics, TNM, defect type/length (Jewer classification for bone defect), plate type, number of osteotomies, ischemia time, re-exploration, postoperative radiotherapy (PORT), chemotherapy, postoperative wound infection, length of stay. Endpoints: Plate exposure; time to plate exposure (Kaplan–Meier). Statistics: Univariate and multivariable logistic regression (pre-specified covariates); Kaplan–Meier curves for exposure-free probability; α=0.05. Results Overall exposure rate:  28.8% (74/292). Independent risk factors: Postoperative radiotherapy: adjusted OR 3.73 (95% CI 1.35–10.30), p=0.011. Postoperative wound infection: adjusted OR 10.71 (95% CI 5.15–22.26), p<0.001. Time-to-event: 3-year exposure–free probability 65.9% with PORT vs 92.5% without (p<0.001); 55.3% with infection vs 91.2% without (p<0.001). Other associations:  Re-exploration associated on univariate analysis (OR 2.61; p=0.04) but not multivariable (p=0.27). Non-significant factors (multivariable):  Plate type, defect type/length, number of osteotomies. Length of stay:  Longer with exposure (26.1±12.5 vs 24.2±7.1 days; p<0.001). Management of exposure (n=74): Conservative care: 24.3%. Surgical: plate removal only 50%; plate removal + regional flap 13.5%; plate removal + free flap (ALT 6.8%, fibula 4.1%). Conclusion After fibula free flap mandibular reconstruction for primary oral cancer, postoperative radiotherapy and postoperative wound infection are independent, major drivers of plate exposure. Strengths & limitations Strengths: Large, disease-specific cohort; multivariable modeling; inclusion of time-to-event analysis. Limitations: Retrospective design; potential confounding by indication for PORT; soft-tissue coverage or need for external skin replacement was not reported . Critiques and questions Soft-tissue coverage matters:  The study acknowledges difficulty quantifying soft-tissue coverage; yet healthy, durable soft tissue coverage is central to hardware preservation. Improved reporting measures (e.g., flap skin paddle area/neck tissue thickness) would strengthen inference. Infection pathway:  Infection remained the dominant predictor (OR ≈10.7). It likely mediates exposure via wound breakdown and biofilm. Clinicians should focus on infection reduction to limit hardware exposure. Bottom line:  In FFF mandibular reconstruction for primary oral cancer, surgeons must take strong measures to ensure adequate soft tissue coverage, minimize infections and treat infections early/aggressively, and (presumably) place incisions lower on the neck when able.

Authors: Doloff JC, Veiseh O, de Mezerville R, Sforza M, Perry TA, Haupt J, Jamiel M, Chambers C, Nash A, Aghlara-Fotovat S, Stelzel JL, Bauer SJ, Neshat SY, Hancock J, Araujo Romero N, Elizondo Hidalgo Y, Mora Leiva I, Mendonça Munhoz A, Bayat A, Kinney BM, Hodges HC, Miranda RN, Clemens MW, Langer R. Journal:  Nature Biomedical Engineering, October 2021 PMID:   34155355 Goal of the Study The researchers investigated how the surface topography (roughness) of silicone breast implants affects the foreign body response (FBR)—the immune reaction that leads to inflammation and fibrotic capsule formation. They compared a wide range of implant textures in mice, rabbits, and humans to identify which surface design minimizes fibrosis and immune activation. Key Findings 1. Implant surface roughness directly shapes the immune response. The study investigated implants ranging from completely smooth (0 μm roughness) to highly textured (90 μm, similar to Biocell). Highly textured surfaces triggered the strongest inflammatory response, increased macrophage infiltration, T-cell and B-cell recruitment, and thick, sometimes double-layered capsules. These severe responses mirrored clinical complications seen in humans, such as capsular contracture, chronic inflammation, and the specific association of textured implants with BIA-ALCL (breast implant–associated anaplastic large cell lymphoma). 2. A moderate roughness of ~4 μm (SmoothSilk) produced the least inflammation and fibrosis.  This surface performed better than both fully smooth and more aggressively textured surfaces. Among all surfaces tested, implants with ~4 μm average roughness: Developed the thinnest, least fibrotic capsules Had reduced inflammatory cytokine expression Avoided double-capsule formation Recruited significantly fewer macrophages 3. Regulatory T cells (Tregs) play a crucial role. The 4 μm surface uniquely increased levels of FOXP3+ regulatory T cells around the implant. These Tregs: Suppressed pro-fibrotic macrophage activity Limited overall inflammation Helped keep capsule formation thin and soft When tested in T-cell–deficient mice , the anti-fibrotic benefit of the 4 μm surface disappeared , proving that T-cells—especially Tregs—are essential for this protective effect. 