Key Takeaways Intraoperative frozen margins only changed management in   Paper Info Journal of Surgical Oncology , Vol 131, 2025, pp 694-698; accepted 10 Sep 2024.   Background Intra-operative frozen-section assessment of peripheral margins is traditional in musculoskeletal oncology, yet evidence in soft-tissue sarcoma (STS) is sparse.   Objective Quantify practice patterns, clinical impact, and cost-utility of peripheral-margin sampling (Frozen and Permanent) during STS resection.   Methods Retrospective review (2005-2019), multi-institutional Inclusion: Extremity or truncal soft tissue sarcoma Primary tumor ≥ 2 years follow up Exclusion: Osseous disease Re-excisions Pathology charges were evaluated to determine cost of margin assessment Results A total of 179 patients were included 119 (66%) had peripheral margins sent (frozen or permanent) Frozen margin n = 27 (23%) Permanent margin n = 92 (77%) Only 1 case in which frozen margins were sent returned positive, resulting in a wider resection at the time of initial surgery On average, sending margins added approximately $5,000, not including OR time Conclusion Routine peripheral-margin sampling provides limited actionable information, modest diagnostic agreement, and substantial cost. A selective, indication-based approach is recommended.   Strengths & Limitations Strengths :  Multi-institution, includes diverse STS subtypes. Limitations :  Retrospective, under-powered for outcome correlations.

Plastic and Reconstructive Surgery, May 2025 Key Takeaways: The scapular flap offers a reliable alternative to the fibular flap in mandibular/maxillary reconstruction with comparable outcomes. Scapular flaps required fewer osteotomies and resulted in better donor-site outcomes. The addition of a muscle flap reduced complications. Objective To compare surgical outcomes, donor-site morbidity, and quality of life between angular artery-based scapular flaps and fibular flaps for head and neck osseous reconstruction. Methods Retrospective analysis (n=120, 2016–2022) at two Swedish university hospitals. Surgical outcomes, osteotomies, soft tissue use, donor-site morbidity (DASH - Hand/Shoulder evaluation, SEFAS - Foot/Ankle evaluation), and patient QoL (FACE-Q) were assessed. Results 58 scapular flaps 26 used for mandible, 32 used for maxilla 62 fibula flaps 60 used for mandible, 2 used for maxilla Scapular flaps required significantly fewer osteotomies for lateral mandibular defects. LD muscle use in scapular flaps significantly reduced complications like fistulas and nonunion (P=0.039). Donor-site morbidity was lower in the scapula group (P=0.001). No significant difference in QoL scores. Complication Scapula (n=58) Fibula (n=62) P Flap failure 1 4 0.36 Soft tissue partial necrosis 4 3 0.71 with exposed bone/plate 4 0 0.05 Fistula 6 4 0.51 Nonunion 1 1 0.5 ORN 4 1 0.19 Donor site complication 1 9 0.01 Medical/Respiratory complication 6 1 0.04 Facial appearance (FACE-Q) 68 +/- 23 60 +/- 21 0.767 Eating/Drinking (FACE-Q) 54 +/- 22 60 +/- 20 0.113 Conclusion Scapular flaps are effective alternatives to fibular flaps, with comparable function and superior donor-site morbidity. The chimeric nature allows for the easy addition of a muscle flap, which can help mitigate surgical complications Strengths and Limitations Strengths: Multicenter design, matched defect types, validated PROMs. Limitations: Retrospective, shorter follow-up in scapula group. Future Directions Further prospective studies evaluating long-term functional and aesthetic outcomes are warranted. Clinical Relevance Scapular flaps are a viable primary option for selected mandibular and maxillary reconstructions.

