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Authors : Fortelny RH, Baumann P, Hofmann A, Riedl S, Kewer JL, Hoelderle J, Shamiyeh A, Klugsberger B, Maier TD, Schumacher G, Köckerling F, Wöste G, Pession U, Albertsmeier M. Affiliation : Multicenter European group, sponsored by Aesculap AG Journal : Hernia, Aug 2025 PMID : 40879826 Key takeaways Five-year incisional hernia (IH) was 9% with short-bite vs 14% with large-bite; difference not significant  (OR 1.60; p=0.155). IH increased from 1→3→5 years in both groups, consistently favoring the short-bite arm. Both cohorts used a P4HB monofilament (Monomax) suture Short-stitch cohort used 2-0 P4HB Long-stitch cohort used #1 P4HB Most 5-year IHs were epigastric; ~36% (15/42) underwent repair. Background Incisional hernia is the most common long-term complication after midline laparotomy, with an estimated incidence averaging ~10–20%. Objective Compare 5-year IH after elective midline closure using standardized P4HB suture with short-bite vs large-bite techniques. Methods Design/setting/LOE: Prospective, multicenter, parallel, double-blind RCT (Germany/Austria). Level I. Enrollment/analysis: 425 randomized (2014–2019). 5-year ITT n=362 (short-bite 175; large-bite 187). PP n=216 (108/108). Eligibility (core):  Adults ASA I–III; primary midline laparotomy ≥15 cm; protocol later dropped BMI ≥ 30 exclusion and allowed benign pancreatic disease. Interventions (how the stitches differed): Large-bite (“long-stitch”):  ~10 mm from fascial edge and between bites; #1 P4HB looped Target 4:1 SL:WL (Stitch length to wound length ratio) Short-bite (“small-stitch”):  5–8 mm from edge, ~5 mm apart; 2-0 P4HB single stranded suture Target SL:WL ≥ 5:1 Blinding: Patients and outcome assessors blinded; surgeons not blinded. Primary endpoint:  IH at 1, 3, and 5 years (exam plus ultrasound/CT/MRI; EHS criteria). Secondary endpoints:  30-day complications (prior reports); EQ-5D-5L at baseline, 30 days, 1, 3, and 5 years. Stats/power: Planned n=468 to detect 50% relative IH reduction at 1 year; recruitment stopped after 424 randomized, reducing power for long-term differences. Results Primary outcome (5 years):  ITT IH 9.14% (16/175) short-bite vs 13.90% (26/187) large-bite; OR 1.60 (95% CI 0.82–3.10), p=0.155. Trajectory: Persistent separation of curves with significant cumulative increase overall from 1→3→5 years (ITT 4.83%→9.02%→16.03%). Hernia characteristics:  Mostly epigastric (52%); sizes <4 cm in 48%; repairs in 15/42 (36%). Quality of life:  Early advantages for short-bite (pain/self-care at 30 days–1 year; anxiety at 3 years) but no group differences at 5 years. Conclusion In primary laparotomy closures, the short-bite technique kept 5-year IH numerically lower than large-bite, but differences were not statistically significant; absolute IH remained comparatively low in both groups. Strengths & limitations Multicenter, double-blind RCT with imaging-confirmed IH and 5-year follow-up. Same suture material across arms isolates stitch geometry. Underpowered at 5 years due to early stop/attrition; technique adherence managed via SL:WL targets and training. Clinical relevance Reconstructive surgeons should understand this approach to primary laparotomy closure , but recognize that hernia repair outcome may not translate.

