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

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

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

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

Panchik D, J Reconstr Microsurg, 2019. PMID 29935493. Key takeaways Exercise (aerobic, resistance, stretching, yoga, Pilates) is safe  for women with or at risk of BCRL—no modality worsened swelling or symptoms. Meta‑analysis showed no significant change in limb volume after exercise. Upper‑extremity function (DASH) improved significantly  with exercise. Benefits extend beyond edema control: better quality of life, strength, BMI, pain, mental health.   Background Avoidance of upper‑limb exercise was long advised after breast cancer treatment. Emerging data challenge this paradigm and suggest an active role for exercise in BCRL care. Methods Design: Systematic review & meta‑analysis (level 1 evidence). Search: 4 databases, 2005‑2017; 807 records → 26 strong‑quality  studies (EPHPP quality tool). Participants: Women only, mean age 56 y. 50% had ≤50 participants. Across the 26 included studies, 58 % specifically evaluated unilateral BCRL. The rest allowed bilateral or mixed cases. Study types: 24 RCTs (92%), 3 cohorts. Interventions: Six exercise categories; most ≥8 weeks. Outcomes: Absolute/relative arm volume; Disabilities of Arm, Shoulder & Hand (DASH). Statistics: Fixed/random effects SMDs with SAS. Results 46 % studies positive, 54 % neutral for edema; none negative. Absolute (4 studies) and relative (4 studies) limb‑volume meta‑analyses showed no significant pre/post difference. Pooled DASH data from five studies showed a statistically significant functional gain; the authors did not provide the pooled effect size, so the exact magnitude cannot be quantified from the published data. Ancillary gains: decreased pain; increased strength, QoL, BMI. Conclusion Multiple forms of exercise can be safely incorporated into BCRL management, improving function and patient‑reported outcomes without exacerbating swelling. Limb volume appears unaffected by exercise.  Strengths & limitations Rigorous quality appraisal; majority RCTs. Broad range of exercise modalities broadens applicability. Small meta‑analysis sample sizes limit precision & introduce bias. Women‑only data; compression garment use inconsistently reported. Clinical relevance Lymphatic surgeons can confidently recommend aerobic, resistance, or mind‑body exercise as part of comprehensive CDT.

Key Takeaways In a single-center cohort, NSM with implant based reconstruction produced clinically and statistically higher psychosocial and sexual well-being  than skin-sparing mastectomy (SSM) with delayed nipple reconstruction, while physical well-being and breast-specific satisfaction were comparable. Surgical-site complication rates were low and not significantly different  between groups. Paper Info The Breast Journal, January 2016 Design: Single institution (MSK) retrospective cohort with prospective PROs   Background Preserving the nipple–areola complex has aesthetic appeal, but its impact on health-related quality of life (HRQOL) versus SSM with nipple reconstruction has been under-reported. Objective To determine whether nipple preservation improves patient-reported psychosocial, sexual, physical, and satisfaction outcomes after implant-based breast reconstruction. Methods Population 254 women (52 NSM, 202 SSM) Inclusion Immediate two stage implant based reconstruction >5 mo follow up Therapeutic or prophylactic mastectomy <Stage IIB Outcome measures Breast Q reconstruction module Analysis t-test for Breast Q domains Multivariate linear regression controlling for confounders BMI, cup size, time-to-survey, RT, ppx vs therapeutic Results Multivariate findings  – NSM independently increased psychosocial (β 6.8, p = 0.05) and sexual well-being (β 7.5, p = 0.05). No other covariate reached significance. Complications  – Overall events were infrequent; full-thickness flap necrosis (7.7 % NSM vs 5.9 % SSM) was the commonest; differences were nonsignificant. Conclusion Within the limits of a retrospective, non-randomized design, NSM offers a measurable psychosocial and sexual quality-of-life advantage over SSM with nipple reconstruction, without added morbidity. These data support discussing NSM’s psychological benefits during shared decision-making. Strengths & Limitations Strengths Validated PROs Multivariate adjustment for confounders Limitations Small NSM sample (n=52) Retrospective design No preop/baseline Breast-Q scores Longer follow up in SSM cohort Future Directions Larger prospective or matched studies with baseline PROs. Inclusion of objective aesthetic and sensory assessments alongside BREAST-Q. Clinical Relevance When possible, nipple sparing techniques should be employed

