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

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

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

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

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

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

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

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

Authors : Yoo K-E, Lee M K, Chung J E, Lee K-T Affiliation : Dept. of Plastic Surgery, Samsung Medical Center; Dept. of Plastic Surgery, Ewha Womans University, Seoul, South Korea Journal : Journal of Plastic, Reconstructive & Aesthetic Surgery (JPRAS). 2025 PMID : 40779991 Key takeaways In 109 facial free flaps, distal recipient vessels  performed comparably to main trunk (superficial temporal/facial)  with no increase  in perfusion‑related complications. Adoption of distal vessels rose from 20.0% to 70.6%  over time ( p = 0.002 ), reflecting a deliberate practice shift. Distal vessel use enabled shorter pedicles  (67.9 vs 79.3 mm) and tighter flap‑to‑defect sizing  (ratio 1.09 vs 1.26), without longer OR time. Multivariable analysis: distal vessel choice not associated  with adverse events; diabetes and active smoking  were significant risk factors. Post hoc power was low (≤8.5%)  for primary endpoints; type 2 error risk is high. Background Superficial temporal vessels (STV) and facial vessels (FV) are reliable facial recipients but may be distant from defects, necessitating long pedicles, vein grafts, and larger flaps. Distal facial branches could reduce morbidity and expand flap choices if outcomes are equivalent. Objective Compare perioperative characteristics and outcomes of distal recipient vessels  versus main trunk STV/FV  in microsurgical facial soft‑tissue reconstruction. Methods Design/setting/LOE:  Retrospective cohort, single surgeon at a high‑volume tertiary cancer center; 2017–2023. n enrolled/analyzed:  109 patients (119 cases screened; 10 excluded). Mean age 64.2 ± 16.6  years; BMI 25.1 ± 4.3  kg/m²; 62.4% male . Inclusion/exclusion:  Included facial soft‑tissue free flap  reconstructions. Excluded neck reconstructions, pedicled/local flaps, and flow‑through cases using another flap’s pedicle as recipient. Single‑surgeon cases only. IRB approved. Groups: Main trunk  (STV/FV) n = 53  vs Distal vessel  branches/small vessels n = 56 . Main trunk vessels included the superficial temporal vessel (STV) or the facial vessel (FV) Distal recipients included branches off aforementioned main trunk vessels and were located more proximal to the defect.  Recipient selection was based on intraoperative identification and judged “reliable,” regardless of size. Recipient details (distal): Parietal branch  STV (n=31); others included occipital (n=7), angular (n=5), inferior labial (n=5), supratrochlear (n=4),  plus isolated cases (infraorbital, dorsal/lateral nasal, transverse facial). Flaps used:  ALT most common overall; distal group favored SCIP/TDAP/other perforator  flaps; main trunk group used more ALT/RFF . Endpoints:  Primary— perfusion‑related complications  (total/partial loss; threatened flap). Secondary—overall flap‑site complications, reoperation, hospital LOS, operative metrics. Statistics:  χ²/Fisher’s for categorical; t‑test/Mann–Whitney for continuous; univariable and multivariable logistic regression for independent associations; temporal trend across quartiles; post hoc power for primary endpoints; α = 0.05. Results Temporal adoption:  Distal recipients increased from 20.0% → 70.6%  across quartiles ( p = 0.002 ). Operative characteristics:  Distal group had shorter pedicles  (67.9 ± 31.2 vs 79.3 ± 28.3 mm; p = 0.045 ) and smaller flap‑to‑defect ratios  (1.09 ± 0.11 vs 1.26 ± 0.30; p < 0.001 ). Total OR time  and ischemia time : no significant differences . Complications:  Overall flap‑site complications 14.7%  (9/53 main trunk vs 7/56 distal; p = 0.509 ). Perfusion‑related : 7.3%  (4/53 vs 4/56; p = 0.936 ). Total flap loss : 3/109 (2.8%)  (1 vs 2; p = 0.591 ). Reoperation  for flap‑site issues: 11.9%  (7 vs 6; p = 0.688 ). Length of stay:  Trend toward shorter LOS  in distal group ( 10.3 ± 5.5 vs 13.0 ± 9.7  days; p = 0.079 ). Vein availability:  In 10 cases , distal artery suitable but no vein —used main‑trunk vein with interposition grafts . Outcomes similar with/without conversion. Regression:  Distal vessel use not independently associated  with perfusion‑related complications; diabetes  and active smoking  were significant predictors. Power:  Post hoc power for detecting group differences: flap failure 8.5% ; perfusion‑related complications 5.1% . Conclusion For facial free‑flap reconstruction distant from STV/FV, using nearby distal recipient vessels is feasible and safe  in experienced hands, without higher perfusion‑related complication rates  and with advantages in tissue economy and flap selection . Strengths:  Largest cohort to date evaluating distal facial recipients; single‑surgeon technical consistency; clear definitions; multivariable adjustment; meaningful operational metrics (pedicle length, sizing). Limitations:  Retrospective, single‑surgeon/single‑center (external validity); nonrandom allocation with high potential for  selection bias ; small numbers per specific distal vessel; low statistical power  for rare events; lack of routine preop vascular imaging; no standardized vein diameter data. Clinical Relevance This report presents the refinement of a distal recipient‑vessel approach for head and neck free flap reconstruction, not a robust analytical study. In experienced hands, distal branches are feasible and does not markedly raise flap complications. They allow shorter pedicles, smaller flaps and presumably less surgical trauma, which can improve outcomes. Although underpowered for statistics, this series encourages surgeons to consider distal recipient options.

