Authors: Hendrickson SA; Dusseldorp JR. Affiliation: Chris O’Brien Lifehouse Hospital, Sydney, Australia. Journal: Plastic and Reconstructive Surgery — Ideas and Innovations, October 2025 PMID: 40178538 Summary The article describes a medial paramuscular (MPM) approach to deep inferior epigastric artery (DIEA) pedicle dissection performed from the deep surface of the rectus muscle via a midline or paramedian fascial incision. The technique aims to minimize intramuscular splitting and motor nerve injury while enabling routine rectus diastasis plication during donor-site closure. Technique overview Preoperative CT angiography (CTA) for perforator mapping. Identification of medial-row perforators with a short intramuscular course and adequate caliber when using a single-perforator DIEP. Initial short fascial window around the target perforator (not paramedian/midline). Intramuscular perforator dissection through this "lateral" fascial incision. Author recommends placing a vessel loop or glove to mark the intramuscular perforator Make a midline or bilateral paramedian fascial incision (often ~12–15 cm; Y-extension around the umbilicus as needed). Deep-surface dissection of the DIEA: ligation at the external iliac origin, caudal-to-cranial pedicle elevation, and delivery through the initial lateral fascial incision. Standard microvascular anastomosis to recipient vessels. Closure strategy Lateral fascial incisions closed primarily. Routine rectus diastasis plication in epigastric, umbilical, and hypogastric zones to reinforce the midline and to imbricate/"hide" the long midline fascial incision. Mesh not used routinely; considered when preoperative examination suggests true abdominal wall weakness or hernia. Evidence presented Five-year bilateral series reported lower clinically significant abdominal bulge after minimally invasive, deep-surface pedicle harvest methods (robotic or MPM) compared with traditional long intramuscular splits. Traditional bilateral intramuscular split: 4/61 patients (6.6%) with clinically relevant bulge. Minimally invasive (robotic or MPM): 0/32 patients (0%) with clinically relevant bulge. Retrospective, nonrandomized series. Novelty and context Deep-surface pedicle harvest and nerve-sparing principles are established in robotic DIEP. The contribution here is an open, nonrobotic method that seeks similar nerve-sparing advantages while integrating routine diastasis plication so that a long midline fascial incision does not translate into clinical morbidity. A midline-incision approach has been described elsewhere; this report formalizes a practical protocol pairing exposure with planned plication. PMID: 39703378 Advantages Nerve-sparing pedicle harvest without robotic or other specialized equipment. Anatomically aligned with medial-row, short-course perforators favored in standard DIEP planning. Donor-site synergy: diastasis plication reinforces the midline and neutralizes the effect of the longer fascial incision. Useful for bilateral or bipedicled reconstructions where long muscle splits increase denervation risk. Limitations and risks Evidence quality is limited to retrospective, noncomparative experience; outcome reporting combines robotic and MPM cohorts. Requires a substantial midline/paramedian fascial incision, with attendant risks (peritoneal entry, bowel injury) in reoperative abdomens. Benefit is anatomy-dependent; long intramuscular perforator courses may still necessitate more extensive splitting. Potential hemodynamic considerations of tight plication (e.g., intra-abdominal pressure) should be monitored; data specific to DIEP patients are limited. Integration with abdominal wall reconstruction principles Midline plication converts diastasis into a reinforced linea alba, redistributing forces when tissue quality is acceptable and lateral closures are tension-appropriate. For true hernias or markedly attenuated fascia, a lower threshold for prophylactic mesh in a retrorectus or preperitoneal plane is reasonable, individualized to intraoperative findings. Practical application Consider in patients with rectus diastasis ≥2 cm and favorable medial-row, short-course perforators on CTA, especially in bilateral or bipedicled cases or in centers without robotic capability. Plan the incision and plication together so that exposure and reinforcement are coordinated steps. Bottom line The MPM approach is a pragmatic, anatomy-driven open technique that seeks the nerve-sparing benefits of deep-surface pedicle harvest without robotics and couples exposure with routine diastasis plication to maintain donor-site integrity. It is useful when CTA demonstrates a medial-row dominant perforator with short intramuscular course, allowing a single-perforator DIEP. This represents yet another technique in the reconstructive armamentarium to minimize donor-site morbidity when patient anatomy allows.