Authors: Abdul-Rahman N-H, Harris M, Bottegal M, Sridharan S, Spector M, Snyderman C. Affiliation: University of Pittsburgh School of Medicine; Department of Otolaryngology. Journal: Otolaryngology–Head and Neck Surgery, Sept. 2025. PMID: 40407209   Key takeaways Clinically significant postoperative pulmonary complications (PPCs) occurred in 27% of head and neck microvascular free flap (MVFF) patients. Independent predictors of PPCs: advanced tumor stage  (OR 1.29), longer surgery duration  (OR 1.08 per hour), and postoperative hematoma (OR 2.98). PPCs markedly worsened survival: HR 3.94  for mortality; 1-year survival 75.6% with PPCs vs 89.4% without . This study built and internally validated a head and neck free flap–specific risk calculator (nomogram; AUC 0.65), outperforming generic tools ARISCAT (general preop lung‑risk score): AUC 0.51 Gupta (NSQIP pneumonia/respiratory failure): AUC 0.45 Background Postoperative pulmonary complications are frequent after major oncologic head and neck surgery but definitions and prediction tools have been inconsistent for this population. Objective Quantify PPC incidence, identify risk factors and survival impact after MVFF, evaluate ARISCAT and Gupta models, and propose an MVFF-specific nomogram. Methods Design/setting: Retrospective review at a tertiary academic center. Level of evidence: III. Cohort: 638  MVFF reconstructions (August 2019–May 2024). Exclusions: Prior head and neck radiation therapy (RT) patients were excluded. Exposure variables:  Pre-, intra-, and postoperative factors (e.g., tumor stage, operative time, estimated blood loss, hematoma, transfusion). Outcome: PPCs within 30 days; graded with Modified Clavien-Dindo scale (grades 2–5 = clinically significant). Grade 1 (mild):  Hypoxia or atelectasis only; no treatment required. Grade 2 (moderate):  Bronchospasm; pleural effusion not needing invasive intervention; or atelectasis needing intervention/with effusion or hypoxia. Grade 3 (severe):  Pneumonia, lung abscess, or significant atelectasis needing invasive intervention and/or with respiratory failure or pneumonia. Grade 4 (life-threatening):  ARDS, respiratory failure, or cardiopulmonary collapse. Grade 5:  Death from a PPC. Statistics: Univariate and multivariable logistic regression for PPCs; survival analysis (Cox) for mortality; model performance by AUC; creation of a nomogram with Youden-index cutoff. Results Incidence: Grades 2–5 PPCs occurred in 27%  of patients. Univariate signals:  Longer surgery (mean 10.06 ± 2.67 h; P  = .006), estimated blood loss ≥200 mL ( P  = .006), stage III/IV ( P  = .013), hematoma ( P  < .001), postoperative transfusion ( P = .037). Multivariable predictors of grades 2–5 PPCs: Tumor stage: OR 1.29  (95% CI 1.06–1.57; P  = .012) Surgery duration: OR 1.08  (95% CI 1.01–1.17; P  = .031) Hematoma: OR 2.98  (95% CI 1.50–5.94; P  = .002) Tumor location:  No association with PPC risk on univariate testing (e.g., oral cavity vs laryngeal/hypopharyngeal; cutaneous vs aerodigestive). Resource use and adverse outcomes:  ICU transfer 17.7% with PPCs vs 3.6% without  ( P  < .001); length of stay 12.4 days  overall (range 2–87). Mortality: In-hospital 1.4% (n=9) —all with grade 5 PPCs. One-year mortality 13.48% overall; deaths at 1 year 24.1% with PPCs vs 9.6% without  ( P < .001). PPC independently predicted death ( HR 3.94 , 95% CI 1.69–9.22; P  = .002). Modeling: MVFF-specific model AUC 0.65 ; ARISCAT ~ 0.51 ; Gupta ~ 0.45 . Nomogram high-risk cutoff ≥27%  predicted probability. Conclusion Clinically significant PPCs are common after MVFF for head and neck cancer and are strongly associated with ICU use, longer hospitalization, and higher short- and long-term mortality; general PPC prediction scores underperform, supporting a tailored, head and neck–specific risk model. Strengths and limitations Strengths Clinically meaningful PPC definition (grades 2–5) tied to treatment and outcomes. Large, contemporary MVFF cohort with linkage to ICU use, length of stay, and 1‑year mortality. Head‑and‑neck–specific risk calculator demonstrates superiority over generic tools (ARISCAT, Gupta). Predictors are actionable (tumor stage, operative duration, postoperative hematoma). Limitations Single‑center, retrospective design limits external validity. Prior head and neck RT patients were excluded, narrowing generalizability to a high‑risk population. Model performance is modest (AUC ~0.65) with likely high specificity and lower sensitivity; thresholding may miss at‑risk patients. Mixed timing of predictors: inclusion of postoperative hematoma limits preoperative triage utility. Coarse covariate granularity: airway strategy (planned tracheostomy vs early extubation), bony vs soft‑tissue reconstruction, extent of neck dissection, and ERAS compliance not fully explored. Outcome adjudication details (e.g., pneumonia criteria, inter‑rater reliability) not described in depth. Clinical relevance Make pulmonary prevention a core reconstructive objective.  Standardize airway plans (planned tracheostomy vs early extubation), pulmonary hygiene, early mobilization, and incentive spirometry alongside flap checks. Shorten and stage operations thoughtfully.  Use two‑team approaches, efficient sequencing, and avoid unnecessary delays to reduce operative time. Prioritize meticulous hemostasis and early detection of bleeding.  Given hematoma’s association with PPCs and mortality, reinforce OR and PACU protocols for recognition and intervention. Use risk tools judiciously.  The study’s nomogram can guide level of care (e.g., step‑down vs ICU) and counseling, but do not rely on ARISCAT/Gupta; combine the nomogram with clinical judgment, especially for advanced stage tumors and very long cases. Triage resources.  Consider closer postoperative monitoring and dedicated respiratory therapy for patients with advanced tumor stage, prolonged operative duration, or intraoperative events.

