Authors: Kuijpers CJ, Van Cann EM, Dieleman FJ, Bergsma JE, van Es RJJ, Rosenberg AJWP Affiliation: University Medical Center Utrecht, the Netherlands Journal: International Journal of Oral and Maxillofacial Surgery, January 2026 PMID: 41130859 Key takeaways Two venous anastomoses were associated with fewer takebacks and flap failures in free forearm flap head and neck reconstruction. Primary RFFF Revision: 8.8% with one vein vs 2.9% with two veins; P = 0.045. Failure: 8.8% with one vein vs 2.1% with two veins; P = 0.018. Full cohort (Ulnar and radial forearm flaps) Revision: 8.3% with one vein vs 2.8% with two veins; P = 0.031. Failure: 6.7% with one vein vs 2.0% with two veins; P = 0.033. A single venous anastomosis independently predicted vascular revision (adjusted OR 3.16; P = 0.039) and flap failure (adjusted OR 4.50; P = 0.015). Background Free forearm flaps are workhorse flaps for head and neck reconstruction. Vascular compromise remains uncommon but consequential, and the value of a second venous anastomosis remains debated. Objective Determine whether two venous anastomoses reduce surgical vascular revision and flap failure compared with one venous anastomosis in free forearm flap head and neck reconstruction. Methods Design: Prospective single-center cohort, 1998–2023; Level III evidence. Population: 364 patients, 368 free forearm flaps. 314 radial free forearm flaps (RFFF); 54 ulnar free forearm flaps (UFFF). 359/368 flaps (97.6%) were primary reconstructions. Primary analysis: 306 primary RFFF. One vein: 68. Two veins: 238. Full cohort analysis: All RFFF and UFFF, primary and secondary reconstructions (368). One vein: 120. Two veins: 248. Baseline balance: Primary RFFF groups were similar for sex, age, ASA class, T-stage, prior radiotherapy, and sampled smoking status. In the full cohort, one-vein patients were slightly older and UFFF were disproportionately in the one-vein group. Technique: Arterial anastomoses were end-to-end. Venous anastomoses were end-to-end or end-to-side; couplers were introduced in 2019 at surgeon discretion. One surgeon routinely completed a single venous anastomosis, while the other three routinely completed two. Venous drainage, full cohort: One-vein flaps used the deep system in 92.5%. Two-vein flaps used both superficial and deep systems in 89.3%. Internal jugular vein was the recipient vein in 93.2% of venous anastomoses. Outcomes: Surgical vascular revision and partial or total flap failure within 4 weeks. Statistics: Fisher exact testing for group comparisons; multivariable logistic regression in the full cohort adjusted for age and flap type. Results Primary RFFF subgroup Vascular revision: 6/68 (8.8%) with one vein vs 7/238 (2.9%) with two veins; P = 0.045; RR 3.00, 95% CI 1.04–8.63. Flap failure: 6/68 (8.8%) with one vein vs 5/238 (2.1%) with two veins; P = 0.018; RR 4.20, 95% CI 1.32–13.34. Overall primary RFFF failure: 11/306 (3.6%): 9 total and 2 partial failures. Revision etiology: 7 venous, 3 arterial, 3 combined arterial/venous. Revision timing: 10/13 revisions occurred on postoperative day 1. Salvage after revision: 10/13 revised flaps (76.9%) were salvaged. Full cohort Vascular revision: 10/120 (8.3%) with one vein vs 7/248 (2.8%) with two veins; P = 0.031; RR 2.95, 95% CI 1.15–7.56. Flap failure: 8/120 (6.7%) with one vein vs 5/248 (2.0%) with two veins; P = 0.033; RR 3.31, 95% CI 1.11–9.89. Overall flap survival: 355/368 (96.5%). Overall flap failure: 13/368 (3.5%): 11 total and 2 partial failures. Revision etiology: 10 venous, 4 arterial, 3 combined arterial/venous. Revision timing: 12/17 revisions occurred on postoperative day 1. Salvage after revision: 13/17 revised flaps (76.5%) were salvaged. UFFF: 2/47 one-vein UFFF failed; 0/7 two-vein UFFF failed. Multivariable analysis, full cohort Surgical vascular revision: one vs two veins, adjusted OR 3.16; 95% CI 1.06–9.44; P = 0.039. Flap failure: one vs two veins, adjusted OR 4.50; 95% CI 1.34–15.05; P = 0.015. Age and flap type were not significantly associated with either outcome. Conclusion In this 25-year prospective cohort, two venous anastomoses were associated with lower vascular revision and flap failure rates than one venous anastomosis. The authors conclude that a second venous anastomosis should be considered to reduce flap failure risk, while acknowledging that confirmation requires randomized trials or forearm flap-specific meta-analysis. Strengths Consecutive prospective cohort with clear early vascular endpoints. 