4. Findings were consistent across animals and human tissues. Rabbit studies (up to 1 year) and examination of human capsule tissues confirmed the same pattern: SmoothSilk (~4 μm) = thinnest capsules and lowest inflammatory markers Macrotextured implants (Biocell) = thick capsules, debris, strong immune activation, and in ALCL cases, aggressive T-cell–driven inflammation Human specimens from Biocell-associated ALCL showed profoundly elevated inflammatory and cytotoxic T-cell gene signatures. Conclusion Implant surface topography strongly influences the foreign body response. A finely controlled, micro-scale surface roughness —specifically around 4 μm—provides the optimal balance: it limits macrophage activation and fibrosis while supporting a protective regulatory T-cell response. This research suggests that such microtextured surfaces may offer the safest and most biocompatible design for long-term silicone breast implants, while highly textured implants pose greater inflammatory and oncologic risks.

Authors:  Meyer A, Bird C, Nazir N, Collins M, Lai EC, Farmer R, Butterworth J, Holding J Affiliation:  University of Kansas Medical Center Journal:  Journal of Reconstructive Microsurgery, Sept 2025 PMID:   41067263 Key takeaways In 1,745 DIEP flaps (1,099 patients), 32.4% used ≥2 veins; 24.5% of all flaps (427/1745) had prophylactic  augmentation (extra outflow without clinical congestion). 8% (n=140) of flaps were augmented due to signs of congestion Routine augmentation did not  reduce returns to OR, venous compromise, or flap loss versus single-vein anastomosis. Operative time was longer  with augmentation (~559 vs 506 minutes; p<0.001). Authors propose a selective decision pathway ; add outflow only for documented congestion. Background Whether DIEP flaps benefit from routine second-vein outflow remains debated; evidence for prophylactic augmentation is limited and practice varies. Objective Compare single-vein versus venous-augmented DIEP outcomes and present a practical intraoperative decision pathway. Methods Design/setting: Retrospective cohort, single academic center, 2009–2023. Cohort: 1,099 patients / 1,745 DIEP flaps. Prophylactic augmentation = additional venous outflow without  intraoperative congestion. Endpoints: Return to OR (any cause; venous suspicion), suspected venous congestion, early/late flap loss, operative time. Stats: Bivariate comparisons; p<0.05 significant. Results Venous strategy distribution:  1 vein 67.6% (1180/1745); ≥2 veins 32.4% (565/1745). Prophylactic augmentation 24.5% (427/1745). Required augmentation for congestion 8.0% (140/1745). Return to OR (any cause):  5.6% (97/1745) overall No difference  one vein vs ≥2 veins (p=0.14) or one vein vs prophylactic  subset (p≈0.09–0.10). Suspected venous compromise:  2.3% (41/1745); no difference  single vs augmented (p=0.48) or single vs prophylactic  (p=0.95). None of the required-augmentation flaps re-returned for venous suspicion. Flap loss:  Early loss 1.5% (27/1745) and late loss 2.2% (38/1745); no significant  differences between groups. Operative time:  Longer with ≥2 veins (557.4±124.6 min) vs single vein (505.6±130.7; p<0.001 ); prophylactic  ≈559.4 min vs single (p<0.0001). Flap size:  Actual flap weight was not reported . BMI was higher in multi-vein and prophylactic  groups (e.g., multi-vein > single-vein; prophylactic > single-vein), suggesting surgeons more often augmented prophylactically  in higher-BMI patients Conclusion Routine prophylactic venous augmentation  in DIEP reconstruction does not improve  returns to OR, venous congestion, or flap survival, and prolongs  operative time. Reserve additional outflow for declared  congestion using a structured pathway. Strengths & limitations Strengths: Large single-center experience; clear operational definitions; reporting of early/late events and operative time. Limitations: Retrospective; potential selection bias (e.g., higher BMI in prophylactic group); 14-year practice evolution; no multivariable adjustment. Critiques and questions Confounding: Prophylactic cases showed higher BMI; multivariable or propensity analyses would clarify causality. Event granularity:  Standardized perfusion metrics (ICG/thermal imaging) and flap-weight data would contextualize outflow needs. External validity:  The proposed pathway is sensible; prospective implementation could test whether unnecessary second anastomoses decline without missed congestion events, but a large study would be needed to be adequately powered.