Authors: Levy J, Wagner BD, Shammas RL, Boe LA, Ariyan CE, Brady MS, Allen RJ Jr, Matros E, Mehrara BJ, Nelson JA. Affiliation: Memorial Sloan Kettering Cancer Center Journal: Hernia, Sept. 2025 PMID: 40960565 Key takeaways In 102 oncologic patients, hernia recurrence was 8.8%  (9/102) at median 26.1 months; 0/49  in clean vs 9/53 (17.0%)  in contaminated wounds. Retrorectus mesh placement and bilateral external oblique release  were associated with lower recurrence  (HRs ≈0.05 and ≈0.16) on univariable competing-risk analysis. Surgical-site complications occurred in 24% ; most common were seroma 8.8% and superficial dehiscence 7.8% . Background Oncologic patients have elevated wound and infection risks after ventral/incisional hernia repair. P4HB, a slowly resorbable mesh, may balance strength and biocompatibility in high-risk fields. Objective Evaluate hernia recurrence and surgical-site complications after incisional hernia repair with P4HB mesh in oncologic patients and identify surgical techniques linked to improved outcomes. Methods Design/setting/LOE: Retrospective single-center cohort, 2018–2023; Level III evidence. Population: Adults with prior intra-abdominal/pelvic malignancy and incisional hernia undergoing hernia repair with P4HB mesh. N = 102 . Inclusion/exclusion: Included oncologic laparotomy history + P4HB mesh repair. Excluded synthetic/biologic mesh, primary suture, bridging, prophylactic mesh at index cancer surgery. Techniques: Mesh placed retrorectus (Rives–Stoppa), underlay, or onlay ; component separation recorded (external oblique release or transversus abdominis release). Wound classification:  CDC wound classes I–IV recorded; outcomes also compared as clean (Class I) vs contaminated (Classes II–IV). Ventral Hernia Working Group (VHWG) or European Hernia Society (EHS) hernia grades were  not reported . Primary endpoints:  Hernia recurrence  and surgical-site complications (hematoma, infection/cellulitis, superficial dehiscence, abscess). Follow-up/assessment: Median 26.1 months (IQR 15.1–40.1); recurrence assessed by CT (88%) or exam (12%); competing-risk analysis with death as competing event. Statistics: Wilcoxon, χ²/Fisher; Fine–Gray competing-risk regression (univariable only; multivariable modeling not performed due to few recurrence events ); α = 0.05. Results Cohort characteristics:  Median age 63; BMI 26; ASA III 76%; 52% contaminated fields  (CDC classes: I 48%, II 43%, III 8%, IV 1%); 68% retrorectus  placement; 71% bilateral external oblique release ; frequent concomitant oncologic procedures. Recurrence:  8.8% overall;  0%  in clean (Class I) vs 17.0%  in contaminated (Classes II–IV); P = 0.003 . Complications: Any 24% ; seroma 8.8% , superficial dehiscence 7.8% , hematoma 6.9%, infection/cellulitis/abscess 6.9%; similar across wound classes. Technique associations (competing-risk models): Retrorectus vs onlay:  HR 0.05  (95% CI 0.01–0.34; P = 0.010). Bilateral external oblique release:  HR 0.16  (95% CI 0.04–0.65; P = 0.010). Conclusion In oncologic incisional hernia repair, P4HB mesh yielded low recurrence and acceptable complication rates; retrorectus placement and bilateral external oblique release were associated with fewer recurrences. Strengths & limitations Strengths: Focused oncologic cohort; high rate of imaging-based recurrence assessment, though timing not standardized; technique-level analysis. Limitations: Retrospective single-center design; no multivariable adjustment (few recurrence events) → risk of residual confounding (e.g., contamination, case complexity influencing technique choice). Hernia grading (VHWG/EHS), defect size/loss-of-domain, and detailed oncologic variables (prior radiation, chemotherapy timing), smoking/diabetes were not reported or adjusted.  Imaging follow-up timing was not standardized. Generalizability may be limited (high-volume cancer center, average BMI 26 ). Clinical relevance P4HB is a reasonable mesh option in contaminated or high-risk settings, balancing strength with long-term resorption. Critiques and notes Selection bias/confounding by indication:  Technique choice (retrorectus plane, bilateral external oblique release) likely varied by wound cleanliness and defect complexity; without multivariable adjustment, the reported associations may reflect case selection rather than true technique effect. Missing anatomic/oncologic context:  Key predictors (defect size, loss of domain, prior mesh explant/infection, radiation history, VHWG/EHS grade) are not reported, limiting risk adjustment and external validity. Follow-up adequacy:  Given P4HB resorption over ~12–18 months, a median 26-month follow-up is reasonable, yet late recurrences beyond 24–36 months remain plausible. Outcome scope:  Important endpoints—reoperation, mesh explantation, chronic pain, and patient-reported outcomes (function/quality of life)—are missing, constraining clinical interpretation. Comparative effectiveness:  The absence of a comparator cohort (permanent synthetic or biologic mesh) or propensity-matched controls limits interpretation of the 17% recurrence observed in contaminated fields.