Authors : AlQhtani A Z, Lee N, Kim H, Eom J S, Han H H Affiliation : Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea Journal : Journal of Reconstructive Microsurgery, Sept 17, 2025 PMID : 40962273 Key takeaways Optimal ICGA timing differs by flap type in a rat model. Perforator flaps: best necrosis prediction at ~50 seconds post-injection. Random flaps: ~150 seconds (p = 0.0028). Mean necrosis: 47.3% (perforator) vs 55.1% (random). Findings support flap-specific ICGA protocols; translation to humans requires validation. Background ICG angiography (ICGA) is widely used for flap perfusion assessment, but optimal interpretation timing is inconsistent across studies and may vary by flap type. Objective Identify flap-specific ICGA timing windows that best predict eventual tissue necrosis for perforator and random pattern flaps in a controlled preclinical model. Methods Design/setting/LOE:  Preclinical randomized rat study; single-lab experiment (Level of Evidence not applicable/animal study). Sample:  Sixteen male Sprague–Dawley rats randomized: perforator (n=8) vs random flap (n=8). Deaths during experiment: 1 perforator, 2 random → analyzed ≈13 animals. Flap models:  Perforator: 6×4 cm² lower abdominal flap based on superficial epigastric artery; Random: 3×10 cm² dorsal flap without dominant perforator. ICG protocol:  0.25 mg ICG via femoral vein; near-infrared images every 10 s (0–60 s) then every 30 s to 4 min. Hypoperfusion = fluorescence <30% of peak. Outcome measures:  (1) ICGA hypoperfused area (time-resolved), (2) gross necrosis on postoperative day 7; compared alignment over time. Statistics:  Mann–Whitney U where applicable; interval-censored survival with EMICM; generalized log-rank; proportional hazards regression; α<0.05. Results Alignment window (ICGA vs final necrosis): Perforator flaps: necrosis matched ICGA boundary between 10–50 s, most often 30–40 s. Random flaps: alignment occurred 30–150 s, most commonly 120–150 s. Best single time points:  50 s (perforator) vs 150 s (random) for necrosis prediction; generalized log-rank p = 0.0028; proportional hazards p = 0.0032. Necrosis burden (mean ± SD):  47.3% ±14.3 (perforator) vs 55.1% ±16.1 (random). Attrition:  3 intra-study deaths (1 perforator, 2 random) excluded; remaining animals analyzed for timing correlation. Conclusions ICGA interpretation should be flap-specific: early time points (~50 s) best predict necrosis in perforator flaps, whereas later windows (~150 s) are optimal in random flaps; adopting tailored timing may reduce false positives and improve intraoperative decisions. Strengths:  Randomization to flap type; predefined imaging cadence; objective intensity threshold (<30% peak); time-to-event modeling aligns ICGA signal with hard endpoint (necrosis day 7). Limitations:  Animal model; non-identical flap sizes (6×4 vs 3×10 cm²) may affect perfusion dynamics; small N with attrition; gross necrosis without histopathology; device-/platform-specific considerations. Clinical relevance For intraoperative ICGA in human surgery, consider earlier reads for perforator flaps and extended observation for random (e.g., mastectomy) flaps. Differences in human physiology and ICGA platforms mean these exact seconds are not directly transferrable; the concept—tailor timing to flap vascular topology—is the actionable takeaway. Questions/critiques Potential biases/confounders:  Different flap surface areas and tissue thickness may alter perfusion kinetics; lack of temperature/vasoactive control reporting; gross (not histologic) necrosis assessment; small cohorts reduce precision of “best time” estimates. External validity:  Human flaps vary (vasopressors, comorbidities, radiation, thickness) and clinical systems may acquire later time windows; translation needs prospective clinical validation by flap class.