25-year institutional experience. Separate, cleaner analysis of primary RFFF. Same directional signal in both the primary RFFF subgroup and full cohort. Limitations Nonrandomized allocation; number of veins was influenced by surgeon preference. Single-center, four-surgeon series over a long period with evolving technique and perioperative practice. Smoking was not prospectively documented and was only retrospectively sampled. Low event rates yield wide confidence intervals and limited subgroup power. Cannot determine whether benefit comes from simply adding a second vein or specifically from dual-system drainage. Venae comitantes size was not reported. Clinical relevance For RFFF or UFFF head and neck reconstruction, this study supports a low threshold for two venous anastomoses when anatomy and recipient vessels allow. The absolute flap failure reduction was clinically meaningful: 8.8% to 2.1% in primary RFFF and 6.7% to 2.0% in the full cohort. Editorial notes This study asks a long-debated question: does adding a second venous anastomosis reduce takeback and flap loss in head and neck reconstruction? In this cohort, one-vein flaps had consistently higher revision and failure rates in both the primary RFFF subgroup and the full cohort. The main caveat is confounding. Anastomosis number was not randomized and may reflect surgeon preference, era, flap type, recipient-vessel quality, ischemia time, or defect complexity. Failures were also not stratified by surgeon or early versus late study period. A key missing detail is venae comitantes caliber. A prior study (Yu 2011) suggested that deep-system drainage is reliable when the venae comitantes are at least 1 mm at the wrist incision, while smaller venae comitantes should prompt use of the superficial system. Kuijpers reports whether the deep and/or superficial systems were used, but not VC size. That distinction matters: the worse outcomes in one-vein flaps may reflect inadequate deep-system caliber, lack of second-system redundancy, or both. Because most two-vein flaps used both superficial and deep systems, this paper is best read as support for dual outflow when feasible, not definitive proof that any two equivalent veins are superior to one.

Authors: Fry BT, Schoel LJ, Howard RA, Thumma JR, Kappelman AL, Hallway AK, Ehlers AP, O’Neill SM, Rubyan MA, Shao JM, Telem DA Affiliation: University of Michigan, Ann Arbor Journal: JAMA Surgery, January 2025 PMID: 39535784 Key takeaways Component separation use surged: 1.6% to 21.4% of inpatient repairs from 2007–2021. Despite being used for more complex patients, component separation had lower 10-year operative recurrence than repairs without it. The absolute recurrence difference was modest: 11.2% vs 12.9% at 10 years, favoring component separation. High-volume surgeons had statistically lower recurrence, but the clinical effect was small: 11.9% vs 13.6%. Claims data cannot assess hernia size, anterior vs posterior release, true clinical recurrence, or appropriateness of technique use. Background Component separation is used to achieve midline fascial closure in large or complex ventral hernias. Its use has expanded rapidly, especially after renewed interest in posterior component separation and transversus abdominis release, but population-level long-term recurrence data have been limited. Objective To evaluate contemporary national trends in component separation use and compare long-term operative recurrence after ventral hernia repair with versus without component separation. A secondary aim was to determine whether surgeon component-separation volume was associated with recurrence. Methods Design: Retrospective cohort study using 100% Medicare administrative claims data; observational Level III evidence. Study period: January 1, 2007, through December 31, 2021; analysis performed 2024. Population: Adults 18 years or older undergoing elective inpatient ventral hernia repair. Hernia types included: Ventral, incisional, umbilical, and epigastric anterior abdominal wall hernias. Exclusions:◦ Prior hernia repair within at least 2 years before index operation.◦ Repairs coded as recurrent ventral hernia.◦ Non–Fee-for-Service Medicare patients.