Authors: Bertoch T; D’Aunno D; McCoun J; Solanki D; Taber L; Urban J; Oswald J; Swisher MW; Tian S; Miao X; Correll DJ; Negulescu P; Bozic C; Weiner SG Affiliation: Multicenter US Trial (sponsored by Vertex Pharmaceuticals) Journal: Anesthesiology, March 2025 PMID: 40117446 Key takeaways JOURNAVX (suzetrigine)  was FDA approved on January 30, 2025 , with the official indication: treatment of moderate to severe acute pain in adults. First‑in‑class oral, selective NaV1.8 inhibitor ( non-opioid ) studied for moderate‑to‑severe acute pain after abdominoplasty and bunionectomy. Primary endpoint (vs placebo) was met  in both trials (SPID48 superiority). SPID48 = summed pain intensity difference over 48 h : time‑weighted area under the curve of pain‑score reduction from baseline; higher values = more total relief. Overall 48‑h analgesia comparable to hydrocodone/acetaminophen (HB/APAP). Lower nausea/vomiting than HB/APAP ; adverse events mostly mild–moderate. Background Opioids remain common for moderate–severe postoperative pain despite tolerability and dependency concerns. Targeting peripheral sodium channel NaV1.8  offers analgesia without central opioid liabilities. Objective Evaluate whether suzetrigine  provides superior 0–48 h pain relief (SPID48) versus placebo and compare outcomes to HB/APAP; assess onset of meaningful relief. Methods Design: Two randomized, double‑blind, placebo‑ and active‑controlled phase 3 trials (NAVIGATE‑1 bunionectomy; NAVIGATE‑2 abdominoplasty). Treatment window 48 h. Population: Adults (18–80) with moderate–severe pain (NPRS ≥4) post‑procedure. Randomization 2:2:1 to suzetrigine : HB/APAP : placebo. Intervention & comparators: • Suzetrigine: 100 mg loading, then 50 mg q12h (oral). • Active control: hydrocodone/acetaminophen 5/325 mg q6h. • Rescue: ibuprofen 400 mg q6h PRN. • Double‑dummy blinding. Endpoints: • Primary: SPID48 vs placebo. • Key secondary: SPID48 vs HB/APAP; time to ≥2‑point NPRS reduction vs placebo. • Safety and adverse events. Results Primary endpoint (SPID48):  Suzetrigine was superior to placebo in both trials on the SPID48 measure (greater time‑weighted pain relief over 0–48 h). Versus HB/APAP:  No superiority on SPID48; overall analgesia at 48 h was similar . Onset: Faster time to clinically meaningful pain relief vs placebo. Safety: AEs mostly mild–moderate; lower nausea/vomiting than HB/APAP . Common AEs ≥4% included nausea, constipation, headache, dizziness, hypotension, and vomiting. Serious AEs were uncommon and balanced. Mechanism of action Suzetrigine selectively inhibits NaV1.8, a voltage‑gated sodium channel expressed on peripheral sensory nociceptors. NaV1.8 drives nociceptor excitability and action‑potential firing in inflammatory tissue; selective peripheral blockade reduces pain transmission while sparing central nervous system sodium channels (e.g., NaV1.1/1.6), aiming to avoid respiratory depression, euphoria, and addiction liability associated with opioids . Unlike nonselective sodium‑channel blockers, NaV1.8 selectivity is designed to preserve motor function and minimize CNS effects. Contraindications CYP3A / grapefruit:  Contraindicated with strong CYP3A inhibitors . Avoid grapefruit (CYP3A inhibition ↑ exposure). Oral contraceptives:  May reduce efficacy ; use nonhormonal backup during therapy and for 28 days after . Hepatically cleared; avoid in severe hepatic impairment , reduce dose in moderate impairment Dosing Loading: 100 mg PO once  (two 50‑mg tablets). Maintenance: 50 mg PO q12h  for up to 48 h (3–4 maintenance doses). Typical course:   5–6 total tablets  depending on whether a final 48‑h dose is given. Pricing $15.50 per 50‑mg tablet. 6‑tablet course (includes 48‑h dose): $93.00. Safety profile Common AEs:  nausea, headache, dizziness, constipation, vomiting; generally mild–moderate. Serious AEs:  rare and balanced across arms in trials. GI tolerability:   less nausea/vomiting than HB/APAP . CNS/respiratory: No signal of opioid‑type respiratory depression in the controlled 48‑h setting. Clinical relevance Consider suzetrigine (JOURNAVX) as a nonopioid anchor in multimodal protocols in patients prone to opioid‑related nausea/constipation or opioid addiction.  Use the simple 100 mg load → 50 mg q12h regimen for a 48‑h course. Current evidence addresses acute postoperative pain up to 48 h; data for chronic pain or longer courses are limited.