Authors:  Gonzalez M, Zietowski M, Patel R, Chattha A, Cripps CN, Beederman M  Affiliation:  Section of Plastic & Reconstructive Surgery, University of Chicago Medicine  Journal:  Journal of Reconstructive Microsurgery, Jan 2025   PMID :  39875120   Key takeaways   The five-factor modified frailty index (mFI-5)  provides a model to determine surgical risk and guide clinical decision making across specialties   The five variables include functional status , diabetes , chronic obstructive pulmonary disease , congestive heart failure  and hypertension.   In 219 trauma patients, mFI-5 ≥2  was a statistically significant indicator predictive of: any complication  (OR 3.83), reoperation  (OR 5.39), and hematologic complications  (OR 3.67).  mFI-5 = 1  was not  predictive; BMI  independently predicted wound infection  (OR 1.09 per BMI unit).  Background   Lower-extremity trauma reconstructions have high complication rates; the role of frailty  (mFI-5) as a risk stratifier in this cohort has been unclear.  Objective   Assess whether mFI-5  predicts postoperative complications after lower-extremity free-flap  reconstruction for trauma.  Methods   Design:  Retrospective NSQIP analysis (2012–2020).  Cohort:   n=219  trauma patients undergoing lower-extremity free flaps; grouped by mFI-5 = 0, 1, ≥2 .  Outcomes (30 days):  any complication, wound infection, hematologic complication (transfusion/DVT), readmission, reoperation, discharge destination, prolonged LOS.  Stats:  Univariate tests + multivariable logistic regression; p<0.05 .  Results   Patient profile:  Mean age 47.6 ±16.2 ; 64.8% male . Distribution: mFI-5 0 ( 65.3% ), 1 ( 25.6% ), ≥2 ( 9.1% ). Higher mFI-5 associated with older age , higher BMI , and dyspnea .  Event rates:  Any complication  22.4% (49/219) ; readmission  6.8% ; reoperation  12.3% .  mFI-5 ≥2 (vs 0):   Any complication: OR 3.829 , 95% CI 1.45–10.15, p=0.007 .  Reoperation: OR 5.385 , 1.83–15.88, p=0.002 .  Hematologic: OR 3.669 , 1.27–10.64, p=0.017 .  mFI-5 = 1:  Not significant for any complication, wound infection, readmission, or reoperation.  Other predictors:   BMI  predicted wound infection (OR 1.092 , p=0.014 ); age  predicted discharge to facility (OR 1.03  per year, p=0.009 ).  Conclusion   In trauma patients undergoing lower-extremity free-flap reconstruction, mFI-5 ≥2  robustly identifies those at higher risk of complications , reoperation , and hematologic events . Incorporating mFI-5  into preoperative assessment can sharpen counseling and postoperative planning.  Strengths & limitations   Strengths:  National dataset; focused trauma cohort; adjusted analyses demonstrating independent predictive value of mFI-5 ≥2 .  Limitations:  30-day outcomes only; database constraints (e.g., flap-specific details, socioeconomic factors); modest mFI-5 ≥2  sample (n=20).  Clinical relevance   Consider frailty when completing presurgical screening for LE trauma patients:  Calculate mFI-5 ; flag ≥2  as high risk—plan tighter hemostasis, early DVT prophylaxis, and closer monitoring.  Target modifiable risks:  Address BMI-related wound risks  (glucose control, nutrition, offloading) and plan resources for higher discharge support with increasing age.