◦ Cases lacking concurrent CPT code for hernia repair. Exposure: Component separation identified by CPT code 15734 for myofascial release with concurrent ventral hernia repair coding. Primary endpoints: Annual proportion of inpatient ventral hernia repairs using component separation. Operative recurrence up to 10 years. Secondary endpoint: Operative recurrence after component separation stratified by surgeon volume. Recurrence definition: Subsequent hernia operation; this is operative recurrence, not true clinical recurrence. Statistical approach: Cox proportional hazards models adjusted for age, sex, race and ethnicity, comorbidities, hernia subtype, operative approach, mesh use, component separation, and year of surgery. Hospital-level clustering was used for the primary model; surgeon-level clustering was used for surgeon-volume analysis. Results Cohort characteristics Total patients: 218,518 Medicare beneficiaries. Component separation: 23,768 patients, or 10.9%. No component separation: 194,750 patients, or 89.1%. Mean age: 69.1 years. Sex: 58.5% female, 41.5% male. Median follow-up: 7.2 years. Compared with non–component separation patients, those receiving component separation were: Slightly younger. More often male. More comorbid, including higher obesity prevalence. More likely to undergo open repair. More likely to receive mesh. Utilization trend Total inpatient ventral hernia repairs decreased from 17,661 in 2007 to 7,330 in 2021. Component separation use increased from 1.6% in 2007 to 21.4% in 2021. Operative recurrence Adjusted cumulative operative recurrence was lower with component separation: 1 year: 0.7% with component separation vs 0.9% without. 3 years: 4.2% vs 4.9%. 5 years: 6.8% vs 7.9%. 10 years: 11.2% vs 12.9%; P = .003. This is notable because component separation is generally reserved for larger, more complex, or multiply recurrent hernias, which should bias toward higher recurrence rather than lower recurrence. Surgeon volume Surgeon-specific data were available for 23,627 component separations, performed by 6,480 surgeons. After Medicare volume adjustment: 72.4% of surgeons performed fewer than 2 component separations per year. 97.4% performed fewer than 5 component separations per year. High-volume surgeons were defined as the top 5% by annual component separation volume. Median annual volume: Low-volume group: 1.2 cases/year. High-volume group: 4.9 cases/year. Ten-year operative recurrence: High-volume surgeons: 11.9%. Low-volume surgeons: 13.6%. P = .004. Conclusion Component separation was associated with lower long-term operative recurrence after ventral hernia repair among Medicare beneficiaries, despite being used in patients likely to have more complex hernias. Surgeon volume was statistically associated with recurrence, but the absolute effect was small. Strengths Very large national cohort using 100% Medicare claims. Long median follow-up of 7.2 years, with recurrence tracked up to 10 years. Captures real-world practice across a broad range of surgeons, not just expert hernia centers. Quantifies both adoption trends and long-term recurrence, which prior studies often did not. Limitations Operative recurrence underestimates true clinical recurrence because it only captures patients who undergo another operation. Medicare claims lack key surgical details: hernia width, loss of domain, wound class, mesh plane, mesh type, fixation strategy, fascial closure quality, and prior abdominal wall history. Cannot distinguish anterior component separation, posterior component separation, and transversus abdominis release. Selection bias is unavoidable: patients selected for component separation likely differed in ways not measurable in claims. Surgeon-volume analysis is imperfect because Medicare volume was inflated to estimate all-payer volume. Lower recurrence in the component separation group could partially reflect inappropriate use in smaller hernias, where recurrence risk is already low.

Authors: Sidhu AS, Chopra AA, Ahmed S, Corpuz GS, Towfighi PN, Danforth RM, Lester ME, Hassanein AH Affiliation: Indiana University School of Medicine; Penn State College of Medicine Journal: Journal of Plastic, Reconstructive & Aesthetic Surgery, February 2026 PMID: 41308379 Key takeaways Analysis of the TriNetX multicenter EMR network showed that Class III obesity patients (BMI >40) had significantly higher 90-day wound debridement rates than Class I/II patients (BMI 30–40). GLP-1 agonist use (within 1 year before surgery) in BMI 30–40 kg/m² patients (class I and II obesity) was not associated with higher 90-day dehiscence, debridement, or revision rates. Patients with BMI 30–40 kg/m² who used GLP-1 agonists had lower 90-day revision surgery rates than both BMI 30–40 nonusers and BMI >40 nonusers. The study supports preoperative GLP-1–assisted weight loss for BMI >40 patients pursuing DIEP, but only as an association. Major missing data: actual weight loss, diabetes control, GLP-1 agent/dose/duration adherence, smoking, mastectomy timing, and flap-specific complications. Background Obesity increases wound morbidity after DIEP flap breast reconstruction, and BMI >40 kg/m² is often treated as a high-risk threshold for autologous reconstruction. GLP-1 agonists are increasingly used for obesity and diabetes, but their effect on DIEP-specific outcomes has not been well defined. Objective To evaluate whether GLP-1 