Pu JJ, Plastic and Reconstructive Surgery , 2025 (Ideas & Innovations). PMID: 39626201   Key takeaways End-to-side cross-face graft restored protective lip–chin sensation in all six patients (≥ S3). Two patients achieved full tactile and two-point recovery (S4). Average static and moving 2-point discrimination: 12.4 mm and 8.4 mm, respectively. No loss of sensation on the donor (contralateral) side. Technique allows for reinnervation when proximal stump is absent   Background Segmental mandibulectomy transects the inferior alveolar nerve, leaving the lower-lip numb. This may hamper eating, speech, and quality of life. Traditional interposition nerve grafts are lengthy and may be impossible if the proximal stump is retracted within the mandible.   Objective Assess feasibility and early sensory outcomes of an end-to-side cross-face nerve graft from the contralateral mental nerve to reinnervate the distal mental nerve after mandibulectomy.   Methods Design: Prospective pilot case series (Level IV). Setting: Two tertiary centers; simultaneous fibula free-flap jaw reconstruction. Participants: 6 adults (3 M/3 F), mean age 57.2 y; malignant tumors (5 SCC, 1 verrucous). Inclusion: Segmental mandibulectomy with mental-nerve loss; ≥ 12 mo follow-up. Intervention: 7 cm autologous donor nerve (lateral sural cutaneous or motor branch to FHL harvested from within the fibula donor site) sutured end-to-end to the distal mental stump and end-to-side into an epineural window on the contralateral mental nerve (4 × 9-0 nylon stitches). Primary endpoint:  Sensory recovery via Mackinnon–Dellon Modified MRC scale. Secondary endpoints:  Static & moving two-point discrimination; operative time; donor-site morbidity. Stats: Descriptive (n too small for inferential testing).   Results Graft metrics:  Mean length 63.3 mm; neurorrhaphy time 33.5 min. Primary outcome:  100 % achieved ≥ S3; 2/6 S4. Two-point discrimination:  Static 12.4 mm; moving 8.4 mm. Follow-up: Mean 14.3 mo (range 12–18 mo). Safety: No contralateral sensory deficit; no flap or graft complications; minimal donor-site changes.   Conclusion End-to-side cross-face grafting reliably restores lower-lip sensation after mandibulectomy while preserving contralateral nerve function, potentially offering a simpler alternative to interposition grafts.   Strengths & limitations Strengths: Addresses anatomic situations where proximal IAN is inaccessible. Nerve graft is more out of the way for bony inset and fixation. Limitations: Small sample; no control group. Short follow-up; long-term durability unknown. Sensory testing not blinded.   Future directions Larger, controlled studies comparing this approach to conventional interposition nerve grafts and to processed nerve allografts are warranted.   Clinical relevance Surgeons reconstructing segmental mandibulectomy defects can consider this technique to provide patients meaningful sensory restoration. It offers surgeons an option for reinnervation when the proximal ipsilateral nerve stump is not available. The authors suggest this approach may require shorter grafts (and thus faster reinnervation), but the average graft length (6.3 cm) was on par with previously reported interposition graft lengths. Limited options still persist for when the distal mental nerve stump has been resected.