Authors : Yono S, Hannoudi A, Chamseddine H, Rama S, Bensenhaver JM, Yoho D, Tepper D, Evangelista MS, Nathanson SD, Atisha DM. Affiliation : Division of Plastic and Reconstructive Surgery, Henry Ford Health, Detroit, MI. Journal : The Breast, July 2025 PMID : 40682911 Key takeaways In 187 ALND patients (121 LyMPHA; 66 ALND-only), LyMPHA reduced BCRL risk by ~47% (HR 0.53; 95% CI 0.28–0.98; P = 0.043). Kaplan–Meier curves showed significantly lower cumulative BCRL incidence with LyMPHA (P = 0.003). Patient-reported functional impairment was lower with LyMPHA (median 4.7% vs 11.6%; P = 0.045). Drain duration was shorter with LyMPHA (median 13 vs 15 days; P = 0.042) with no increase in complications. Background Breast cancer–related lymphedema (BCRL) impairs function, increases infection risk, and burdens patients and health systems. Preventive strategies at the time of axillary lymph node dissection (ALND) are a priority. Objective Evaluate whether immediate lymphatic reconstruction using LyMPHA at the time of ALND reduces BCRL and improves patient-reported outcomes compared with ALND alone. Methods Design and setting:  Single-center retrospective cohort, 2016–2022. Level of evidence:  III (retrospective comparative cohort). Participants: 187 consecutive breast cancer patients undergoing ALND; 121 received LyMPHA and 66 underwent ALND only. Mean age 56.4 ± 13.6 years. Inclusion/exclusion: Patients undergoing ALND with or without LyMPHA. Control arm also included cases where LyMPHA was attempted but not feasible (no suitable lymphatic/venous targets or intraoperative instability). Intervention: LyMPHA (immediate lymphatic reconstruction) performed after ALND, anastomosing identified arm-draining lymphatics to venous outflow. Intussusception of lymphatic(s) into into a venule, typically a side branch of thoracodorsal. Technique: U-stitch to intussuscept 1–3 lymphatics into the same venule using 8-0/9-0 nylon. Patency confirmation intraoperatively with indocyanine green (ICG) or fluorescein dye transit. Comparator: ALND alone without lymphatic reconstruction. Primary endpoint:  Time to development of BCRL up to 4 years. BCRL defined as symptomatic arm lymphedema (visible swelling, tightness, heaviness/fullness, pain, impaired limb function) documented at follow-up 12–48 months post-op; counted positive  only if symptoms persisted ≥12 months after ALND and  required complete decongestive therapy (consensus definition). Secondary endpoints:  Patient-reported outcomes including functional impairment, drain duration, and postoperative complications. Statistical approach:  Kaplan–Meier analysis with log-rank test; multivariable Cox proportional hazards model adjusting for age, BMI, smoking, and adjuvant therapies. Results Primary outcome (BCRL):  LyMPHA associated with lower cumulative BCRL incidence over time (log-rank P = 0.003). Adjusted effect:  HR 0.53 (95% CI 0.28–0.98; P = 0.043) favoring LyMPHA. Patient-reported function:  Median percent functional impairment 4.7% (LyMPHA) vs 11.6% (ALND-only); P = 0.045. Perioperative course:  Drain duration median 13 vs 15 days (LyMPHA vs control); P = 0.042. Safety: Overall complication rates similar between groups (details per manuscript tables); no signal of harm with LyMPHA. Conclusion Immediate lymphatic reconstruction (LyMPHA) at ALND reduces the risk of BCRL and improves patient-reported function without increasing complications. Strengths Contemporary comparative cohort focused specifically on ALND patients. Time-to-event (KM/Cox) methods quantify prevention beyond incidence. Inclusion of patient-centered outcomes (functional impairment). Limitations Retrospective, nonrandomized design introduces potential selection bias and residual confounding. Single-center experience may limit generalizability; technique and surveillance protocols vary across institutions. Definition of BCRL not based on objective measurements. Clinical relevance For patients undergoing ALND, offering immediate lymphatic reconstruction is reasonable as it may reduce rates of BRCL by as much as half and does not increase complications. Combine ILR with structured postoperative surveillance and early conservative therapy to maximize prevention. Critiques/Questions What precise diagnostic thresholds and surveillance cadence defined incident BCRL, and were evaluators blinded to ILR status? How did regional nodal irradiation (fields, dose, timing) modify BCRL risk within each arm? What proportion of ALND cases lacked suitable lymphatic or venous targets for ILR, and how were these managed? How many anastomoses were performed on average? Did the number of bypasses correlate with outcomes? What occurred if intraoperative patency could not be demonstrated after anastomosis? What was the added operative time (and resource utilization) for LyMPHA?