agonist use is associated with improved 90-day outcomes in obese patients undergoing DIEP-based breast reconstruction, and to inform preoperative weight-loss counseling for patients with class III obesity. Methods Design/database: Retrospective cohort study using TriNetX, a global network of federated EMRs, that aggregates de-identified records from participating health care organizations. Study period: 2005–2025. Population: Adults ≥18 years undergoing DIEP-based autologous breast reconstruction. Procedure codes: CPT 19364; HCPCS S2066, S2067, S2068. Initial sample: 5,618 patients with 90-day follow-up. Groups: Propensity score matching was performed for age, race, and prior radiation. Group 1: GLP-1 agonist use within 1 year before surgery; BMI 30–40 kg/m² Group 2: No GLP-1 agonist; BMI 30–40 kg/m² Group 3: No GLP-1 agonist; BMI >40 kg/m² Outcomes: 90-day wound dehiscence, wound debridement, and revision surgery. Statistics: Chi-square testing for categorical variables; independent t-tests for continuous variables; 95% confidence intervals; significance set at P<0.05. Level of evidence: Retrospective database cohort; therapeutic level III. Results Baseline characteristics After matching, groups were similar for age, race, ethnicity, and prior radiation. Mean ages in the matched comparisons were approximately: Group 1 vs Group 2: 51.6 vs 51.7 years. Group 1 vs Group 3: 51.6 vs 51.3 years. Group 2 vs Group 3: 48.3 vs 48.2 years. 90-day wound dehiscence Group 1 vs Group 2: 16.6% vs 14.2%; RD −2.4%; 95% CI −9.3 to 4.5; P=0.500. Group 1 vs Group 3: 16.3% vs 19.2%; RD 3.0%; 95% CI −4.5 to 10.4; P=0.436. Group 2 vs Group 3: 13.8% vs 17.3%; RD 3.5%; 95% CI 0.5 to 8.0; P=0.087. No statistically significant dehiscence differences were observed. 90-day wound debridement Group 1 (GLP-1) had significantly lower rates (6.9%) than Group 3 (13.3%; $P=0.032$). Note: For the Group 2 vs. 3 comparison, an internal discrepancy exists between the text (4.6% vs 7.8%) and Table 2 (8.1% vs 11.8%), though both show a statistically significant increase in Group 3 (P=0.019). 90-day revision surgery Group 1 vs Group 2: 5.7% vs 11.4%; RD 5.7%; 95% CI 0.4 to 11.0; P=0.037. Group 1 vs Group 3: 5.4% vs 10.8%; reported as “OR: 5.4%” in the table, likely intended as risk difference; 95% CI 0.1 to 10.7; P=0.046. Group 2 vs Group 3: 10.0% vs 10.5%; RD 0.5%; 95% CI −3.8 to 2.9; P=0.780. Conclusion The authors conclude that patients with BMI >40 kg/m² seeking DIEP flap reconstruction should be counseled that weight loss with GLP-1 agonist therapy to a lower obesity class may decrease wound complications. In this dataset, GLP-1 agonist use in class I/II obesity was not associated with increased short-term wound morbidity. Strengths Large cohort of 5,618 DIEP reconstruction patients. Clinically relevant BMI/GLP-1 comparison groups. Limitations Key inference is indirect: the authors imply GLP-1 therapy could help BMI >40 patients lose weight into a lower-risk BMI class, but the study does not show that Group 1 was formerly BMI >40 or document actual weight loss. Retrospective database study; coding-dependent and cannot establish causation. Limited matching: age, race, and prior radiation only. No granular data on GLP-1 agent, dose, adherence, weight loss, diabetes control, smoking, or reconstruction details. Outcomes were broad administrative endpoints, not DIEP-specific complications. Editorial Notes The comparator structure is the central weakness. The clinically interesting cohort is BMI >40 patients treated with GLP-1 therapy who successfully lose weight before DIEP. That group is not directly studied. Instead, Group 1 is already BMI 30–40 while using GLP-1 agonists. Therefore, the conclusion about class III obesity patients “weight losing into” a lower obesity class is plausible but not directly proven. Residual confounding is substantial. GLP-1 users may differ systematically from nonusers: endocrine engagement, diabetes control, socioeconomic access, nutrition counseling, health literacy, and institutional optimization pathways. Those factors could reduce complications independent of the medication. The study does not separate weight loss from drug exposure. GLP-1 agonists could improve glycemic control, reduce inflammation, improve endothelial function, or simply select for patients who achieved meaningful preoperative weight loss. Without pre-GLP-1 BMI, day-of-surgery BMI trajectory, HbA1c, albumin/prealbumin, and diabetes status, mechanism cannot be assigned. The 90-day revision endpoint is difficult to interpret. Revision surgery within 90 days after DIEP may reflect a wound healing or flap complication, but may also represent a revision to improve cosmesis.