Authors:  Rizvi I, Kahramangil B, Wang E, Swiekatowski K, Nye JR, Trost JG, Bhadkamkar MA Affiliation:  Division of Plastic and Reconstructive Surgery, UTHealth Houston, McGovern Medical School Journal:  Journal of Reconstructive Microsurgery, Oct 2025 PMID:   41067264 Key takeaways In 333 lower-extremity free flaps, superficial-only  recipient drainage had higher venous complications  than deep  or combined drainage ( 27.8% vs 8.6% vs 4.3% ). On multivariable analysis, superficial-only  increased venous-complication odds vs deep ( OR 4.11 , 95% CI 1.24–11.9; p=0.049 ); dual-vein outflow  reduced odds ( OR 0.34 , 0.16–0.73; p=0.005 ). Background Venous congestion drives most lower-extremity flap failures. Surgeons elect to either use the deep (venae comitantes), superficial (saphenous) recipients, or both deep/superficial systems for free flap reconstruction. Comparative outcome data between the deep and superficial systems are limited. Objective Compare venous complications across deep vs superficial vs combined  recipient drainage and by one vs two  venous anastomoses. Methods Design/setting:  retrospective review, 2016–2024 , tertiary academic center. Cohort: 333  free flaps; primary outcome = composite venous complications (congestion, hematoma, partial/total necrosis) during index hospitalization. Groups: Deep, superficial, or combined drainage; one vs two venous anastomoses. Analysis: Multivariable logistic regression with pre-specified covariates. Results Overall venous complications:   9.3% (31/333) . By drainage system:  Superficial 27.8% , Deep 8.6% , Combined 4.3% ( p=0.028 ). Superficial had more congestion  and total flap necrosis  than deep. Multivariable predictors: Superficial vs deep  drainage: OR 4.11  (1.24–11.9), p=0.049 . Two veins  vs one vein: OR 0.34  (0.16–0.73), p=0.005  (≈66% odds reduction). Practice pattern:  Deep 87.7% (292) , Superficial 5.4% (18) , Combined 6.9% (23) . Two veins used in 68.2%  and associated with fewer venous complications than one ( p=0.004 ). Clinical modifiers:   Diabetes  was more common in the complication group (29.0% vs 10.6%; p=0.007 ). Flap type  also mattered: higher odds with larger flaps such as the latissimus dorsi  ( OR 5.29 ) and ALT  ( OR 3.73 ) vs radial forearm . Conclusion For lower-extremity reconstruction, prioritize deep venous recipients ; avoid superficial-only  drainage when possible. Consider dual-vein outflow  to reduce venous complications, especially in high-risk settings. Strengths & limitations Strengths: Contemporary, sizable cohort; clear drainage definitions; adjusted analysis identifying drainage system and number of veins as independent predictors. Limitations: Retrospective, single-center; small superficial-only  sample; limited detail on vein size/zone-of-injury—selection bias possible; surgeons preferentially used deep system when available. Clinical relevance Choose deep first.  Use venae comitantes as primary recipients; if superficial system is needed, prefer combined  over superficial-only . Favor two veins  when feasible (trauma, bulky flaps, diabetes) to lower venous risk.