Authors: Hendrickson SA; Dusseldorp JR. Affiliation: Chris O’Brien Lifehouse Hospital, Sydney, Australia. Journal: Plastic and Reconstructive Surgery — Ideas and Innovations, October 2025 PMID: 40178538 Summary The article describes a medial paramuscular (MPM) approach to deep inferior epigastric artery (DIEA) pedicle dissection performed from the deep surface of the rectus muscle via a midline or paramedian fascial incision. The technique aims to minimize intramuscular splitting and motor nerve injury while enabling routine rectus diastasis plication during donor-site closure. Technique overview Preoperative CT angiography (CTA) for perforator mapping. Identification of medial-row perforators with a short intramuscular course and adequate caliber when using a single-perforator DIEP. Initial short fascial window around the target perforator (not paramedian/midline). Intramuscular perforator dissection through this "lateral" fascial incision. Author recommends placing a vessel loop or glove to mark the intramuscular perforator Make a midline or bilateral paramedian fascial incision (often ~12–15 cm; Y-extension around the umbilicus as needed). Deep-surface dissection of the DIEA: ligation at the external iliac origin, caudal-to-cranial pedicle elevation, and delivery through the initial lateral fascial incision. Standard microvascular anastomosis to recipient vessels. Closure strategy Lateral fascial incisions closed primarily. Routine rectus diastasis plication in epigastric, umbilical, and hypogastric zones to reinforce the midline and to imbricate/"hide" the long midline fascial incision. Mesh not used routinely; considered when preoperative examination suggests true abdominal wall weakness or hernia. Evidence presented Five-year bilateral series reported lower clinically significant abdominal bulge after minimally invasive, deep-surface pedicle harvest methods (robotic or MPM) compared with traditional long intramuscular splits. Traditional bilateral intramuscular split: 4/61 patients (6.6%) with clinically relevant bulge. Minimally invasive (robotic or MPM): 0/32 patients (0%) with clinically relevant bulge. Retrospective, nonrandomized series. Novelty and context Deep-surface pedicle harvest and nerve-sparing principles are established in robotic DIEP. The contribution here is an open, nonrobotic method that seeks similar nerve-sparing advantages while integrating routine diastasis plication so that a long midline fascial incision does not translate into clinical morbidity. A midline-incision approach has been described elsewhere; this report formalizes a practical protocol pairing exposure with planned plication. PMID: 39703378 Advantages Nerve-sparing pedicle harvest without robotic or other specialized equipment. Anatomically aligned with medial-row, short-course perforators favored in standard DIEP planning. Donor-site synergy: diastasis plication reinforces the midline and neutralizes the effect of the longer fascial incision. Useful for bilateral or bipedicled reconstructions where long muscle splits increase denervation risk. Limitations and risks Evidence quality is limited to retrospective, noncomparative experience; outcome reporting combines robotic and MPM cohorts. Requires a substantial midline/paramedian fascial incision, with attendant risks (peritoneal entry, bowel injury) in reoperative abdomens. Benefit is anatomy-dependent; long intramuscular perforator courses may still necessitate more extensive splitting. Potential hemodynamic considerations of tight plication (e.g., intra-abdominal pressure) should be monitored; data specific to DIEP patients are limited. Integration with abdominal wall reconstruction principles Midline plication converts diastasis into a reinforced linea alba, redistributing forces when tissue quality is acceptable and lateral closures are tension-appropriate. For true hernias or markedly attenuated fascia, a lower threshold for prophylactic mesh in a retrorectus or preperitoneal plane is reasonable, individualized to intraoperative findings. Practical application Consider in patients with rectus diastasis ≥2 cm and favorable medial-row, short-course perforators on CTA, especially in bilateral or bipedicled cases or in centers without robotic capability. Plan the incision and plication together so that exposure and reinforcement are coordinated steps. Bottom line The MPM approach is a pragmatic, anatomy-driven open technique that seeks the nerve-sparing benefits of deep-surface pedicle harvest without robotics and couples exposure with routine diastasis plication to maintain donor-site integrity. It is useful when CTA demonstrates a medial-row dominant perforator with short intramuscular course, allowing a single-perforator DIEP. This represents yet another technique in the reconstructive armamentarium to minimize donor-site morbidity when patient anatomy allows.