Demirdover et al. Plast Reconstr Surg Glob Open , 2025; retrospective case series (Level IV evidence); PMID 40469547.   Concept & indications - The DF is a two‑layer  advancement flap that recruits both gluteus maximus muscle and an overlying fasciocutaneous flap on each side of the midline. It obliterates deep dead‑space and resurfaces post‑sacrectomy wounds with exposed bone and rectum while sparing gait function. Suitable for large midline defects (i.e. post chordoma resection).   Key anatomic points Gluteus maximus Medial third released from underlying piriformis & gluteus medius to allow midline approximation; insertions usually left intact to preserve hip extension. Superior & inferior gluteal arteries Main pedicles; perforators concentrated in predictable zones that must be protected.   Operative steps  (prone position) Perforator mapping – Hand‑held Doppler marks SGA and IGA perforators before incision.  Superior gluteal perforators: Draw a line from the posterior superior iliac spine (PSIS) to the greater trochanter; superior gluteal artery (SGA) perforators cluster along the medial one‑third of this line. Inferior gluteal perforators: Draw a horizontal line parallel to the gluteal fold ~5 cm above it; inferior gluteal artery (IGA) perforators are concentrated in the middle third of the buttock on this line. Muscle layer – Medial gluteus maximus edges (already detached by sacrectomy) are dissected laterally; nerves & pedicles preserved. Tension‑free midline apposition is achieved; partial lateral release if needed. Fasciocutaneous layer – Skin flap elevated (superficial to deep fascia), saving as many perforators (min. 3 per side) as able. Relaxing incisions - If needed, crescent‑shaped cuts in the lateral gluteal border (perforator‑sparse zone) enhance mobility and reduce tension. Wounds closed primarily or skin grafted. Layered closure - Deep : bilateral gluteus maximus muscles advanced and sutured together in the midline Superficial: bipedicled fasciocutaneous flaps advanced across the midline Drains & positioning – Closed‑suction drains; patient prone with 45° rolling for one week, then gradual mobilization avoiding hip flexion.   Pearls & pitfalls Preserve most perforators; ligating too many risks ischemia. Avoid full detachment of gluteus maximus insertion in ambulatory patients. Place relaxing incisions lateral to main perforator zones. Layered design restores buttock contour and tolerates adjuvant radiotherapy.   Post‑operative outcomes (12‑patient series) No flap failures; one superficial abscess managed with drainage/debridement. Mean follow‑up ≈ 21 months.   Note on nomenclature While the authors label this the “Demirdover flap,” the operation is essentially a bilaminar gluteal advancement (muscle plus overlying fasciocutaneous) — a concept previously described in various forms. Eponymous names can obscure the underlying anatomy and make cross‑study comparisons harder; a descriptive term such as “bilaminar gluteal advancement flap” may serve the field better. Clinical Relevance The bilateral gluteal advancement flap provides reconstructive surgeons with another option in their toolkit to reconstruct large sacral defects. It would be interesting to compare this technique with V-Y advancement flaps as well as evaluating strength/ambulation outcomes further.

Aboul Nasr L A, Plast Reconstr Surg Glob Open , 2025. PMID: 40606808   Key Takeaways Inferior-pedicle reductions demonstrated better nipple-areola complex (NAC) sensation at 3 months , but differences equalized by 6–12 months. All pedicles regained baseline sensation within a year .   Background Preserving NAC sensibility is central to patient satisfaction after breast reduction. Pedicle choice influences nerve integrity, yet data comparing techniques are limited.   Objective To compare postoperative NAC sensation after superomedial, medial, and inferior pedicle breast reductions.   Methods Design:  Prospective randomized controlled trial, single tertiary center, 2022 – 2024. Participants: 45 women (90 breasts) randomized 1 : 1 : 1 to superomedial, medial, or inferior pedicle reductions; median age 36–43 y; BMI ≤ 40 kg/m². Exclusion Criteria:  Prior breast surgery, sensory-altering comorbidities, BMI > 40, NAC complications. Intervention: Standardized reduction mammaplasty performed by one surgical team. Endpoints: 1-point discrimination (Semmes-Weinstein monofilaments), crude touch, temperature, pain (needle), and 2-point discrimination measured at 3, 6, 12 months. Statistics: χ² and Kruskal-Wallis tests; α = 0.05; intention-to-treat analysis.   Results Primary outcome (1-point discrimination):  No significant inter-group differences at any time-point. Early (3 mo) sensory tests Temperature: inferior > superomedial & medial (P = 0.0002). Crude touch: inferior > superomedial (P = 0.004). Pain: inferior > others (P = 0.004). 2-point discrimination: inferior > others (P = 0.0002). Late: By 6 months, > 93 % of breasts in all groups recovered pain/temperature/crude touch; by 12 months, no inter-group differences across tests. Complications: Minor NAC necrosis/dehiscence in 8 %–17 % per group; no flap loss.   Conclusion All three pedicles provide safe reduction mammaplasty with full sensory recovery by one year; the inferior pedicle offers earlier return of NAC sensation.   Strengths & Limitations Strengths: RCT design with equal groups; multifaceted sensory testing; standardized surgical team. Limitations: Small sample (n = 45); single center; 12-month follow-up; subjective sensory measures; non-blinded assessors.   Clinical Relevance Surgeons can counsel patients that early numbness is common but typically resolves within a year, regardless of pedicle. Choosing an inferior pedicle may speed early sensory return without compromising long-term outcomes.