Authors: Graziano, Plotsker EL, Amakiri UO, Shammas RL, Vingan PS, Mehrara BJ, Stern CS, Nelson JA, Matros E, Allen RJ Affiliations: Memorial Sloan Kettering Cancer Center Journal: Plast Reconstr Surg , 2025. PMID: 39737758 Key takeaways Among 278 unilateral DIEP patients, median length of stay (LOS) was 2.25 days; most were discharged on POD2. Longer LOS was linked to older age, longer operative time, history of diabetes or immunologic disease; longer operative time was also linked to delayed milestone completion. Implementing ERAS and switching the institutional goal from POD2→POD1 reduced median LOS (2.25→1.54 days) without complication increase; 51% met the new POD1 goal vs 82% meeting old POD2 goal; earlier discharge cohorts met milestones sooner. Background Discharge timing after DIEP is a multifactorial decision based on pain control, patient expectations, and monitoring for complications. Enhanced recovery after surgery (ERAS) protocols after DIEP flaps using TAP (transversus abdominis plane) blocks, multimodal analgesia/antiemetics, early mobilization, and explicit milestone education/posters have pushed patients toward shorter stays. Because most return-to-OR events have been shown to occur within 24 hours, properly selected patients may be safe for as short as a 24-hour hospital stay. Objective Evaluate current time to discharge and identify factors associated with prolonged LOS. Evaluate the safety/feasibility of a POD1 discharge goal versus POD2 within a mature ERAS program. Methods Design/setting: Single-center retrospective cohort at Memorial Sloan Kettering; Level III. Cohort: 278 unilateral DIEP  reconstructions (Jan 2021–Dec 2022). Grouped by actual discharge: POD0–1, POD2, POD≥3. Intervention: TAP blocks (exparel/marcaine/injectable saline), early ambulation, multimodal prophylaxis, clinical milestones (PT eval, flap health, pain, nausea/vomiting, vital signs, incisions, JP output) and educational milestones (drain care, use of lovenox, incision care, showering); goal changed from POD2→POD1 in Sept 2022. Variables of Interest: Demographics (age, race/ethnicity, smoking status, BMI, insurance type, travel distance, marital status), operative details (operative time, timing of reconstruction, ASA classification), comorbidities (diabetes, CVD, HTN, immunologic disease, COPD, psychiatric conditions) Endpoints: LOS, post-op complications, time to complete clinical, and educational milestones   Results LOS distribution: Median LOS 2.25 days; 8.9% POD0–1, 74.8% discharged POD2, 16.2% POD≥3; POD≥3 group with higher smoking incidence and greater operative time Predictors of longer LOS (multivariable): Increasing age β=0.01 days/year (P=0.037); increasing operative time β=0.09 days/hour (P<0.001); history of diabetes β=0.35 days (P=0.004); history of immunologic disease β=0.30 days (P=0.007). Milestones: Increased operative time was only variable associated with prolonged time to milestone completion (R 2 =0.11). Earlier discharge cohorts completed milestones earlier (Pearson’s correlation coefficient 0.524-0.585, p<0.001). Discharge-goal subanalysis: POD1 goal (n=35) vs POD2 goal (n=243) Median LOS 1.54 vs 2.25 days; 51.43% vs 82.30% met goal; complication rates similar. Complications by actual discharge day: POD≥3 had higher rates of hematoma (13.3% vs 3.9%), delayed wound healing (4.4% vs 0%), mastectomy skin flap necrosis (8.9% vs 0.5%), and urgent-care visits (15.6% vs 5.3%) versus POD2. Microvascular safety: No returns to the OR for microvascular compromise among early discharges; flap failure not increased.   Conclusion Within a mature ERAS program, LOS after unilateral DIEP is largely driven by operative time, age, diabetes, and immunologic disease; setting a POD1 goal shortens stay without increasing complications, but only about half of patients achieved POD1 discharge. Strengths & Limitations: Uniform ERAS pathway with explicit milestone tracking; thorough multivariable modeling of LOS and milestone timing Retrospective single-center study design and small sample size with POD1-goal subgroup (n=35) and only 18 patients successfully discharged POD1; limit data quality and power to show differences between groups ERAS intervention is multi-part; difficult to attribute LOS reduction to any one specific sub-intervention This was a very healthy population with median BMI 27.2 and low rates of comorbidities. The median operative time 5.8 hours. Thus, these findings may not be widely applicable to comorbid patients or centers with longer operative times Future directions Prospective validation of a POD1 pathway with preoperative risk scoring (age, diabetes, immune disease) and explicit expectation-setting; define practical age thresholds, quantify cost benefits. Clinical relevance Can certainly aim for shorter hospital stays with implementation of ERAS, but important to risk-stratify preoperatively (age, diabetes, immunologic disease), optimize OR effiency/decrease OR time, and check institutional data to look at rate of microvascular complications beyond 24H to see if POD1 is safe target. For successful targeted discharge date, need to set firm, expectations with patients and staff and reinforce milestone education to support safe, early discharge.