Authors: Graziano, Plotsker EL, Amakiri UO, Shammas RL, Vingan PS, Mehrara BJ, Stern CS, Nelson JA, Matros E, Allen RJ Affiliations: Memorial Sloan Kettering Cancer Center Journal: Plast Reconstr Surg , 2025. PMID: 39737758 Key takeaways Among 278 unilateral DIEP patients, median length of stay (LOS) was 2.25 days; most were discharged on POD2. Longer LOS was linked to older age, longer operative time, history of diabetes or immunologic disease; longer operative time was also linked to delayed milestone completion. Implementing ERAS and switching the institutional goal from POD2→POD1 reduced median LOS (2.25→1.54 days) without complication increase; 51% met the new POD1 goal vs 82% meeting old POD2 goal; earlier discharge cohorts met milestones sooner. Background Discharge timing after DIEP is a multifactorial decision based on pain control, patient expectations, and monitoring for complications. Enhanced recovery after surgery (ERAS) protocols after DIEP flaps using TAP (transversus abdominis plane) blocks, multimodal analgesia/antiemetics, early mobilization, and explicit milestone education/posters have pushed patients toward shorter stays. Because most return-to-OR events have been shown to occur within 24 hours, properly selected patients may be safe for as short as a 24-hour hospital stay. Objective Evaluate current time to discharge and identify factors associated with prolonged LOS. Evaluate the safety/feasibility of a POD1 discharge goal versus POD2 within a mature ERAS program. Methods Design/setting: Single-center retrospective cohort at Memorial Sloan Kettering; Level III. Cohort: 278 unilateral DIEP  reconstructions (Jan 2021–Dec 2022). Grouped by actual discharge: POD0–1, POD2, POD≥3. Intervention: TAP blocks (exparel/marcaine/injectable saline), early ambulation, multimodal prophylaxis, clinical milestones (PT eval, flap health, pain, nausea/vomiting, vital signs, incisions, JP output) and educational milestones (drain care, use of lovenox, incision care, showering); goal changed from POD2→POD1 in Sept 2022. Variables of Interest: Demographics (age, race/ethnicity, smoking status, BMI, insurance type, travel distance, marital status), operative details (operative time, timing of reconstruction, ASA classification), comorbidities (diabetes, CVD, HTN, immunologic disease, COPD, psychiatric conditions) Endpoints: LOS, post-op complications, time to complete clinical, and educational milestones   Results LOS distribution: Median LOS 2.25 days; 8.9% POD0–1, 74.8% discharged POD2, 16.2% POD≥3; POD≥3 group with higher smoking incidence and greater operative time Predictors of longer LOS (multivariable): Increasing age β=0.01 days/year (P=0.037); increasing operative time β=0.09 days/hour (P<0.001); history of diabetes β=0.35 days (P=0.004); history of immunologic disease β=0.30 days (P=0.007). Milestones: Increased operative time was only variable associated with prolonged time to milestone completion (R 2 =0.11). Earlier discharge cohorts completed milestones earlier (Pearson’s correlation coefficient 0.524-0.585, p<0.001). Discharge-goal subanalysis: POD1 goal (n=35) vs POD2 goal (n=243) Median LOS 1.54 vs 2.25 days; 51.43% vs 82.30% met goal; complication rates similar. Complications by actual discharge day: POD≥3 had higher rates of hematoma (13.3% vs 3.9%), delayed wound healing (4.4% vs 0%), mastectomy skin flap necrosis (8.9% vs 0.5%), and urgent-care visits (15.6% vs 5.3%) versus POD2. Microvascular safety: No returns to the OR for microvascular compromise among early discharges; flap failure not increased.   Conclusion Within a mature ERAS program, LOS after unilateral DIEP is largely driven by operative time, age, diabetes, and immunologic disease; setting a POD1 goal shortens stay without increasing complications, but only about half of patients achieved POD1 discharge. Strengths & Limitations: Uniform ERAS pathway with explicit milestone tracking; thorough multivariable modeling of LOS and milestone timing Retrospective single-center study design and small sample size with POD1-goal subgroup (n=35) and only 18 patients successfully discharged POD1; limit data quality and power to show differences between groups ERAS intervention is multi-part; difficult to attribute LOS reduction to any one specific sub-intervention This was a very healthy population with median BMI 27.2 and low rates of comorbidities. The median operative time 5.8 hours. Thus, these findings may not be widely applicable to comorbid patients or centers with longer operative times Future directions Prospective validation of a POD1 pathway with preoperative risk scoring (age, diabetes, immune disease) and explicit expectation-setting; define practical age thresholds, quantify cost benefits. Clinical relevance Can certainly aim for shorter hospital stays with implementation of ERAS, but important to risk-stratify preoperatively (age, diabetes, immunologic disease), optimize OR effiency/decrease OR time, and check institutional data to look at rate of microvascular complications beyond 24H to see if POD1 is safe target. For successful targeted discharge date, need to set firm, expectations with patients and staff and reinforce milestone education to support safe, early discharge.

