Search this site

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

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

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

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

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

Authors:  Kunkler IH, Russell NS, Anderson N, et al. Journal:  New England Journal of Medicine, November 6, 2025 Trial:   SUPREMO randomized phase 3 Key takeaways In intermediate-risk post-mastectomy patients (pT1–2N1; pT3N0; or pT2N0 with grade 3 and/or lymphovascular invasion), chest-wall RT did not improve 10-year overall survival vs no RT (81.4% vs 81.9%; HR 1.04, 95% CI 0.82–1.30). RT halved chest-wall recurrences (HR 0.45, 95% CI 0.20–0.99) but the absolute reduction was <2% over 10 years (1.1% vs 2.5%). No differences in disease-free or distant metastasis–free survival (10-yr DFS 76.2% vs 75.5%; DMFS 78.2% vs 79.2%). In a triple-negative subgroup, overall survival was worse with RT (HR 1.91, 95% CI 1.06–3.46). Background Whether to irradiate the chest wall after mastectomy for intermediate-risk disease (pT1–2N1; pT3N0; or pT2N0 with grade 3 and/or lymphovascular invasion) is controversial in the modern systemic therapy era. Objective Test whether omitting chest-wall RT compromises overall survival at 10 years in intermediate-risk patients treated with contemporary multimodality therapy. Methods Design/setting: International, randomized, phase 3 trial; chest-wall RT (40–50 Gy) versus no chest-wall RT. Primary endpoint: overall survival (OS). Secondary: chest-wall/locoregional recurrence, DFS, DMFS, safety. Median follow-up 9.6 years. Population: 1607 randomized; ITT: 808 RT, 799 no RT; intermediate-risk post-mastectomy; high uptake of chemotherapy (~85%) and endocrine therapy (~79%); trastuzumab ~20%. Results Overall survival (primary):  10-yr OS 81.4% (RT) vs 81.9% (no RT); HR 1.04 (P=0.80). Chest-wall recurrence:  1.1% vs 2.5%; HR 0.45 (95% CI 0.20–0.99). Absolute benefit <2%. Locoregional recurrence:  2.7% vs 4.5%; HR 0.61 (95% CI 0.36–1.03). Distant metastasis–free survival:  78.2% vs 79.2%; HR 1.06 (95% CI 0.86–1.31). Disease-free survival:  76.2% vs 75.5%; HR 0.97 (95% CI 0.79–1.18). Subgroups: No OS interaction by nodal status or age; triple-negative patients had worse OS with RT (HR 1.91, 95% CI 1.06–3.46). Safety: Overall toxicities were low; pulmonary events were uncommon but numerically higher with RT (e.g., grade ≥2 lung events 13 vs 5). Cardiac deaths ≤1% in both groups. Conclusion In intermediate-risk patients after mastectomy receiving modern systemic therapy, routine chest-wall RT did not improve 10-year OS, while offering a small absolute reduction in chest-wall recurrences. Strengths & limitations Strengths: Large, international RCT with long follow-up and high systemic-therapy adherence; robust RT quality assurance. Limitations: Initiated nearly two decades ago; evolving axillary and neoadjuvant practices; event rates lower than anticipated, limiting power for small effects. Clinical relevance For pT1–2N1 or selected pN0 with high-risk features after mastectomy, these data support considering omission of chest-wall RT when regional nodal RT is not otherwise indicated, given no OS/DMFS benefit and very low baseline chest-wall failure. Be cautious in triple-negative disease: the signal for worse OS with RT warrants multidisciplinary discussion and alignment with emerging de-escalation trials. When nodal irradiation is needed, modern planning can treat nodes while avoiding the chest wall/reconstruction, aligning with reconstructive goals and minimizing late effects. Commentary SUPREMO reflects today’s reality: excellent systemic therapy drives very low chest-wall recurrence, shrinking the marginal value of routine chest-wall RT in intermediate-risk patients. The absolute gain (<2%) in local control is unlikely to translate into survival, and late-effect avoidance (cardiac, pulmonary, reconstructive outcomes) is a compelling reason to individualize and, in many cases, omit chest-wall RT.