Authors: Nakamura S, Yasunaga Y, Nakao J, Araki J, Mori H, Ogino A Affiliations: Shizuoka Cancer Center and Toho University Omori Medical Center, Japan Journal: PRS Global Open, 2025. PMID: 40757385. Key Takeaways The authors identified four external jugular vein (EJV) confluence types (based on CT): SCV — EJV drains to the subclavian vein (47%) Venous angle — EJV drains at the IJV–SCV junction/angle (37%) IJV — EJV drains into the internal jugular vein (11%) Non‑EJV (absent) — no identifiable EJV on CT (5%) In 16% (IJV + non‑EJV) of cases, the EJV would be rendered an unsuitable recipient if the IJV is sacrificed. Patterns did not differ by side or sex; 46% had matching bilateral patterns. Background Recipient‑vein selection drives free‑flap success. Variable EJV terminations can jeopardize outflow when IJV is ligated or resected. Objective Define a CT‑based classification of EJV confluence patterns and estimate suitability of the EJV as a recipient vein for microvascular anastomosis. Classification system SCV type : EJV drains to the subclavian vein  distal to the venous angle. Interpretation : Generally safe for EJV anastomosis even if IJV is resected. Venous angle (VA) type : EJV drains at the junction of IJV and SCV . Interpretation : Usually safe; drainage remains independent of the IJV trunk. IJV type : EJV drains into the internal jugular vein  proximal to the venous angle. Interpretation : At risk —resection/ligation of IJV can eliminate EJV outflow; plan alternate recipient. Non‑EJV type : No identifiable EJV on CT. Interpretation : Treat as unavailable ; select a different recipient vein. Methods Design/LOE : Single‑center retrospective observational CT study; Level of Evidence IV. Setting/dates : Cancer center; April–November 2022. Participants : 50 consecutive patients (100 neck sides); excluded prior head/neck surgery. Imaging : Contrast‑enhanced CT (≈2‑mm slices); EJV traced from origin to confluence. Endpoints : Primary—distribution of confluence types. Secondary—side/sex differences; bilateral symmetry; clinical suitability. Statistics : Descriptive; chi‑square for categorical comparisons (α=0.05). Results Distribution : SCV 47%, venous angle 37%, IJV 11%, non‑EJV 5%. Bilateral symmetry : Same pattern both sides in 23/50 patients (46%). Side/sex : No significant differences by laterality or sex. Clinical context : Two patients required IJV resection; both had SCV‑type EJV. Suitability : IJV‑type and non‑EJV together ≈16%—potentially unsuitable for EJV anastomosis if IJV is sacrificed. Conclusion Most EJVs terminate in the SCV or venous angle, but ~1 in 6 sides are IJV‑type or lack an EJV and may be unsafe for EJV‑based anastomosis—supporting routine preoperative CT mapping and proactive recipient‑vein planning. Strengths & Limitations Strengths : Practical, CT‑based schema; explicit surgical implications; bilateral assessment in consecutive cohort. Limitations : Single‑center retrospective design; small sample; CT may miss very small EJVs; no systematic intraoperative confirmation. Clinical Relevance Before head/neck free flaps, check for the presence and branching pattern of the EJV on CT . If IJV‑type  or non‑EJV , line up an alternate recipient if there is a chance of ipsilateral IJV sacrifice.

Authors: Spoer DL, Berger LE, Huffman SS, Lava CX, Dekker PK, Ko JA, Truong BN, Towfighi PN, Ghyasi N, Fan KL, Song DH Affiliations: MedStar Georgetown University Hospital Journal: Plast Recnostr Surg. Oct 2024. PMID 38470977 Key Takeaways LIFT (Latissimus Dorsi with Immediate Fat Transfer)  offers similar patient-reported outcomes (PROs) compared to abdominally based free flaps (Ab-FF)  with fewer reoperations and shorter hospital stays. LIFT is associated with a higher seroma rate but reduced risk of dehiscence, operative complications, and need for revisions. BREAST-Q scores at 1 year were similar across domains between both groups. LIFT is a viable alternative for patients unsuitable for microsurgical reconstruction or with contraindications to abdominal based free flaps   Background Autologous breast reconstruction is favored for long-term satisfaction. While Ab-FFs are considered the gold standard for breast reconstruction, they require microsurgical expertise. LIFT, combining a latissimus dorsi flap with fat grafting, offers autologous reconstruction without the need for microsurgery expertise or abdominal donor site.   Objective To compare postoperative complications and PROs at 1 year between LIFT and Ab-FF techniques.   Methods Design:  Retrospective cohort study (2017–2022) Patients:  281 total (408 breasts) All patients were primary breast reconstruction and offered both LIFT vs. Ab-FF 70 patients (86 breasts) underwent LIFT 211 patients (322 breasts) underwent Ab-FF (DIEP, MS-TRAM, or SIEA) Outcomes:  Complication rates, reoperations, and BREAST-Q domains at multiple intervals Results Demographics:  LIFT patients were older (56 vs. 53 years; P <0.001) with higher comorbidity index. Ab-FF patients received more adjuvant and neoadjuvant chemo/RTX Operative Time:  LIFT reduced mean OR time by 113 mins (unilateral) and 96 mins (bilateral) Hospital Stay:  LIFT had significantly shorter stays (median 1 vs. 3 days; P <0.001) Complications: Seroma:  Higher in LIFT (19% vs. 4%; P <0.001) Dehiscence & Takebacks:  Lower in LIFT (dehiscence 9% vs. 17%; takebacks 0% vs. 6%; P <0.05) Reoperations and Fat Grafting:  Lower in LIFT (revision 52% vs. 75%; fat grafting 36% vs. 53%; P <0.01) Multivariable Analysis: LIFT independently associated with increased odds of seroma (OR 5.05; P <0.001) LIFT predicted decreased odds of dehiscence (OR 0.37), reoperation (OR 0.37), and fat grafting (OR 0.59) BREAST-Q Outcomes:   Survey response from 116/281 (41%) patients Survey given at 1, 3, 6, and 12 months 96/211 (46%) – Ab-FF 20/70 (29%) – LIFT At 12-month mark there was no statistically significant difference between all domains on BREAST-Q data Ab-FF tended to increase with time Physical wellbeing was lower initially for LIFT patients   Conclusion LIFT offers an effective alternative to Ab-FF with fewer complications, shorter recovery, and comparable satisfaction. It is especially useful for patients in which microsurgery or abdominal flap harvest is not possible.   Strengths and Limitations Strengths:  Comprehensive multivariable analysis Limitations:  Retrospective design, incomplete BREAST-Q follow-up (41% response rate). Captures both revision reconstruction and primary reconstruction Future Directions Prospective, multicenter trials with broader demographic inclusion and long-term follow-up are needed to validate LIFT’s applicability. Clinical Relevance Often considered a salvage option, the LD flap (with fat grafting) enables fully autologous reconstruction without microsurgery, offering comparable patient satisfaction to abdominal free flaps with fewer complications and shorter recovery. These findings suggest LIFT may be underutilized and merits consideration as a first-line option in a broader range of patients.