Authors : Teotia SS, Troia TC, Kim LJ, Haddock NT Affiliation : Department of Plastic Surgery, University of Texas Southwestern Medical Center Journal : Plastic and Reconstructive Surgery – Global Open, December 2025 PMID : 41377927 Key takeways In patients with prior abdominoplasty (n=39), LAP was used more often than PAP and yielded higher BREAST-Q satisfaction across most domains. Overall flap-related complication rates were similar between prior-abdominoplasty and no-abdominoplasty cohorts despite higher BMI and comorbidities in the former. Within the prior-abdominoplasty subgroup, LAP had markedly higher postoperative satisfaction with breasts, psychosocial well-being, and chest physical well-being than PAP; sexual well-being trended higher. LAP bilateral cases took longer operative time than PAP. Background After abdominoplasty, the abdomen is frequently unavailable for deep inferior epigastric perforator (DIEP) flaps. Surgeons must pivot to alternative donor sites. The LAP and PAP flaps are leading second-line options, but direct comparative data in the specific context of prior abdominoplasty are limited. Objective Compare outcomes and patient-reported satisfaction (BREAST-Q) of LAP versus PAP autologous breast reconstruction in patients with a history of full abdominoplasty. Methods Design : Retrospective single-institution cohort (2011–2023); Level of Evidence III. Population : All microsurgical breast reconstructions (n=264); subset with prior full  abdominoplasty (n=39) analyzed against those without (n=225). Mini-abdominoplasty or liposuction-only patients were excluded. Flap selection : Individualized; no rigid algorithm (patient anatomy/preferences). Exposures : LAP vs PAP flaps within the prior-abdominoplasty subgroup. Endpoints : Postoperative complications (fat necrosis, infection, seroma, hematoma, wound issues, flap loss) and BREAST-Q domains (satisfaction with breasts; psychosocial; physical well-being: chest; sexual well-being). Responses at standard intervals were included regardless of timing. Statistics : χ² for categorical variables; independent-samples t test for continuous variables; α=0.05. Results Cohort characteristics Prior-abdominoplasty patients were older and had higher BMI and more hypertension/diabetes than those without abdominoplasty. Despite higher risk profiles, any flap complication  was similar between groups. Flap usage and configuration (prior-abdominoplasty subgroup) LAP favored over PAP after 2018. Configurations: bilateral LAP (n=18), unilateral LAP (n=6), bilateral PAP (n=11), unilateral PAP (n=2), plus small stacked combinations. Operative time Bilateral LAP mean 516.6 ± 84.9 minutes vs bilateral PAP 365.2 ± 101.8 minutes (longer for LAP). Complications (prior-abdominoplasty vs no-abdominoplasty) Any flap complication: 38.5% vs 32.4% (NS). Specific events (fat necrosis, infection, seroma, hematoma, flap loss) were not significantly different; breast wound dehiscence trended higher with prior abdominoplasty. BREAST-Q (prior-abdominoplasty LAP vs PAP) Satisfaction with breasts: 74.6 (LAP)  vs 45.8 (PAP) [P < 0.001] . Psychosocial well-being: 77.6  vs 54.0 [P < 0.001] . Physical well-being—chest: 88.0  vs 51.0 [P < 0.001] . Sexual well-being: 59.8  vs 47.4 [P = 0.942]. Conclusion For patients with prior abdominoplasty seeking autologous reconstruction, LAP provides higher patient-reported satisfaction than PAP with comparable complication rates, at the expense of longer operative time. LAP should be strongly considered as a primary alternative donor site in this scenario. Strengths Focused, clinically relevant subgroup (post-abdominoplasty) where DIEP is unavailable. Inclusion of BREAST-Q adds patient-centered perspective. Limitations Retrospective design without standardized flap-selection algorithm → High potential for selection bias. BREAST-Q limited to responders; timing heterogeneous. Single institution; learning-curve effects likely (LAP adoption after 2018) and may influence operative time and outcomes. Modest abdominoplasty subgroup sample (power constraints for complication comparisons and sexual well-being domain). Clinical Relevance Counseling : In post-abdominoplasty patients, particularly those with truncal adiposity, LAP may yield superior satisfaction and chest comfort compared with PAP. Trade-offs : Expect longer OR time with LAP; plan resources accordingly. Complication profiles are similar, supporting shared decision-making driven by anatomy, desired volume/shape, and scar preferences. Planning : Given equivalent safety signals, prioritize donor site matching to volume and contour goals; discuss scar visibility (LAP: back/flank; PAP: posterior thigh) but emphasize that breast shape/volume may dominate satisfaction. Critiques and questions Selection bias : Without a prespecified algorithm, were PAPs chosen for patients with poorer lumbar perforators or less truncal adiposity, inherently disadvantaging PAP satisfaction? A prospective algorithmic comparison would help. Volume/contour hypothesis : The authors suggest LAP’s volume/contour advantages drive higher satisfaction in higher-BMI/truncal adiposity phenotypes. Future work should quantify delivered flap volume, projection, and breast anthropometrics to validate mechanisms.