Phuyal D et al. Plast Reconstr Surg Glob Open  2025. PMID: 40678603   Key takeaways A robotic DIEP flap was successfully harvested with a 15 cm pedicle that included 9.1 cm intramuscular (IM) course with a 3.5 cm fascial incision. The robot was used to complete the deep IM dissection from inside the abdomen , eliminating the usual need to lengthen the fascial incision. This challenges the long‑held rule that candidate for robotic harvest should have a perforator with short IM courses  (usually < 4 cm).   Conventional robotic DIEP approach Perforator isolation and intramuscular dissection performed open Robot used to harvest sub-rectus pedicle from within the abdomen (TAP approach) Green line = pedicle segment usually harvested robotically. A = intramuscular segment, B = sub‑rectus segment, C = entire pedicle length. The fascial incision that can be spared is B, calculated as C − A. The primary benefit of the robot is to minimize the length of the anterior rectus fascial incision. Thus, traditionally, only patients with a short (<4 cm) intramuscular course were selected for robotic harvest, otherwise the benefit would be negated. The "spared" fascial incision length can be calculated but subtracting the IM length from the total pedicle length   Innovation Perforator isolation and initial superficial intramuscular dissection was performed open (via 3.5cm fascial incision) The robot was used to harvest the sub-rectus pedicle AND complete the intramuscular dissection from within the abdomen If proven reproducible, this effectively upends the benefit equation and expands the candidacy of Robotic DIEPs to many more patients   Methods (case report) Patient: 43‑yo woman, BMI 30; delayed autologous reconstruction post‑radiation. Dominant perforator:  medial row, 1.8 mm caliber; IM length = 9.1 cm. Access: 3.5 cm fascial incision; OptiView entry + three 8 mm robotic ports (TAP approach). Robot: da Vinci Xi; harvested pedicle from its origin to perforator, closing posterior sheath robotically.   Results Pedicle length 15 cm; IM portion 9.1 cm. Harvest 90 min; no mesh or muscle repair needed. Pain well‑controlled; discharge POD 3; no donor‑site or flap complications at 6 weeks.   Conclusion Completing the intramuscular dissection robotically preserves the hallmark small fascia incision of robo‑DIEP harvest—even when perforators run nearly 10 cm through the rectus muscle—thereby removing IM‑length >4cm as a strict exclusion criterion  and broadening patient eligibility.   Strengths & limitations Strength: First proof‑of‑concept that long IM courses are feasible without long fascial incisions. Limitations: Single patient; unknown learning curve/reproducibility. Unknown long‑term abdominal‑wall outcomes.   Clinical relevance Surgeons can now consider robotic DIEP harvest for patients whose best perforators have long intramuscular paths , provided pre‑op imaging confirms a feasible trajectory for robotic intramuscular dissection.

Plastic and Reconstructive Surgery, April 2025 Key takeaways: Breasts continue to lose volume after radiation, averaging 20% loss after one year and 26% at five years Macromastia, diabetes, and smoking are associated with increased risk of volume loss Background Breast-conserving therapy (BCT) is commonly utilized for treating early-stage breast cancer. However, subsequent radiation therapy (RT) can lead to breast changes that can be hard to predict. Previous literature indicates a range of volume loss post-BCT/RT, but there is limited quantitative data on how different factors (such as breast size, smoking history, and diabetes) correlate with such changes. Objective This study aimed to quantify the extent of breast volume loss after BCT/RT and identify predictive factors associated with this loss in a cohort of patients. Methods This retrospective study analyzed patients who underwent BCT with radiation for T1 tumors from 2005 to 2023 at UC San Diego Health. Exclusion criteria included previous breast surgery or radiation . Preoperative and postoperative breast volumes were calculated using craniocaudal mammograms and the formula π/3 * height * radius^2. The changes in breast volume over time (1, 3, and 5 years post-RT) were compared using paired t-tests, while multiple regression analysis assessed predictors for volume loss, including baseline breast volume, smoking status, diabetes, and chemotherapy received. Results 115 patients were included On average, patients lost approximately 19.3% of their breast volume within one year after surgery, which increased to about 26.6% by year five. The study identified that: Larger breast volumes experienced a greater percentage of volume loss over five years compared to those with smaller breasts. Patients with a smoking history and diabetes exhibited significantly higher volume loss. Conclusion The anticipated breast shrinkage from BCT/RT is around 20% in the first year, and approximately 26% by five years, varying based on the initial breast size and comorbid factors like diabetes and smoking. Strengths and Limitations Strengths : Data were collected over multiple years, offering a longitudinal view of breast volume changes. The study highlights the importance of initial breast size and associated comorbidities as predictors of post-radiation outcomes. Limitations : This study included only T1 tumors (<2 cm) and did not include details on reconstruction (i.e. volume displacement techniques). Reliance on mammographic calculations for volumes may introduce variability. It is likely that radiated breasts are not as compressible, leading to underestimation of volume when using mammogram as the basis for volume. The study could not correlate imaging data with qualitative assessments of aesthetics, limiting insights into patient satisfaction. Clinical Relevance The study underscores the importance of anticipating breast volume changes post-BCT/RT, which is crucial for both patient education and surgical decision-making Long-term volume loss should be considered when evaluating candidacy for BCT