Authors: Fung E, Godek Mm, Roth JM, Montalmant KE, Yu BZ, Hnderson PW Affiliations: Icahn School of Medicine Mount Sinai Journal: Journal of Plastic, Reconstructive & Aesthetic Surgery, 2025. PMID: 40156946   Key takeaways   TXA reduces postoperative hematoma formation after mastectomy ± reconstruction (2.4% vs 5.5%; OR 0.40; P = 0.001).  TXA shortens drain duration by ~1.2 days and reduces 24-hour drain output by ~42 mL.  No significant effect on seroma or surgical-site infection (SSI).  Safety: no increase in thromboembolism across 947 patients; one pulmonary embolism occurred in controls.  TXA mechanism of action: lysine analogue; indirectly inhibits fibrinolysis (i.e. stabilizes clot) by blocking plasminogen → plasmin activation  Dosing/administration: 1g IV (82%), 1g in 1L irrigation solution (18%)  Contraindications/adverse events: avoid in hypercoagulable patients; may lower seizure threshold and cause visual disturbances  Background   Use of tranexamic acid (TXA) in surgery is increasing; however, existing literature lacks high quality analysis. Outcomes specific to mastectomy and reconstruction require critical analysis to inform standardized protocols.  Objective   Quantify TXA’s effect on hematoma, seroma, SSI, drain output, and drain duration in mastectomy with and without reconstruction.  Methods   Design: PRISMA-guided systematic review and meta-analysis.  Studies: 13 included in final review: RCTs (4), prospective comparative studies (5) and retrospective comparative studies (4) focusing on TXA in setting of mastectomy w/wo breast reconstruction  2,115 patients (44% received TXA)  Setting/procedures: mastectomy ± reconstruction (mastectomy alone (8 studies), autologous (2) or implant-based (3)).  Interventions: TXA via IV (82%) or topical (18%), typically intraoperative (83%); some continued postoperatively; dose varied (0.5-3g; most commonly 1 g).  Endpoints: primary—hematoma and seroma; secondary—SSI, drain output, drain duration, thromboembolic events, explantation.  Statistical approach: Mantel–Haenszel for odds ratios; inverse-variance for mean differences; subgroup analyses by study type, reconstruction type, and route.  Results   Hematoma: 2.4% TXA vs 5.5% control; OR 0.40 (95% CI 0.23–0.70), P = 0.001 .  Seroma: 23% TXA vs 21% control; pooled OR 0.82 (95% CI 0.61–1.10), P = 0.19 .  29% of seromas in TXA required aspiration vs 43% of seromas in control  Subgroup analysis by study type, reconstruction type or route of TXA did not find significant differences between the study and control groups   Drain duration: average drain duration 6.6 ± 5.9 days in the TXA cohort vs 7.6 ± 5.3 days in control (mean difference −1.2, P = 0.03 ).  24-hour drain output: significantly lower with TXA (pooled reduction ~41.8 mL).  SSI: no significant change with TXA.  Thromboembolism: none reported in TXA groups across four studies (n = 947); one pulmonary embolism in controls.  Implant explantation (subset): 8 TXA vs 18 control.    Conclusion   Across mastectomy ± reconstruction, TXA reduces hematoma, shortens drain duration, and lowers early drain output without increasing seroma, SSI, or thromboembolic events.    Strengths & limitations   Largest, most current synthesis focused on mastectomy ± reconstruction.  Consistent hematoma benefit with improved drain-related outcomes.  Heterogeneity in timing, route, and dose; several studies underpowered for secondary endpoints.  Limited adverse-event reporting; need for standardized dosing and safety reporting.    Future directions   Standardize TXA dosing, route, and timing; include flap-specific safety endpoints and cost-effectiveness analyses in future RCTs.    Clinical relevance   For mastectomy ± reconstruction, consider a simple intraoperative TXA regimen (commonly 1 g IV) to reduce hematoma risk and potentially enable earlier drain removal. Counsel that seroma and SSI rates appear unchanged, and screen patients for thrombotic risk before use.