Plastic and Reconstructive Surgery , Sept 2024 Key take aways: Intraflap anastomosis allows for larger flaps with only one set of recipient vessels in the chest. Perforator and recipient vessel selection is critical. The hemi-abdomen with "dominant" perforator serves as the recipient flap Type 1 branching pattern: the superior continuation of the deep epigastric vessels serves as the intraflap recipient Favor more caudal perforator to improve the caliber of the superior continuation Type 2 & 3: the bifurcation or large side branch serves as the intraflap recipient Background Conjoined bilateral DIEP flaps with intraflap anastomosis allow maximal use of abdominal tissue for unilateral breast reconstruction, especially in cases requiring large volume or with limited abdominal bulk. However, anatomical variation in DIEA branching complicates consistent execution of this technique. Objective To develop an algorithmic approach to reliably perform intraflap anastomosis in conjoined bilateral DIEP flap reconstructions, using patient-specific CTA planning to guide pedicle selection and vessel configuration. Methods Design : Retrospective single-surgeon series of 201 consecutive cases (2009–2023). Inclusion : Breast reconstructions using conjoined bilateral DIEP flaps Planning : Preoperative CTA  was used to assess DIEA branching (Types 1–3) and perforator anatomy. Execution : ICG angiography assessed intraoperative perfusion. Primary pedicle selected based on recipient vessel caliber and branching type. Outcome Measures : Alignment of plan vs. intraoperative execution, complications, and flap inset ratio (weight of final flap/weight of harvested flap). Results Flap Type : 100% completed using intraflap anastomosis  (no conversions). Branching Types : Type 1 (49%), Type 2 (38%), Type 3 (13%); most common combination: Type 1–Type 2 (33%). Pedicle Configuration : Type 1 : Caudal perforators favored for larger superior continuations. Type 2 & 3 : Side branches used as recipient vessels. Smaller secondary veins matched to smaller vena comitants to avoid size mismatch. Plan Deviations : 28 cases (14%), primarily to secure better-caliber vessels or optimize perfusion. Complications : Venous congestion: 4 cases (2%), all salvaged Fat necrosis ≥3 cm²: 8% Delayed wound healing: 8.5% (flap), 11.4% (donor) No flap losses Inset Ratio : 0.86 ± 0.10 Conclusion A CTA-driven, anatomy-specific algorithm for selecting recipient vessels enables consistent and safe use of intraflap anastomosis in conjoined bilateral DIEP flaps. High success, low complication rates, and strong plan-execution concordance (>85%) support the technique's reliability. Clinical Implications Surgeons can confidently adopt conjoined bilateral DIEP flaps with intraflap anastomosis by: Prioritizing recipient vessel caliber over perforator size Understanding DIEA branching patterns to guide pedicle choice Leveraging CTA and ICG angiography for precise planning and perfusion validation

Plastic and Reconstructive Surgery , May 2025 Key Takeaways Breast implants are associated with immune activation both locally in the breast tissue and systemically in the blood. Patients with prior implant exposure showed elevated circulating antibodies to breast cancer–associated proteins and upregulated immune-related gene expression in breast tissue. These findings demonstrate that breast implants can stimulate durable immune responses, though the clinical implications—whether protective, neutral, or harmful—remain uncertain and require further investigation.   Background Epidemiologic data suggest women with cosmetic breast implants have a lower incidence of future breast cancer. Prior work has shown that such patients exhibit heightened antibody responses to certain tumor-associated antigens. This study builds on those findings by investigating whether the immune response triggered by silicone implants extends into the adjacent breast parenchyma, potentially contributing to cancer immunosurveillance. Objective To determine whether breast implants alter the immune system, this study compared antibody levels in blood and immune-related gene expression in breast tissue from women with and without prior breast implant exposure.   