Authors:  Somers S, Vitale A, Dadzie A, French M, Eddington D, Agarwal JP, Kwok AC. Affiliation:  Division of Plastic & Reconstructive Surgery, University of Utah Journal:  Journal of Reconstructive Microsurgery, September 2025. PMID:   41067267   Key takeaways A single induction dose of methadone (typically 20 mg IV) lowered postoperative (Day 0-2) and total inpatient opioid use versus standard care. Mean cumulative inpatient opioid administration fell ~37% (87.4 vs 139.1 MME; p=0.03) with methadone use. Antiemetic use was similar between groups. Length of stay was similar (3.2 vs 3.5 days; p=0.14).   Background Enhanced recovery pathways for DIEP and other free flaps attempt to minimize opioid consumption to reduce opioid related side effects, such and nausea/vomiting and opioid dependency. Methadone’s long half-life and NMDA antagonism support single-dose intraoperative use. Objective Assess whether intraoperative methadone reduces perioperative opioid requirements after autologous free-flap breast reconstruction.   Methods Design/setting/LOE: Single-center retrospective cohort; July 2023–August 2024; Level III evidence. Cohorts: Practice change implemented June 2024. Patients before = no methadone; after = methadone. Chronic opioid users excluded. Dose/timing: 10–30 mg IV at induction; 69% received 20 mg. Sample: 112 total patients (methadone 58; control 54). Mean age 49 both groups. BMI slightly lower with methadone (28.1 vs 30.9). Procedures: Predominantly DIEP (~93%); mean operative time ~7.3 hours; similar between groups. Analgesic protocol:  Standard inpatient acetaminophen ± ketorolac. Early ketorolac use higher in methadone cohort; addressed in modeling and subgroup analyses. No routine regional blocks. Primary endpoint:  Daily inpatient opioid use (morphine milligram equivalents, MME) POD0–POD4. Secondary endpoints:  Intraoperative opioid use; acetaminophen/ketorolac exposure; frequency of antiemetic doses; length of stay. Statistics: Group tests plus two-step modeling—logistic regression for any opioid use and linear mixed-effects for daily MME; α=0.05.   Results Intraoperative opioids:  Additional short-acting opioids lower with methadone (4.1 vs 21.3 MME; ~81% reduction). Postoperative opioid use, methadone group vs control (mean MME): POD0: 18.8 vs 27.9 (p=0.06) POD1: 29.0 vs 44.4 (p=0.039) POD2: 22.9 vs 38.7 (p=0.04) POD3–4: no significant differences Cumulative inpatient:  87.4 vs 139.1 (p=0.03) Modeling: Methadone associated with a 26% decrease in daily MME after adjusting for POD, ketorolac dose, BMI, and laterality. Antiemetics: No difference in antiemetic dosing frequency. Length of stay:  3.2 vs 3.5 days; not significant.   Conclusion A single induction dose of methadone (typically 20 mg IV) reduces postoperative and total inpatient opioid requirements after autologous free-flap reconstruction without observed safety penalties or longer stays.   Strengths & limitations Strengths: Contemporary cohort during a defined practice change; standardized POD0–4 endpoints; appropriate mixed-effects modeling. Limitations: Retrospective, single-center, non-blinded; BMI imbalance and greater early ketorolac use; limited capture of adverse effects and pain scores.   Clinical relevance Plastic surgeons should consider a single induction dose of methadone 20 mg IV. It appears to be a pragmatic adjunct that lowers early and total inpatient opioid needs without negative safety effects. Implement with QT-risk screening, respiratory monitoring (RR, SpO₂/EtCO₂), and structured nursing sedation checks.   Critiques and questions Patient-centered outcomes:  Pain scores, sleep quality, mobilization milestones, and satisfaction were not reported; these would clarify functional benefits. Safety capture:  No opioid-related adverse events were recorded, but retrospective designs often miss respiratory events, QTc changes, or PACU delays. Prospective monitoring—including naloxone use, apnea episodes, and QTc—is warranted.