Authors:  Ahmed S, Zaidi SS, Fisher CS, Ludwig KK, Imeokparia FO, VonDerHaar RJ, Bamba R, Danforth RM, Hassanein AH, Lester ME.  Affiliation:  Div. of Plastic Surgery and Breast Surgery, Indiana University, Indianapolis, IN.  Journal:   Plastic and Reconstructive Surgery  (Ideas & Innovations), 2025;156:642e–645e. PMID:  40403293 Key takeaways In patients who developed mastectomy skin necrosis (MSN), prophylactic absorbable beads lowered 90-day surgical-site infection: 6.3% vs 35.6% (P=0.0178).  Tissue expander (TE) removal was reduced with beads: 6.3% vs 33.9% (P=0.0310).  Surgical management needed less often with beads: 50.0% vs 73.5% (P=0.1604).  Findings support placing absorbable antibiotic beads at TE insertion to mitigate infection/implant loss if MSN occurs.  Background MSN occurs in 7–30% of TE reconstructions and can harbor bacteria, driving infection and implant loss. Absorbable antibiotic beads have been described to reduce TE infection when used prophylactically following immediate breast reconstruction but the effect in the presence of skin necrosis is not clear. Objective Evaluate whether prophylactic absorbable calcium sulfate antibiotic beads reduce infection and implant loss among patients who later develop MSN after immediate prepectoral TE reconstruction.  Methods Design/setting:  Single-center cohort analysis of immediate prepectoral TE reconstructions that developed MSN. Groups: Group 1: absorbable calcium sulfate antibiotic beads at time of TE placement Group 2: no beads  Sample:  61 patients (75 breasts): beads 12 pts/16 breasts; no beads 49 pts/59 breasts.  Endpoints (90 days):  Surgical-site infection (SSI), device removal, and surgical management of MSN Stats:  Fisher’s exact test and independent-samples t tests  Results Surgical-site infection:   6.3% (1/16 breasts) with beads vs 35.6% (21/59 breasts) without beads, P=0.0178.  TE loss:   6.3% (1/16 breasts) with beads vs 33.9% (20/59 breasts) without beads, P=0.0310.  Surgical management of MSN:  50.0% (6/12 breasts) with beads vs 73.5% (36/49 breasts) without beads, P=0.1604.  Conclusion Among TE patients who develop MSN, prophylactic absorbable antibiotic beads placed at initial reconstruction were associated with significantly fewer infections and TE loss.  Strengths & limitations Focused MSN cohort answers a common, high-risk clinical scenario.  Clear, clinically meaningful endpoints (SSI, explantation) with absolute counts.  Retrospective, single-center design with small, imbalanced groups (16 vs 59 breasts) limits power and adjustment for confounders.  Clinical relevance Consider prophylactic absorbable antibiotic beads at time of TE insertion, especially when skin-flap perfusion is marginal, given the observed decrease in SSIs and explants among the subset that later develops MSN.