Authors: Aslami ZV, Leland CR, Strike SA, Forsberg JA, Morris CD, Levin AS, Tuffaha SH Affiliation: Johns Hopkins Hospital Journal: Plastic and Reconstructive Surgery, April 2024 PMID: 37199679 Key takeaways Symptomatic neuromas developed after 25% of en bloc musculoskeletal tumor resections. Neuropathic pain was even more common, occurring after 50% of resections. Younger age, multiple resections, and preoperative neuromodulator use independently predicted symptomatic neuroma formation. Documented nerve transection occurred in 26%, but distal numbness occurred in 42%, suggesting occult nerve injury is underrecognized. Neuroma prevention should be considered during oncologic tumor resection, especially when nerves are sacrificed or repeatedly dissected. Background Wide en bloc resection of sarcoma and other musculoskeletal tumors often requires nerve manipulation, transection, or sacrifice to obtain appropriate oncologic margins. When injured nerve ends are left untreated, painful neuromas can develop and contribute to chronic postoperative neuropathic pain. Although neuromas are well described after amputation and peripheral nerve surgery, their incidence after limb-sparing musculoskeletal tumor resection has been poorly defined. Objective To determine the incidence of symptomatic neuroma formation after en bloc resection of skeletal and soft-tissue tumors and identify patient or operative factors associated with postoperative neuroma-related pain. Methods Design: Single-institution retrospective cohort study at a high-volume sarcoma center, 2014–2019; Level III. Population: 231 adult patients undergoing 331 en bloc resections for skeletal or soft-tissue tumors of the trunk or extremities. Exclusions: Non-en bloc resections, primary amputations, pathologic fracture fixation, irrigation/debridement, age <18 years, and insufficient institutional follow-up. Follow-up: Mean follow-up 3.5 years among surviving patients; 75% had at least 2 years of follow-up. Primary outcome: Symptomatic neuroma, defined by clinical pain/Tinel sign or confirmatory testing plus sensory neuropathy in the expected nerve distribution at least 6 months postoperatively. Other outcomes: Neuropathic pain, distal numbness, postoperative neuromodulator requirement, analgesia duration, and pain scores when available. Statistics: Bivariate analysis and multivariable logistic regression controlling for demographic, oncologic, perioperative, and nerve-injury variables. Results Cohort: 331 resections; 91% sarcoma; 77% extremity tumors; mean resection size 12 cm. Nerve involvement/injury: Tumor nerve involvement occurred in 52%, intraoperative nerve manipulation in 51%, documented nerve injury in 34%, and nerve transection in 26%. Symptomatic neuroma: 81 resections met criteria, for an incidence of 25%. Broader neuropathic burden: Neuropathic pain occurred in 50%, distal numbness in 42%, and postoperative neuromodulator use in 40%. Pain burden: Among patients with documented pain scores ≥6 months postoperatively, median visual analog pain score was 6 in the neuroma group. Neuroma cases: Compared with no-neuroma cases, neuroma resections more often involved tumor-nerve involvement (72% vs 46%), intraoperative nerve manipulation (70% vs 44%), nerve injury (51% vs 28%), and subsequent tumor resection (43% vs 27%). Independent predictors of symptomatic neuroma: Age 18–39 years: aOR 3.6; P < 0.01. Age 40–64 years: aOR 2.2; P = 0.04. Multiple resections: aOR 3.2; P < 0.001. Preoperative neuromodulator use: aOR 2.7; P = 0.01. Protective association: Resections including deep fascia or muscle had lower neuroma risk (aOR 0.5; P = 0.045), likely because these cases injure fewer superficial sensory nerves, which are more prone to painful neuroma symptoms. Not independently associated: Radiotherapy, chemotherapy, resection size, and intraoperative nerve injury did not independently predict symptomatic neuroma after adjustment. Conclusion Symptomatic neuromas are common after en bloc musculoskeletal tumor resection and likely underdiagnosed. Younger patients, patients undergoing repeat resections, and patients already requiring neuromodulators for neuropathic pain represent a higher-risk group that may benefit from preoperative pain optimization and planned intraoperative nerve management. Strengths Large series, mean follow-up of 3.5 years. Limitations Retrospective design with heterogeneous documentation of pain, Tinel sign, nerve injury, and quality-of-life impact. Neuropathic pain in oncology patients is multifactorial; tumor recurrence, radiation, chemotherapy, scar compression, and baseline neuropathy are alternative explanations that cannot be fully excluded retrospectively. Only 8% of excisions with documented nerve transection received prophylactic neuroma prevention, limiting ability to assess comparative efficacy of different techniques. Clinical relevance A sacrificed nerve stump during tumor resection should be treated as a source of potential long-term morbidity. When a sensory or mixed nerve is transected and direct repair is not feasible, surgeons should consider a neuroma prevention strategy such as targeted muscle reinnervation, regenerative peripheral nerve interface, muscle implantation, or a vascularized denervated muscle target. The highest-risk patients are younger, undergoing repeat resections, or already requiring neuromodulators for neuropathic pain. These patients should have pain expectations discussed preoperatively, intentional nerve management planned intraoperatively, and a low threshold for postoperative referral to a peripheral nerve surgeon if focal neuropathic pain persists.