Farmer RL, et al. Journal of Reconstructive Microsurgery, 2025. PMID: 39496317. Key takeaways No statistically significant increase in microvascular complications or flap loss with irradiated vessels; comparator underpowered (nonirradiated n=13; wide CI). Perforator recipient vessels did not increase microvascular complications or flap loss as compared with named axial recipient vessels. Postoperative venous events were most common. Plan robust outflow (two veins when feasible) and vigilant early monitoring. ≥2 venous anastomoses were performed in ~41% of cases   Background   Neoadjuvant radiation with limb-sparing surgery for lower-extremity soft tissue sarcoma often creates large defects requiring free flap reconstruction. Whether irradiated or perforator recipient vessels increase microvascular risk is unclear.    Objective Determine if recipient vessel radiation status (irradiated vs nonirradiated) and recipient vessel type (named axial vs unnamed perforator) affect microvascular complications in lower-extremity sarcoma free-flap reconstruction.    Methods Design/LOE: Single-center retrospective cohort (Therapeutic Level III), 2009–2020. Population: 201 patients (204 flaps) after lower-extremity soft tissue sarcoma resection; both irradiated and nonirradiated recipient vessels included. Radiation protocol: Typically 50.4 Gy in 28 fractions; surgery performed ~9 weeks after radiation. Cohorts: 188 (94%) reconstructions used irradiated recipient vessels; 13 (6%) used nonirradiated vessels; irradiated cohort older (mean ~59 vs ~43 years). Interventions: All included patients underwent free-flap reconstruction (fasciocutaneous, musculocutaneous, chimeric). Standard perioperative anticoagulation (intraoperative IV heparin; postoperative SQ heparin). Staged mobilization: bedrest 48 h → sit day 3 → room ambulation day 4 → hallway walks day 6 with ACE wraps. Endpoints: Intra-/postoperative microvascular complications needing reoperation, anastomotic revision, flap loss, or delayed healing; vessel type and radiation status recorded. Statistics: χ² and two-sided t-tests; odds ratios with 95% CI; α = 0.05.    Results   Overall microvascular complications: 28/204 flaps (13.7%). Timing/type: Postoperative 23/28 (82.1%); venous events 20/28 (71.4%); arterial thrombosis 4/28 (14.3%); anastomotic rupture/bleeding 4/28 (14.3%). Irradiation status: 27/191 (14%) complications with irradiated vessels vs 1/13 (7.6%) without; OR 1.98 (0.25–15.82); P = 0.52. Flap survival 98.9% with irradiated vs 100% without. Vessel type: No significant difference in microvascular complications between named axial and perforator recipient vessels (named 19/133 vs perforator 9/71; OR 0.87 (0.37–2.04); P = 0.75). Anatomic distribution: Lower leg had the most events; complications distributed across groin to foot. Practice patterns: Irradiated vessels used in ~94% of cases; perforators common in anterior/medial and posterior thigh; mean recipient vein diameter ~2.4 mm.    Conclusion   In lower-extremity sarcoma reconstruction, anastomosis to irradiated recipient vessels or to perforating branches was not associated with a statistically significant increase in microvascular complications or flap failure; interpretation should be cautious given the small sample of nonirradiated recipient vessels (n = 13).   Strengths & limitations Large single-center series focused exclusively on lower-extremity sarcoma reconstructions. Consistent neoadjuvant radiation regimen enhances internal consistency. Small nonirradiated comparator (n = 13) and age imbalance may limit power and confound comparisons. Radiation status was based on operative/clinical documentation rather than vessel histology.  Clinical relevance For difficult lower-extremity sarcoma defects, surgeons can proceed with free flaps using irradiated vessels or perforating branches as recipients without evidence of higher flap failure. Ensure robust venous drainage and vigilant postoperative monitoring given the predominance of venous events.