Park RH et al. Plastic and Reconstructive Surgery  2024 Oct 1;154(4S):52S-59S . PMID: 38315156 Key takeaways Liposomal + plain bupivacaine TAP block did not lower opioid use  vs plain bupivacaine alone after DIEP reconstruction (60.2 vs 66.9 MME; P = 0.47). Pain scores improved modestly  (VAS 3.6 vs 4.3; P = 0.004 ). Length of stay (2.2 vs 2.1 days) and refill rates (17 % vs 22 %) were unchanged. No differences in 30-day complications or flap failures. Background Enhanced-Recovery protocols for autologous breast reconstruction already curb narcotic needs. Whether adding the longer-acting liposomal bupivacaine to TAP blocks yields extra benefit remains uncertain. Objective To determine if liposomal bupivacaine in TAP blocks reduces postoperative opioid consumption after DIEP-flap breast reconstruction. Methods Design: Single-center, single-blinded RCT (Level II). Setting: University of Virginia, March 2021–December 2022. Participants: 117 women undergoing unilateral or bilateral DIEP flaps; 59 control (plain bupivacaine + epinephrine), 58 experimental (liposomal + plain bupivacaine + epinephrine). Inclusion/Exclusion: ≥18 y; no active opioid use or allergy; ERAS pathway adherence. Intervention: Surgeon-delivered intra-operative TAP block (80 mL control mix vs 100 mL liposomal mix). Primary endpoint:  Total postoperative opioid use in morphine-milligram equivalents (MME) during hospitalization. Secondary endpoints:  VAS pain scores (PACU through 48 h), length of stay, opioid refills, 30-day complications. Stats: α = 0.05; t-test or Mann–Whitney U; power calculation ≥50 per arm. Results Opioids: Mean total MME 60.2 (liposomal) vs 66.9 (control); Δ –6.7 MME; NS (P = 0.47). Pain: Overall mean VAS 3.6 vs 4.3 (–0.7 points); significant (P = 0.004). Significant only in 24–48 h window (3.4 vs 4.1; P = 0.02). Length of stay:  2.2 ± 0.6 vs 2.1 ± 0.4 days; P = 0.55. Opioid refills:  17 % vs 22 %; P = 0.52. Complications: No significant group differences in wound issues, thrombotic events, or flap loss (all P > 0.3). Conclusion Adding liposomal bupivacaine to TAP blocks improved subjective pain but did not reduce opioids, LOS, or complications  versus plain bupivacaine within a standardized ERAS pathway. Strengths & limitations Randomized, blinded design within a uniform ERAS protocol. Powered sample size with contemporary opioid-sparing regimen. Single institution; potential type II error for opioid endpoint. Pain scores not site-specific; postoperative outpatient opioid use unmeasured. Future directions Cost-effectiveness studies and exploration of alternative long-acting local anesthetics or catheter-based blocks are warranted. Clinical relevance For microsurgeons following ERAS, routine liposomal bupivacaine in TAP blocks may not justify extra cost —plain bupivacaine suffices for opioid minimization, though expect slightly higher early pain scores.

Study Snapshot Paper Info New England Journal of Medicine, July 2025 , PMID: 40450658 Background Despite curative surgery and modern adjuvant chemotherapy, 20 – 40 % of stage III or high-risk II colon-cancer survivors recur. Observational data link higher post-treatment physical activity with superior outcomes, but randomized evidence has been lacking.   Methods Study design & scale:  Multicenter (55 international sites), phase-3, open-label RCT; 889 patients randomized 1:1 (2009-2024). Population: Adults with completely resected stage III or high-risk II colon cancer, 2-6 mo after finishing FOLFOX or CAPOX; ECOG 0–1; <150 min wk⁻¹ baseline exercise. Intervention: Three-year, behavior-supported aerobic program targeting ≥ 10 MET-h wk⁻¹ above baseline A MET (Metabolic Equivalent of Task) is the energy you use at rest. Moderate-intensity activities such as brisk walking are about 3–5 METs; vigorous activities like jogging are 6–8 METs. Goal of 150–180 minutes of brisk walking per week (∼30 min on most days) in addition to one’s usual activity . Control: Health-education materials alone. Outcomes & follow-up: Primary: Disease-free survival (DFS). Key secondaries:  Overall survival (OS), SF-36 physical-functioning domain, predicted VO₂, 6-min walk, safety; median follow-up 7.9 y.   Results 5-year DFS: 80.3 % (exercise) vs 73.9 % (control). 8-year OS: 90.3 % (exercise) vs 83.2 % (control). Quality of life: SF-36 physical-functioning improved ~6–7 points in the exercise arm vs 1–3 points in controls at every 6-mo interval through 3 y. Functional fitness: Sustained mean gain of 5–7 MET-h wk⁻¹ plus parallel VO₂ and 6-min-walk improvements. Safety: Grade ≥3 AEs 15.4 % (exercise) vs 9.1 %; musculoskeletal events 18.5 % vs 11.5 % (10 % exercise-related).   Conclusion A rigorously supported, moderate-volume aerobic exercise program  initiated soon after adjuvant chemotherapy meaningfully improves long-term disease-free and overall survival while enhancing functional quality of life , with tolerable risk. These data provide level-1 evidence to integrate structured exercise into routine survivorship care for colon-cancer patients.   Clinical Relevance Level I evidence shows that a modest, structured aerobic program improves survival. Plastic surgeons should investigate prescribe exercise in other reconstructive pathways to enhance outcomes.