Authors: Bhakta P, Ayad S, Hossain MS, Black N, Pratt D, Bernard S, Hofstra RL, Araujo-Duran J, Tu C, Valente SA Affiliation: Cleveland Clinic Journal: The American Journal of Surgery, 2026 PMID: 41880699 Key takeaways Preoperative and intraoperative pectoralis nerve blocks provided similar early opioid-sparing analgesia after mastectomy. Block timing was not independently associated with PACU opioid use or morphine milligram equivalents (MME). More than one-third of patients required no opioids in the post-anesthesia care unit (PACU). Preoperative acetaminophen was the most consistent modifiable factor associated with lower opioid use. Intraoperative blocks may improve workflow without compromising early analgesic efficacy. Background Pectoralis nerve blocks (PNBs) are increasingly used in multimodal analgesia for mastectomy because they reduce opioid exposure and, compared with paravertebral blocks, PNBs offer simpler technique, shorter performance time, and lower complication rates.. However, the optimal timing of block placement remains unclear: anesthesia can perform ultrasound-guided blocks preoperatively, or surgeons can perform direct-visualization blocks intraoperatively after mastectomy. This study asks a practical perioperative question: does timing matter, or can institutions choose the approach that best fits workflow and available expertise? Objective To compare postoperative opioid requirements after preoperative versus intraoperative pectoralis nerve blocks in patients undergoing unilateral or bilateral mastectomy, with or without implant-based reconstruction. Methods Design: Retrospective single-institution cohort study, Cleveland Clinic, 2021–2022; Level III. Population: 122 mastectomy patients receiving pectoralis nerve blocks: preoperative block (n = 69) or intraoperative block (n = 53). Procedures: Unilateral or bilateral mastectomy, with or without immediate implant-based reconstruction. Interventions: Preoperative pectoralis nerve block: anesthesia-performed ultrasound-guided PECS I/II block in the preoperative holding area. Intraoperative pectoralis nerve block: surgeon-performed PECS I/II and field block under direct visualization after mastectomy, before closure. Local anesthetic: All patients received 20 mL of 1.3% liposomal bupivacaine plus variable-dose bupivacaine hydrochloride chosen by the treating clinician based on weight and formulation; bilateral cases received added saline for volume. Outcomes: PACU opioid use, PACU MME, intraoperative MME, pain score at first PACU analgesic, antiemetic use, PACU time, admission/discharge, and block-related complications. Statistics: Group comparisons plus multivariable regression adjusting for age, BMI, laterality, reconstruction, nodal surgery, preoperative medications, local anesthetic use, and operative time; subgroup analyses by unilateral versus bilateral mastectomy. Results Cohort: 69 preoperative blocks (57%) and 53 intraoperative blocks (43%); baseline demographics and cancer/prophylactic indications were similar. Safety: No block-related complications occurred in either group. Operative/workflow findings: Preoperative blocks took median 7 minutes; median time from block completion to incision was 59 minutes. Intraoperative blocks were consistently performed in less than 2 minutes. Opioid-free PACU recovery: 36.1% of all patients required no opioids in PACU. Unadjusted opioid use: More intraoperative-block patients received PACU opioids than preoperative-block patients (75.5% vs 55.1%; P = 0.033), but this difference did not persist after adjustment. Adjusted analysis: Block timing was not associated with PACU opioid use (PPNB OR 0.26; P = 0.13) or PACU MME (β −3.1 MME; P = 0.59). Acetaminophen signal: Omission of preoperative acetaminophen independently increased odds of PACU opioid use (OR 4.87; P = 0.010) and increased PACU MME (β +11 MME; P = 0.002). Subgroup analysis: No statistically significant opioid-use or MME differences by block timing in unilateral or bilateral mastectomy subgroups. PACU time: PACU stay was shorter with preoperative blocks (107 vs 165 minutes; P = 0.012), but discharge planning differed substantially between groups, limiting interpretation. Conclusion Pectoralis nerve blocks are safe and useful within multimodal mastectomy analgesia. In this cohort, preoperative versus intraoperative timing did not independently affect early postoperative opioid requirements, suggesting that block timing can reasonably be guided by institutional workflow, provider expertise, and patient experience. Strengths Directly compares a common anesthesia-performed preoperative strategy with a practical surgeon-performed intraoperative strategy. Uses multivariable adjustment and subgroup analyses to address important procedural differences. No block-related complications were observed, supporting safety of both approaches in this cohort. Limitations Retrospective design; block timing was determined by surgeon preference, creating confounding by practice pattern. Small cohort, especially after subgrouping by laterality and reconstruction type. No standardized enhanced recovery after surgery protocol; acetaminophen, scopolamine, dexamethasone, and opioid administration were provider-dependent. Outcomes were limited mainly to PACU analgesia; post-discharge opioid consumption, rebound pain, satisfaction, and chronic pain were not assessed. Reconstruction type and laterality were imbalanced between groups, reflecting surgeon practice rather than random allocation. Clinical relevance The practical takeaway is that pectoralis nerve blocks are effective components of multimodal analgesia after mastectomy, but the timing of block placement can be adapted to local workflow and provider expertise. Although preoperative blocks are theoretically appealing because they interrupt nociceptive signaling before incision, this study did not show a clear opioid-sparing advantage over intraoperative blocks placed near closure. The more actionable message is that block timing matters less than the consistency of the overall pain pathway. Preoperative acetaminophen was the most reliable modifiable factor associated with lower opioid use, reinforcing that regional anesthesia works best when embedded in a standardized enhanced recovery protocol rather than used as an isolated intervention.