Visconti, et al.  J Plast Reconstr Aesthet Surg , 2022. Key takeaways In 76 advanced-stage (ISL 2b or 3) limb lymphedema cases, lymphaticovenular anastomosis (LVA) yielded a positive 1-year composite outcome (a meaningful limb-size reduction and a lower compression class/less use) in 59.7%. A negative hand/foot sign (spared dorsal hand/foot edema) predicted functional lymphatics and better outcomes; a positive sign (edema of the dorsal hand/foot) predicted worse outcomes. Ultra–high-frequency ultrasound (UHFUS) mapped functional lymphatics when lymphoscintigraphy and ICG showed absent channels, enabling LVA in advanced disease. Upper- and lower-limb circumferences significantly decreased at 1 year.   Background Advanced-stage lymphedema is often managed with vascularized lymph node transfer (VLNT) or debulking because contrast-based mapping can miss functional lymphatics. High- and ultra–high-frequency ultrasound can visualize channels despite dermal backflow, potentially expanding candidacy for LVA.   Objective Evaluate LVA efficacy in advanced-stage secondary limb lymphedema and introduce a simple clinical predictor (“hand/foot sign”) to identify patients with salvageable functional lymphatics.   Methods Design/setting: Multicenter consecutive series (Rome, Italy; Kamogawa, Japan), Jan 2016–Jan 2019. Patients: 76 advanced-stage (ISL 2b/3) secondary upper-limb (ULL, n = 47) or lower-limb (LLL, n = 29) lymphedema; refractory to conservative therapy. Imaging/mapping: Lymphoscintigraphy and ICG lymphography (all with severe dermal backflow; few/any visible channels) plus UHFUS to localize lymphatics/venules. Intervention: LVA (mean 3 anastomoses UE; mean 4 LE). Hand/foot sign (index test): Negative (spared):  Stemmer sign present, no/minimal  pitting on dorsum hand/foot. Positive (not spared):  Puffy dorsum with pitting or non-pitting edema. Outcomes (1 year):  Quantitative—sum of circumferences (SC) change; Qualitative—compression garment class/use; Composite positive  if both good–excellent.   Results Limb size reduction:  ULL SC 143.8 → 133.3 cm; LLL SC 202.7 → 176.5 cm (both p = 0.0001). Composite success:  45/76 (59.7%) positive at 1 year. Predictive value of hand/foot sign: Negative sign strongly associated with functional lymphatics  and larger postoperative SC reductions. Positive sign increased odds of poor–mediocre circumference outcome (OR ~5), need for higher compression (OR ~17), and adverse composite  outcome (OR ~17). Intraoperatively, a negative sign corresponded to large, functional s0/s1 lymphatics (>0.6 mm) with good–excellent SC reduction.   Conclusion Even when dye-based imaging shows no channels, UHFUS can reveal functional lymphatics in advanced-stage lymphedema , enabling effective LVA for many patients; the bedside hand/foot sign  helps triage candidates.   Strengths & limitations Usage of practical, reproducible clinical sign and modern ultrasound mapping to expand application of LVA in advanced stage patients Advanced, homogeneous severity (ISL 2b/3 with dermal backflow V) of patients Case-series design without controls; circumference (not volumetry) predominated; postoperative compression was not tightly documented.   Clinical relevance Do not  exclude advanced-stage patients from LVA solely on “negative” dye studies. Use the hand/foot sign  at bedside to flag likely functional channels and apply UHFUS-guided  mapping to plan LVAs. Expect meaningful limb-size reduction in appropriately selected cases.

Lo Torto F, et al. J Clin Med , 2024. PMID: 39124636. Background:  AFG is widely used in breast reconstruction for contour correction, volume restoration, and improved aesthetics. Its oncologic safety, especially risk of loco-regional recurrence (LRR), remains debated. Methods: Systematic review per PRISMA, covering PubMed, Embase, Web of Science, and Cochrane (Nov 2023–Mar 2024). Included 40 studies (14,078 patients: 7,619 with AFG; 6,459 without AFG). Outcomes focused on LRR. Results: LRR rates: 3.15% with AFG vs 5.3% without AFG . No overall increase in recurrence risk with AFG; some studies showed lower recurrence rates. Meta-analysis: Unmatched studies:  slight nonsignificant increase (RR 1.10, 95% CI 0.84–1.45). Matched studies:  significant reduction in recurrence risk with AFG (RR 0.71, 95% CI 0.55–0.91). Meta-regression: radiotherapy was associated with improved outcomes in AFG patients (p = 0.009). No significant effect from invasive histology or follow-up length. Conclusions: AFG does not increase breast cancer recurrence risk  and appears oncologically safe. Possible protective effect in radiotherapy-treated patients. Evidence limited by heterogeneity, retrospective designs, and lack of standardized reporting. Well-structured, prospective, long-term studies are needed. Take-home: Current data support oncologic safety of AFG in breast reconstruction , with no increased risk of recurrence and potential benefit in selected patients. Counsel on imaging-visible changes (oil cysts, calcifications) and coordinate surveillance—especially in radiated breasts.