New England Journal of Medicine, April 2025 Key take aways: PD-1–based immunotherapy is especially effective against mismatch repair–deficient tumors due to their high mutational burden, which increases neoantigen expression and immune system recognition. Background Mismatch repair–deficient (dMMR) tumors, including certain colorectal, gynecologic, and genitourinary cancers, are highly responsive to PD-1 blockade. Prior studies in rectal cancer showed that neoadjuvant immunotherapy could eliminate the need for surgery. This trial evaluated whether that strategy could extend to all early-stage, resectable dMMR solid tumors. Study Design A phase 2 trial enrolled 124 patients with stage I–III dMMR solid tumors. Patients received dostarlimab (500 mg IV every 3 weeks for 6 months). Response was assessed with imaging, endoscopy, and circulating tumor DNA (ctDNA). Patients achieving a clinical complete response (cCR) could opt for nonoperative management. Cohort 1 : Locally advanced dMMR rectal cancer (n=50) Cohort 2 : dMMR nonrectal solid tumors (n=67), including colon, gastric, urothelial, and gynecologic malignancies Results Clinical Complete Response (cCR): Cohort 1 : 100% (49/49) achieved cCR; 37 maintained it at 12 months Cohort 2 : 65% (35/54) achieved cCR; 33 chose nonoperative management Overall:  82/103 (80%) patients avoided surgery without compromise to resectability Recurrence-Free Survival at 2 Years: Overall: 92% Rectal cancer cohort: 96% Nonrectal cohort: 85% No patients lost the opportunity for curative resection due to treatment delay Adverse Events: Mostly grade 1–2 and reversible (fatigue, rash, pruritus) Grade ≥3 in <5% of patients Clinical Relevance This study supports neoadjuvant PD-1 blockade as a viable, organ-preserving strategy for early-stage dMMR tumors. Patients with rectal cancer uniformly avoided surgery, with promising extension to select nonrectal tumors. Importantly, oncologic safety was maintained even with deferred surgery. Considerations for Practice Nonoperative management may now be considered in dMMR tumor patients showing robust response to neoadjuvant PD-1 blockade.

PRS Global Open, March 2025 Key take aways: Secondary healing of small (<3x3 cm) wounds on the tip or ala yields superior cosmetic outcomes compared to FTSG, although time to heal is slightly longer Background The treatment strategies for small nasal wound defects post-tumor excision often involve complex decisions regarding cosmetic outcomes and healing duration. Objective This study's primary aim was to evaluate the short- and long-term healing outcomes and cosmetic results of using FTSG versus secondary healing in patients with nasal defects post-tumor excision. Methods RCT at Linköping University Hospital Inclusion: 18+ yo Wound measuring 3x3 cm or smaller on the tip or alae Max depth: intact perichondrium (i.e. graftable) Participants randomized to FTSG or secondary healing Both groups were dressed with PolyMem (hydrophilic polyurethane foam) dressings Primary outcomes included hand scar quality as assessed by Patient and Observer Scar Assessment Scale (POSAS) : POSAS performed in short term (1 and 4 weeks) and long term (6 mo) Results A total of 30 patients were enrolled, and after exclusions for re-excision or withdrawal, 26 were analyzed. Median age of participants was 74.5 years, 50% were male. Healing times presented as median (IQR) were 35.0 days in the secondary healing group (SH) versus 28.0 days in the skin graft group (FTSG), with no statistically significant difference (P = 0.47). At the 6-month follow-up, the SH group demonstrated superior scores in observer-assessed key parameters: vascularity (P = 0.003), pigmentation (P = 0.007), thickness (P = 0.002), and relief (P = 0.01). Overall, patient-reported outcomes showed significant satisfaction in the SH group regarding scar aesthetics Conclusion While the healing duration was slightly longer for secondary healing, the long-term cosmetic results indicated that this approach may provide superior long-term outcomes compared to skin grafting. Strengths and Limitations Strengths include the randomized controlled design and the comprehensive follow-up using validated scar assessment tools. Limitations include: Small sample size Long-term follow up limited to 6mo Average age was 75 yr; do results apply to younger population? Future Directions Studies need to evaluate if these results are generalizable to younger patients Consider hybrid approaches (i.e. Integra then FTSG) Clinical Relevance The findings suggest a less invasive (and presumably less costly) approach may yield better cosmetic outcomes in elderly patients with small (3x3 cm), superficial ablative wounds of the tip or alae