Authors: Lisa AVE, Zeneli F, Mazzucco M, Barbieri B, Rietjens M, Lissidini G, Vinci V, Bartoletti M, Belati A, Bavaro D Affiliation: European Institute of Oncology and Humanitas University/IRCCS Humanitas Research Hospital, Milan Journal: Frontiers in Surgery, October 2024 PMID: 39469540 Key takeaways Gram-positive organisms dominated implant infections after breast reconstruction, especially Staphylococcus species and Staphylococcus aureus. Gram-negative infections were less common but clinically important, with Pseudomonas being the leading Gram-negative pathogen. Overweight and obese patients had proportionally more Gram-negative infections than normal-BMI patients. Positive preoperative MSSA/MRSA screening strongly predicted later Staphylococcus aureus infection. Culture-driven therapy: preoperative cultures were often concordant with intraoperative cultures and should inform early antibiotic selection. Background Infection after implant-based breast reconstruction can lead to hospitalization, treatment delays, implant loss, and reconstructive failure. Empiric antibiotic selection is often broad and institution-dependent because there are no universally accepted guidelines for infected breast prostheses. This study examines the microbiology of severe periprosthetic infections requiring explantation, with the goal of making empiric therapy and prevention strategies more rational. Objective To characterize the organisms responsible for periprosthetic infections after implant-based breast reconstruction, compare Gram-positive and Gram-negative infection patterns, and identify patient or surgical factors associated with specific pathogen groups. Methods Design: Multicenter retrospective cohort study at two major Italian breast centers, January 2018–March 2024; Level III. Population: 214 patients with clinically infected implant-based breast reconstruction requiring implant removal; 9,800 total reconstructions were performed during the study period, with 2% requiring explantation. Inclusion: History of mastectomy and implant-based reconstruction with clinical infection leading to surgical implant removal. Cultures: Preoperative periprosthetic fluid/tissue cultures and intraoperative implant/tissue cultures at explantation were reviewed when available. Variables: Age, BMI, smoking, diabetes, chemotherapy, radiotherapy, mastectomy type, axillary dissection, reconstruction type, drain duration, timing of explantation, MSSA/MRSA screening, antibiotic treatment, and culture results. Pathogen groups: Gram-positive, Gram-negative, mixed, fungal, and mycobacterial infections; multidrug resistance defined as resistance to ≥3 antibiotics. Statistics: Descriptive analysis with Chi-square/Fisher exact testing; significance set at P < 0.05. Results Cohort: Mean age 53.9 years; mean BMI 25.0; 31.8% received radiotherapy, 41.1% chemotherapy, and 21.5% were active smokers. Reconstruction: Immediate expander placement was most common (64.5%), followed by direct-to-implant reconstruction (20.1%) and expander-to-implant exchange (13.6%). Culture availability: Preoperative cultures were available in 120 patients; intraoperative cultures were available in 151 patients. Dominant organisms: Gram-positive bacteria were most common preoperatively (45.8%) and intraoperatively (53.7%). Staphylococcus species predominated, especially Staphylococcus aureus. Staphylococcus aureus: Isolated in 34.1% of preoperative cultures and 32.7% of intraoperative cultures. Gram-negative organisms: Less frequent but meaningful: 11.2% preoperatively and 17.3% intraoperatively. Pseudomonas was the most common Gram-negative organism. Patient factors: BMI correlated with pathogen class (P = 0.007). Normal-BMI patients had more Gram-positive infections, while overweight and obese patients had higher proportions of Gram-negative infections. Smoking: Smoking status correlated with pathogen distribution (P = 0.032); current and former smokers had more mixed infections. Reconstruction type: Two-stage reconstruction had more mixed infections than direct-to-implant reconstruction (P = 0.019). Culture concordance: Among patients with both positive preoperative and intraoperative cultures, results were concordant in 77.8% and partially concordant in 13.9%. Timing: Most infections were early, occurring within 6 weeks (62.2%); pathogen distribution did not significantly differ between early and late infections. Clinical presentation: Gram-negative infections were more likely to present with localized symptoms only rather than systemic symptoms (P = 0.040). MSSA/MRSA screening: Positive preoperative MSSA/MRSA swabs were strongly associated with later Staphylococcus aureus infection (60.0% vs 23.4% with negative swab; P < 0.001). Antibiotics: Fluoroquinolone-targeted therapy was associated with reduced intraoperative culture positivity (P = 0.008), although treatment selection was nonrandomized. Conclusion Severe periprosthetic infections after implant-based breast reconstruction requiring explantation are most often caused by Gram-positive organisms, particularly Staphylococcus aureus. However, Gram-negative organisms, especially Pseudomonas, remain important and should be considered when selecting