Low JE, J Plast Reconstr Aesthet Surg, 2025. PMID: 40493997 Problem Prioritizing reconstructed breast shape over proximity of ipsilateral SIEV to the IMVs can lead to orientation-limited reach for venous congestion cases. Venous congestion remains a meaningful threat in 2-15% of DIEP flap breast reconstruction cases for which the SIEV can serve as a valuable lifeboat. Solution In unilateral cases, the authors advocate prophylactic banking of the contralateral superficial inferior epigastric vein (SIEV) from the discarded hemiabdomen to reduce operative time in takebacks. Technique and Advantages Harvest the contralateral SIEV after inset of DIEP flap. The length of SIEV graft can be 12-20cm if dissected into the flap. Flush the SIEV graft with heparinized saline on wet gauze to demonstrate patency, side branches, or vessel injury. Bank the SIEV graft in the lateral pocket of the DIEP flap close to the axilla Be sure to mark or orient the ends of the vein graft! Banking the SIEV graft can reduce operative time during emergency take backs and may help avoid additional scars from other vein graft options (i.e. cephalic turn down). The banked graft can be used to reach IMV or axillary system vein branches. Conclusion In unilateral DIEP reconstruction, pre-emptive banking of the contralateral SIEV is a low-cost, low-morbidity maneuver that equips the team with a long autologous vein graft for rapid venous supercharging or pedicle extension if congestion arises—expediting salvage and preserving aesthetics, particularly in delayed/radiated (higher risk) breasts.

Plastic and Reconstructive Surgery, October 2024 Key Takeaways All three flap types (DIEP, PAP, LAP) yield similar patient satisfaction scores and complication profiles. DIEP flaps had higher breast wound and necrosis rates. PAP flaps showed higher donor-site infections and wounds. LAP flaps were most often rated superior in matched aesthetic head-to-head comparisons. Background Autologous breast reconstruction offers higher satisfaction than implants. While DIEP flaps are the standard, PAP and LAP flaps provide viable alternatives for patients with abdominal contraindications. Objective To compare DIEP, PAP, and LAP flaps in terms of postoperative complications, patient-reported satisfaction (BREAST-Q), and aesthetic outcomes using crowdsourced ratings. Methods Retrospective review of 150 patients (50 per flap type) who underwent bilateral reconstruction. Propensity matching based on age, BMI, comorbidities, and treatment exposure. Assessed postoperative complications, BREAST-Q scores, and crowdsourced aesthetic ratings of matched postoperative images. Results Demographics:  No significant differences in age, BMI, race, or comorbidities. Complications: DIEP: Higher breast wound (22%) and necrosis (14%) rates. PAP: Higher donor-site wounds (32%) and infections (14%). LAP: Higher donor-site seromas (20%). BREAST-Q Scores:  No statistically significant differences. LAP had higher satisfaction in breast and psychosocial domains; PAP scored higher in sexual well-being. Aesthetics:  DIEP flaps had highest average global rating. However, LAP flaps were most frequently preferred in matched pair image comparisons (P < 0.05). Complication / Outcome DIEP (%) PAP (%) LAP (%) Breast Wound 22% 4% 6% Flap Necrosis 14% 0% 2% Donor-Site Infection/Wound 4% 32% 14% Aesthetic Preference 33% 18% 49% Conclusion All three flaps are safe and yield high satisfaction. LAP flaps may provide superior aesthetic results when matched for patient morphology. Flap choice should be tailored to patient anatomy, goals, and surgeon experience. Strengths and Limitations Strengths:  Propensity matching, multi-dimensional outcome assessment, inclusion of patient-reported and aesthetic outcomes. Limitations:  Single-center design, potential bias from surgeon experience, unequal BREAST-Q response numbers. Future Directions Evaluate progressive tension sutures for LAP donor sites. Explore impact of surgical experience and technique evolution over time. Long-term studies assessing aesthetics and function across broader populations. Clinical Relevance This study supports a tailored approach in flap selection. Surgeons should consider donor-site characteristics and aesthetic potential in line with patient-specific goals and body morphology.

Malagón & Yamamoto, Ann Plast Surg, 2025; PMID 40400056 Key takeaways • High‑frequency ultrasound (HFUS, 18 MHz) identified lymph vessels in 99.7 % of 349 incisions  across 97 limbs. • Mean lymphatic / venous diameters: 0.65 mm vs  0.81 mm . • Limb volume index fell 281.2 → 267.6  (LEL, P = 0.002) and LeQOLiS improved 48.3 → 21.9 (P < 0.001). • Median incision length 1.97 cm ; LVA took 21.7 min  on average. • Standardized eight‑step HFUS protocol streamlines pre‑op mapping for supermicrosurgical LVA.   Background   Lymphovenous anastomosis efficacy hinges on locating functional collectors and reflux‑free veins. Ultrasound offers a radiation‑free, bedside alternative to ICG or MR lymphangiography but lacks standardization.   Objective   Describe a reproducible HFUS mapping technique and evaluate its reliability, accuracy, and clinical impact in secondary lower‑limb lymphedema.   