Authors: Nguyen A, Leach GA, Ahmed S, Clark RC, Sorice SC, Nazerali RS, Hassanein AH, Reid CM. Affiliation: University of California San Diego; Indiana University; Stanford University. Journal: Aesthetic Surgery Journal, accepted 2025 PMID: pending Key takeaways In 295 tissue expander reconstructions, infections occurred in 7 breasts (2.4%); only 1 (0.3%) occurred after 6 weeks. Infection rates were similar between PMMA plates (4.3%) and calcium sulfate (CS) beads/discs (1.5%); difference not significant. CS was associated with lower wound dehiscence (0% vs 3.2%), less mastectomy flap necrosis (4.0% vs 13.9%), and fewer returns to the OR (4.7% vs 17.7%). No postoperative oral antibiotics were given; low infection rates suggest local delivery may safely replace routine oral prophylaxis. Background Periprosthetic infection after implant-based reconstruction is common and may lead to explantation. Local antibiotic delivery (via PMMA or CS) can extend pocket antibiotic exposure beyond the early postoperative period without systemic side effects. Objective Evaluate the efficacy and safety of prophylactic antibiotic-loaded cement—non-absorbable PMMA vs absorbable CS—in reducing infections in two-stage tissue expander reconstruction. Methods Design/setting/level of evidence:  Multi-institutional retrospective cohort; Level III. Time frame & surgeons:  Consecutive cases November 2021–February 2025 by two surgeons at two institutions. Population:  189 patients, 295 breasts (two-stage tissue expander reconstructions). PMMA in 93 breasts (31.5%); CS in 202 (68.5%). Intervention/comparators: PMMA plates loaded with vancomycin + tobramycin (non-absorbable). CS beads/discs loaded with vancomycin + gentamicin (absorbable). Co-interventions:  No postoperative oral antibiotic prophylaxis. Endpoints (90-day):  Hematoma, infection (antibiotics ± operation), wound dehiscence, mastectomy flap necrosis, return to the operating room, implant loss. Statistical approach:  Group comparisons and multivariable regression (odds ratios) assessing association of cement type with outcomes. Results Any infection:  7/295 breasts (2.4%); 6 within 6 weeks (2.0%), 1 after 6 weeks (0.3%); mean onset 37 ± 18 days. By cement type:  PMMA 4/93 (4.3%) vs CS 3/202 (1.5%), P = 0.21. Organisms cultured:  Staphylococcus aureus (including penicillin-resistant), Staphylococcus lugdunensis, and Klebsiella oxytoca. Device loss:  4 explants (1.4%): 2 necrosis, 1 hematoma, 1 infection. Comparative safety signals (CS vs PMMA): Wound dehiscence: 0.0% vs 3.2%, P = 0.03. Mastectomy flap necrosis: 4.0% vs 13.9%, P = 0.004; adjusted OR for PMMA 3.43 (P = 0.047). Return to the operating room: 4.7% vs 17.7%, P = 0.01; adjusted OR for PMMA 4.5 (P = 0.01). Hematoma and implant loss: no significant differences. Context:  Pre-intervention institutional infection rates were 6.1% and 16.7%; with local antibiotics and no postoperative orals, pooled rate was 2.4%. Conclusion Local antibiotic cement (PMMA or CS) during tissue expander reconstruction produced low infection and device-loss rates without oral antibiotics; CS showed fewer wound problems and fewer returns to the operating room than PMMA, with similar infection prevention. Strengths & limitations Strengths: Multi-institutional cohort; clinically relevant endpoints; organism-level detail; regression adjusting for confounders. Limitations: No contemporaneous control without local antibiotics; potential selection and technique confounding; underpowered for small differences; later adoption of staging may bias comparisons toward CS. Critiques and questions Causation vs association:  The lower necrosis and return-to-OR rates with CS may reflect learning curve or patient population rather than an intrinsic material effect. A prospective, surgeon-balanced design is needed. Antibiotic choices and kinetics:  The study mixes vancomycin + tobramycin (PMMA) with vancomycin + gentamicin (CS). Differences in aminoglycoside choice, elution, and geometry could alter coverage (e.g., S. lugdunensis, gram-negatives). Pocket-specific pharmacokinetics would clarify. Generalizability & next steps:  Without a no-cement control, the absolute benefit over modern pocket prep plus perioperative IV antibiotics is uncertain. A multicenter randomized trial comparing standard care vs PMMA vs CS—with standardized flap-staging, drain policy, and an infectious-disease–guided no-oral-antibiotic pathway—would be practice-changing. Safety signals to monitor:  CS re sorption course and PMMA removal burden (comfort, contour) were not systematically measured; future work should include patient-reported chest wall discomfort and imaging artifacts.