Authors:  Rothchild E, Saini N, Smith IT, Yom J, Ricci JA. Affiliation:  Albert Einstein College of Medicine; Donald & Barbara Zucker School of Medicine at Hofstra/Northwell (Radiology; Plastic Surgery). Journal:   Journal of Reconstructive Microsurgery  , October 2025 DOI : 10.1055/a-2717-4909. Key takeaways In 117 FFF patients, higher peroneal Bollinger scores independently predicted any 90-day complication (adjusted OR 2.23). Each doubling of Bollinger score increased complication risk by 123% and LOS by 27%. LLACS (lower-limb arterial calcification score) alone did not predict overall complications; signal only for fistula on univariate analysis. Combining Bollinger + LLACS identified a high-risk group with 8.36× higher odds of complications. Background Atherosclerosis and arteriosclerosis in donor vessels may compromise free-flap outcomes; yet, current CTA assessments are largely qualitative. Objective Test whether quantitative CTA-derived metrics, the peroneal Bollinger score  (luminal stenosis) and LLACS  (arterial wall calcification), stratify perioperative risk in fibula free flap (FFF) reconstruction. Methods Design/setting/LOE: Retrospective cohort, university-affiliated tertiary center; Aug 2021–Mar 2023; outcomes within 90 days. Level III. n: 117 consecutive FFF patients (mean age 56.8; mean BMI 27.0). Imaging protocol:  Routine lower-extremity CTA (single-arterial or triple-phase); 3-mm reformats; scores calculated on PACS. Scoring: Bollinger: segmental luminal stenosis on contrast phase, peroneal segment only. Scored 0–15 quantifying luminal stenosis severity/extent; higher = worse donor vessel quality. LLACS: Agatston calcification on non-contrast crural segment. Endpoints: Any complication (infection, hematoma, seroma, fistula, dehiscence, flap failure); length of stay (LOS). Stats: Scores log2(score+1) transformed; logistic regression for complications; Poisson for LOS; ROC cutoffs; combined risk strata (low/moderate/high). Adjusted for BMI, gender, smoking, ASA, CCI. Results Complications: 42/117 (35.9%); infection 23.9%; dehiscence 8.5%; fistula 4.3%; hematoma 3.4%; flap failure 3.4%. Median LOS 11 days. Primary outcome:  Increasing Bollinger score → any complication (unadj OR 2.10; adj OR 2.23, p=0.044). Flap failure (signal):  Unadjusted OR 3.38 (p=0.035); multivariate not estimable due to low events. LOS: Higher Bollinger associated with longer LOS (β=1.27, p<0.001). ROC cutoffs:  Bollinger 0.5 (OR 3.95 for any complication); LLACS 8.4 (NS). LLACS alone:  No independent association with overall complications; trend for fistula (unadj OR 1.25; adjusted borderline). Combined risk matrix:  High-risk (both above cutoffs) → OR 8.36 vs low-risk for any complication. Conclusion Quantitative CTA scoring—especially the peroneal Bollinger score —adds actionable risk stratification for FFF; pairing it with LLACS  further isolates a very high-risk cohort. Strengths & limitations Strengths: First quantitative, vessel-specific assessment in FFF; standardized CTA protocol; multivariable modeling; creation of a pragmatic risk matrix. Limitations: Retrospective, single-center; 90-day horizon only; exclusion of severe peroneal occlusions (selection bias); modest event counts limited failure modeling.   Critiques and questions Generalizability & thresholds:  Cutoffs (Bollinger ≥0.5; LLACS ≥8.4) have modest AUCs and wide CIs; they should be prospectively validated across centers with standardized CTA phases/recons. The highest complication-specific OR is risk for hematoma, which has questionable relationship to atherosclerotic occlusion. Causality vs correlation:  Bollinger is vessel-specific (plausible pathophysiology), but residual confounding (e.g., smoking intensity, diabetes severity) may persist despite adjustment. Event counts limit failure modeling. Implementation: Reporting Bollinger routinely requires minimal extra time if radiology templates include a peroneal segment score, but may be difficult for surgeons alone to implement.