empiric antibiotics, particularly in higher-BMI patients or patients with localized presentations. Strengths Multicenter cohort from two high-volume breast cancer centers. Includes both preoperative and intraoperative cultures, allowing assessment of culture concordance. Links pathogen class to clinically useful variables, including BMI, smoking, reconstruction type, symptoms, and MSSA/MRSA screening. Limitations Retrospective design with incomplete culture data and dependence on medical record accuracy. No data on surgical measures used for prevention of infection during implant placement, such as disinfection or antibiotic irrigation, which may have differed between the surgeons and centers. No data on drain placement and drain care/dressings. No data on routine antibiotic prophylaxis after implant placement. Only includes infections severe enough to require explantation, so findings may not apply to milder infections managed with antibiotics or salvage. Antibiotic selection was not standardized or randomized, limiting conclusions about treatment effectiveness. No detailed implant salvage outcomes, reconstructive abandonment rates, or long-term recurrence data. Institutional microbiology and resistance patterns may not generalize to other regions or hospitals. Clinical relevance Empiric therapy should include reliable Gram-positive coverage, with MRSA coverage guided by local risk and patient history. Add Gram-negative coverage, especially antipseudomonal coverage, when the patient is overweight/obese, has drainage or a fluid collection, has prior antibiotic exposure, or when local antibiograms support it. Preoperative MSSA/MRSA screening could be helpful: a positive result should trigger decolonization and should raise suspicion for Staphylococcus aureus if postoperative infection develops.

Authors: Aryanpour Z, Cronin JE, Shah A, Yang JH, Haas EJ, Winocour J, Kaoutzanis C, Mathes DW, Egan KG Affiliation: University of Colorado Anschutz Medical Campus Journal: Plastic and Reconstructive Surgery, April 2026 PMID: 41051269 Key takeaways Vitamin D insufficiency was common, affecting 40.8% of DIEP flap patients. 25-hydroxyvitamin D insufficiency was independently associated with surgical-site infection, donor-site seroma, and medical complications. The association persisted after adjustment for BMI, albumin, supplementation, operative time, and reconstruction timing/laterality. Vitamin D testing and supplementation may identify a low-cost, modifiable risk factor before abdominally based breast reconstruction. Background Vitamin D (25-OHD) insufficiency is increasing globally and estimated to be as high as 40% in the general population and even higher in the cancer population. Vitamin D is biologically plausible as a wound-healing factor because it influences immune function, inflammation, angiogenesis, and cellular differentiation. This study evaluates whether perioperative vitamin D insufficiency is associated with postoperative complications after DIEP flaps. Methods Design: Single-institution retrospective cohort study, 2015–2023 Population: 147 patients undergoing DIEP flap autologous breast reconstruction with perioperative 25-OHD testing within 3 months of surgery. Vitamin D insufficient: <30 ng/mL; n = 60 Vitamin D sufficient ≥30 ng/mL; n = 87 Outcomes: Return to OR, readmission, flap loss, surgical-site infection, donor-site seroma, recipient-site infection, delayed wound healing, fat necrosis, mastectomy flap necrosis, medical complications. Statistics: Univariate analysis and multivariable logistic regression adjusting for albumin, supplementation, BMI, operative time, reconstruction timing, and laterality. Results Mean age 51 years old; BMI 29.6 kg/m²; 60 patients (40.8%) were vitamin D insufficient. Albumin was similar between groups. Vitamin D insufficient patients more likely to undergo bilateral reconstruction (83.3% vs 64.4%) and immediate reconstruction (51.7% vs 24.1%). Vitamin D insufficiency was associated with surgical-site infection (OR 2.86; P = 0.04), donor-site seroma (OR 13.23; P < 0.01), and medical complications (OR 4.05; P = 0.02) in univariate analysis. On multivariate analysis, vitamin D insufficiency remained independently associated with surgical site infection (OR 4.63, p=0.02), recipient site infection (OR 5.88, p=0.02), donor-site seroma (OR 15.96, p=0.02), and medical complications (OR 6.51, p<0.01) Patients taking perioperative vitamin D had higher 25-OHD levels, but supplementation was not shown to reduce complications in this retrospective cohort. Conclusion Perioperative vitamin D insufficiency was independently associated with higher surgical-site infection, recipient-site infection, donor-site seroma, and medical complication risk after DIEP flap breast reconstruction. Vitamin D status may represent a simple, low-cost optimization target, but prospective studies are needed to prove that screening and supplementation improve outcomes.

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

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

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

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

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