Methods Design: Technical description plus retrospective analysis (Level III). Setting: Two tertiary centers, Barcelona & Tokyo. Patients: 61 patients (all women), 97 lower limbs, secondary lymphedema post‑gynecologic cancer; mean age 56.7 y; BMI 23.5. Intervention: Pre‑op HFUS (18 MHz linear probe) mapping the day before surgery; markings for lymph vessels & superficial veins. Eight‑step HFUS protocol:   Transducer  – choose ≥15–18 MHz linear probe. Preset  – select “superficial abdomen/vessels” setting. Mode, depth & gain  – use B‑mode; depth ≈2 cm; gain ~66. Anatomical layers  – identify dermis, subcutaneous tissue, superficial fascia. Focus – set focal zone just below superficial fascia. Lymph vessel  – trace hypoechoic channel with halo; confirm no Doppler signal. Vein  – locate nearby compressible superficial vein, similar or larger diameter. Marking – mark lymph (green) and vein (blue) paths; plan incision perpendicular. Surgical data: incision number/length, LVA count, time per LVA, vessel diameters, detection rate. Outcomes: LEL index  – limb‑volume index derived from circumferential measurements (lower score = less edema); recorded pre‑ and post‑LVA. LeQOLiS  – Lower‑Extremity Lymphedema Quality‑of‑Life Score (0–100, higher = worse QoL); self‑reported pre‑/post‑op. Statistics: Paired t‑test; significance p < 0.05.   Results Detection: ≥1 lymph vessel found in 99.7 % of incisions. Workload: 3.7 ± 1.9 LVA/limb; 21.7 min per anastomosis. Incisions: 1.97 cm (1.2–3.8). Volumes/QoL: LEL −13.6 points; LeQOLiS −26.4 points (both significant). No major complications.   Conclusion  An eight‑step HFUS protocol enables reliable pre‑operative mapping, allows small incisions and short operative times, and is associated with meaningful limb‑volume reduction and QoL gains.   Strengths & limitations   High vessel detection and objective postoperative improvements. Detailed practical protocol enhances reproducibility. Operator‑dependent; single sonographer/device. No imaging comparator or randomized control. Only secondary lower‑limb cases—generalizability limited.   Future directions  Assess learning curves across centers, compare HFUS with UHFUS/ICG‑L in RCTs, and extend to primary and upper‑limb lymphedema.   Clinical relevance  Plastic surgeons can integrate HFUS mapping into outpatient workflow to target >0.6 mm lymph vessels and adjacent low‑pressure veins, shortening operations, improving identification of functional lymphatics, and improving outcomes.

Casey et al, J Reconstr Microsurg, 2025. PMID: 39362641 Key takeaways In 300 DIEP candidates, lumbar fat thickness was ≥2.5× abdominal in low‑BMI women (20 mm vs 47 mm; ratio 2.53). Lumbar‑to‑abdominal thickness ratio fell with rising BMI (2.53 → 1.85; p < 0.001). Fourth lumbar perforator lies consistently 6.4–9.5 cm lateral to the spinous process (mean 7.7 cm) , independent of BMI. Findings support the lumbar artery perforator (LAP) flap as a volume source when abdomen and thighs are lean.   Background Low‑BMI patients often lack sufficient abdominal or thigh donor fat for standard autologous breast reconstruction. Clinical observation suggests lumbar fat persists even when BMI is low.   Objective Quantify lumbar vs abdominal subcutaneous thickness across BMI strata and map lumbar perforator location to evaluate LAP flap feasibility in thin patients.   Methods Design: Retrospective cohort, CT angiography analysis (Level III). Setting: Royal Marsden Hospital, London; DIEP database 2012‑2019. Participants: 300 women split into three equal cohorts of 100 each—low BMI (<22 kg/m²), normal BMI (22–24 kg/m²), and high BMI (>30 kg/m²)—scheduled for DIEP reconstruction; mean age 52 y. Measurements: Subcutaneous thickness at the level of the umbilicus and the L4-5 interspace; in addition, the distance of the fourth lumbar perforator was recorded. Endpoints: Ratio of lumbar‑to‑abdominal thickness (primary); perforator coordinates (secondary). Statistics: One‑way ANOVA for group comparisons; significance p  < 0.05.   Results Thickness: Low‑BMI abdominal 20 mm vs lumbar 47 mm (ratio 2.53); normal 2.12; high 1.85.  Skeletal landmark: Fourth LAP consistently lay 7.7 ± 0.7 cm lateral to the spinous process across BMI groups (p = 0.09).  Surface landmark: Midline‑to‑LAP distance expanded with BMI (8.6 cm low vs 10.7 cm high; p < 0.001), reflecting greater soft‑tissue girth.    Conclusion CT data confirm that even very thin women retain proportionally greater lumbar subcutaneous fat relative to abdominal fat and have reliable perforator anatomy, justifying the LAP flap as a primary autologous option when abdominal or thigh tissue is insufficient.   Strengths & limitations Large imaging cohort with equal BMI distribution. Objective CTA measurements and statistical rigor. Retrospective; no actual LAP reconstructions or clinical outcomes measured.  Volume extrapolated from 1‑D thickness; true flap weight not calculated. Single‑center UK cohort of DIEP candidates—generalizability limited.   Future directions Prospective studies should correlate CTA‑predicted lumbar volume with harvested LAP flap weight, refine patient selection algorithms, and report surgical/esthetic outcomes.   Clinical relevance When a low‑BMI patient lacks abdominal or PAP donor volume, pre‑operative CTA should include lumbar imaging; a LAP flap can reliably yield autologous tissue with acceptable donor contour.