Chawla M, et al. Plast Reconstr Surg Glob Open , 2025. PMID: 40765683   Key takeaways Tamoxifen use at the time of implant placement was associated with lower capsular contracture odds (OR 0.40, P = 0.006). Radiation increased capsular contracture odds (OR 3.05, P = 0.002). Surgical complications (hematoma and infection) increased odds (OR 2.66, P = 0.04). Smooth implants showed lower odds than textured (OR 0.32, P < 0.001). No significant impact of subpectoral placement or use of ADM on capsular contracture formation. Background Capsular contracture affects ~8%–15% of implant-based reconstructions and often necessitates revision. Estrogen signaling has been implicated in capsule formation; with higher amounts of estrogen increasing the presence of myofibroblasts and collagen surrounding implants. Tamoxifen may have antifibrotic effects resulting in reduced rates of capsular contracture. Objective Assess whether concurrent breast cancer hormone therapy—specifically tamoxifen—modulates capsular contracture risk after implant-based reconstruction. Methods Design/setting/LOE: Single-center retrospective case–control of patients undergoing capsulectomy/capsulotomy (Feb 2013–Dec 2021). Sample: 914 charts screened; 331 met criteria; mean age at implant 47.4 years. Inclusion: Revision after two-stage implant reconstruction (tissue expander → implant). Key exclusions: non–breast cancer, tissue-expander capsulectomy, unverifiable tamoxifen schedule. Tamoxifen exposure was defined as being on active therapy at the time of implant placement. Variables: Demographics; implant plane/texture; ADM; radiation, chemotherapy, aromatase inhibitors; postoperative complications. Outcome = capsular contracture at explant (Baker 3–4 noted). Statistics: Univariate ORs (chi-square); multivariable stepwise logistic regression; ROC performance. α=0.05. Results Cohort: 331 patients; 236 no contracture (71.3%); 95 high-grade contracture (28.7%). Subpectoral 74.9%; smooth implants 55.3%. Primary findings (univariate): Tamoxifen at implantation: OR 0.40 (95% CI 0.12–0.74), P = 0.006. Smooth vs textured surface: OR 0.32 (0.18–0.59), P < 0.001. Radiation: OR 3.05 (1.54–6.02), P = 0.002. CKD: OR 10.33 (1.14–93.66), P = 0.025 Surgical complications: OR 2.66 (1.07–6.61), P = 0.04. Multivariable (final model): Lower odds with tamoxifen and smooth implants; higher with radiation and longer implant age; ROC AUC 0.7686. Conclusion Among breast cancer patients receiving implant reconstruction, concurrent tamoxifen exposure at implantation correlated with reduced capsular contracture risk; radiation, complications and CKD significantly increased risk. Strengths & limitations Multivariable modeling with discrimination assessment (AUC 0.77). Retrospective single-center design; outcome grading variability (poor interobserver reliability). Confounding by implant era/texture possible and did not account for operative techniques (antibiotic washes, placement or ADM use). Clinical relevance For implant-based reconstruction in ER+ patients, discuss potential tamoxifen-associated protection against contracture at the time of implantation and counsel on radiation-related risk; optimize techniques to minimize postoperative complications.