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

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

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

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

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

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

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

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.