Methods The study population comprised healthy adult women undergoing elective cosmetic breast surgery at a single academic institution. Participants were stratified into two cohorts based on prior implant exposure: Implant-naïve (IN):  Undergoing primary augmentation Implant-exposed (IE):  Undergoing revision augmentation  following prior implant placement Exclusion criteria included history of cancer, autoimmune disease, immunosuppression, HIV, or hepatitis. Systemic Immune Response Assessment: Serum samples were tested for antibodies to MUC-1, ER-α, mammaglobin-A, CEA, and HER-2 using ELISA. These proteins are commonly associated with breast cancer and are used as biomarkers to assess immune recognition of tumor-related antigens. Longitudinal analysis was conducted in a subset of patients with samples at baseline, 1 month, and 6 months post-implantation. Local Immune Response Assessment : Breast tissue was analyzed via quantitative RT-PCR and bulk RNA sequencing. Statistical analyses included Wilcoxon rank-sum tests, Mann-Whitney U tests, and multivariable regression to adjust for confounders including age and pregnancy history.   Results Cohort Details: Blood samples were analyzed from 188 patients: 117 implant-naïve and 71 implant-exposed. Breast tissue samples were analyzed from 65 patients: 35 implant-naïve and 30 implant-exposed. Antibody Levels:  IE patients had significantly elevated levels of antibodies to: MUC-1 (OD450: 0.42 vs. 0.33; P =0.001). MUC-1 is a glycoprotein commonly overexpressed in breast cancer and plays a role in tumor progression and immune evasion. ER-α (OD450: 0.20 vs. 0.17; P =0.036). ER-α is the estrogen receptor commonly used to classify breast cancers as ER-positive Mammaglobin-A (OD450: 0.33 vs. 0.23; P =0.001). Mammaglobin-A is a breast tissue–specific protein that is frequently overexpressed in breast cancer and serves as a marker for diagnosis and immune response profiling. No differences were observed for CEA or HER-2. These elevations persisted at 6 months post-implant in longitudinally followed patients. Tissue Gene Expression: IE breast tissue showed increased expression of plasma cell–associated genes (CD138 ↑1.90×, P =0.01; PAX5 ↓0.53×, P =0.031), suggesting enhanced B-cell activation and differentiation into antibody-secreting plasma cells in implant-exposed breast tissue. Th17-associated genes were significantly elevated, indicating increased activity of a T-cell subset involved in inflammation, autoimmune responses, and potentially anti-tumor immunity. IL17A (2.16×, P =0.004), RORC (1.66×, P =0.024), and BATF (2.36×, P <0.001), supporting enhanced Th17 pathway activation in implant-exposed breast tissue. Subgroup Findings: MUC-1 antibody levels were higher with saline vs. silicone implants ( P =0.034) Duration >10 years was associated with higher MUC-1 antibody levels ( P =0.002) No significant differences in antibody levels were observed by implant texture, pocket location, rupture status, or capsular contracture.   Conclusion Breast implants trigger a measurable immune response that extends from the local breast tissue into the bloodstream. This response includes B-cell activation and elevated antibodies to breast cancer–associated proteins. While not confirming a protective effect, the findings suggest that implants may stimulate immune pathways relevant to breast cancer detection or surveillance.   Strengths and Limitations Strengths: Integration of systemic and local immune data in a sizable, well-defined cohort Use of both protein and gene expression analyses Limitations: Cohorts differed by age, menopausal status, and parity; although adjusted for in regression, residual confounding may exist Lack of control groups undergoing non-implant breast surgery (e.g., mastopexy) limits attribution solely to implants   Discussion Commentary (Keane et al.) Commended the study’s originality but emphasized key limitations in design. Advocated for matched cohort or propensity score–matched studies. Raised concerns that surgery-related inflammation (not the implant alone) may drive immune changes. Questioned long-term relevance of Th17 response given its complex role in both cancer immunity and autoimmunity. Suggested future research evaluate changes in immune response post-explantation, and in relation to adjunct procedures such as capsulectomy.   Clinical Relevance This study provides evidence that breast implants are associated with measurable local and systemic immune activation, including elevated antibodies to tumor-associated proteins and immune gene expression in breast tissue. While the clinical impact remains unclear, these findings support the need for further investigation into whether implant-induced immune changes influence breast cancer risk or detection.