PMID: 39636700 Plast Reconstr Surg. 2025 Jul 1;156(1):162-169. Key Takeaways Unrestricted limb positioning after POD 7 is as safe as a formal dangling protocol (also beginning POD 7)  for preventing partial flap loss in lower‑extremity free flaps. No meaningful differences were observed in hospital stay, major complications, or minor wound events. Background Venous congestion is a potential cause of partial flap loss after lower‑extremity free‑flap reconstruction. Graduated dangling protocols are intended to condition venous outflow but may prolong hospitalization and vary across institutions. Objective To determine whether allowing the leg to hang freely from postoperative day (POD) 7 onward is non‑inferior —that is, no worse than —a standard graduated dangling protocol for preventing partial flap loss. Methods Design:  Multicenter, parallel‑group, randomized non‑inferiority trial conducted at four tertiary centers in the Netherlands. Target enrollment:  130 patients (80 % power, one‑sided α = 0.025) with a non‑inferiority margin of 12 % absolute risk difference in partial flap loss. Participants:  Adults ≥ 18 years undergoing primary lower‑extremity free‑flap reconstruction for trauma, tumor resection, or chronic infection. Randomization:  On POD 7, concealed 1:1 allocation to Graduated dangling protocol  – four sessions per day starting at 5 min and increasing to 30 min by POD 10. Unrestricted positioning  – sitting, standing, and ambulation without time limits. Primary outcome:  Partial flap necrosis requiring operative debridement within 6 weeks. Secondary outcomes:  Complete flap loss, DVT/PE, surgical‑site infection, split‑thickness graft take, and hospital length of stay through 90 days. Statistical analysis:  Risk differences with Agresti‑Caffo 95 % confidence intervals; non‑inferiority declared if the upper CI bound was < 12 %. Preplanned interim analyses at 25 % and 50 % enrollment led to early stopping at 75 participants after the non‑inferiority boundary was crossed. Results Partial flap loss:  2 / 39 patients (5.1 %) in the dangling group versus 1 / 36 patients (2.8 %) in the no‑dangling group. The difference is roughly 2 extra cases per 100 patients and remains well within the pre‑set 12 % safety margin, so skipping dangling was considered equally safe . Complete loss:  None in either arm. Median length of stay:  14 days with dangling vs 13 days without (no statistical difference). Conclusion Foregoing a formal dangling regimen from POD 7 onward does not increase partial flap necrosis  and simplifies postoperative care. Strengths and Limitations Strengths Randomized multicenter design, prespecified safety margin, blinded outcome review. Limitations Many centers now initiate dangling as early as POD 3 (PMID: 39750583), so both study arms represent relatively late protocols. Trial stopped early at 75 of the planned 130 patients, so small differences may have been missed. The acceptable safety margin (12 %) is quite generous. Future Directions Evaluate benefits of even earlier unrestricted positioning (POD 3–5). Consider incorporating tissue oximetry for individualized mobilization protocols. Clinical Relevance Unrestricted position of lower extremity free flaps after POD 7 does not increase flap failure compared to a dangle protocol beginning at POD 7.