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.

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

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

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

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

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