Authors: Nakamura S, Yasunaga Y, Nakao J, Araki J, Mori H, Ogino A Affiliations: Shizuoka Cancer Center and Toho University Omori Medical Center, Japan Journal: PRS Global Open, 2025. PMID: 40757385. Key Takeaways The authors identified four external jugular vein (EJV) confluence types (based on CT): SCV — EJV drains to the subclavian vein (47%) Venous angle — EJV drains at the IJV–SCV junction/angle (37%) IJV — EJV drains into the internal jugular vein (11%) Non‑EJV (absent) — no identifiable EJV on CT (5%) In 16% (IJV + non‑EJV) of cases, the EJV would be rendered an unsuitable recipient if the IJV is sacrificed. Patterns did not differ by side or sex; 46% had matching bilateral patterns. Background Recipient‑vein selection drives free‑flap success. Variable EJV terminations can jeopardize outflow when IJV is ligated or resected. Objective Define a CT‑based classification of EJV confluence patterns and estimate suitability of the EJV as a recipient vein for microvascular anastomosis. Classification system SCV type : EJV drains to the subclavian vein  distal to the venous angle. Interpretation : Generally safe for EJV anastomosis even if IJV is resected. Venous angle (VA) type : EJV drains at the junction of IJV and SCV . Interpretation : Usually safe; drainage remains independent of the IJV trunk. IJV type : EJV drains into the internal jugular vein  proximal to the venous angle. Interpretation : At risk —resection/ligation of IJV can eliminate EJV outflow; plan alternate recipient. Non‑EJV type : No identifiable EJV on CT. Interpretation : Treat as unavailable ; select a different recipient vein. Methods Design/LOE : Single‑center retrospective observational CT study; Level of Evidence IV. Setting/dates : Cancer center; April–November 2022. Participants : 50 consecutive patients (100 neck sides); excluded prior head/neck surgery. Imaging : Contrast‑enhanced CT (≈2‑mm slices); EJV traced from origin to confluence. Endpoints : Primary—distribution of confluence types. Secondary—side/sex differences; bilateral symmetry; clinical suitability. Statistics : Descriptive; chi‑square for categorical comparisons (α=0.05). Results Distribution : SCV 47%, venous angle 37%, IJV 11%, non‑EJV 5%. Bilateral symmetry : Same pattern both sides in 23/50 patients (46%). Side/sex : No significant differences by laterality or sex. Clinical context : Two patients required IJV resection; both had SCV‑type EJV. Suitability : IJV‑type and non‑EJV together ≈16%—potentially unsuitable for EJV anastomosis if IJV is sacrificed. Conclusion Most EJVs terminate in the SCV or venous angle, but ~1 in 6 sides are IJV‑type or lack an EJV and may be unsafe for EJV‑based anastomosis—supporting routine preoperative CT mapping and proactive recipient‑vein planning. Strengths & Limitations Strengths : Practical, CT‑based schema; explicit surgical implications; bilateral assessment in consecutive cohort. Limitations : Single‑center retrospective design; small sample; CT may miss very small EJVs; no systematic intraoperative confirmation. Clinical Relevance Before head/neck free flaps, check for the presence and branching pattern of the EJV on CT . If IJV‑type  or non‑EJV , line up an alternate recipient if there is a chance of ipsilateral IJV sacrifice.

Authors: Spoer DL, Berger LE, Huffman SS, Lava CX, Dekker PK, Ko JA, Truong BN, Towfighi PN, Ghyasi N, Fan KL, Song DH Affiliations: MedStar Georgetown University Hospital Journal: Plast Recnostr Surg. Oct 2024. PMID 38470977 Key Takeaways LIFT (Latissimus Dorsi with Immediate Fat Transfer)  offers similar patient-reported outcomes (PROs) compared to abdominally based free flaps (Ab-FF)  with fewer reoperations and shorter hospital stays. LIFT is associated with a higher seroma rate but reduced risk of dehiscence, operative complications, and need for revisions. BREAST-Q scores at 1 year were similar across domains between both groups. LIFT is a viable alternative for patients unsuitable for microsurgical reconstruction or with contraindications to abdominal based free flaps   Background Autologous breast reconstruction is favored for long-term satisfaction. While Ab-FFs are considered the gold standard for breast reconstruction, they require microsurgical expertise. LIFT, combining a latissimus dorsi flap with fat grafting, offers autologous reconstruction without the need for microsurgery expertise or abdominal donor site.   Objective To compare postoperative complications and PROs at 1 year between LIFT and Ab-FF techniques.   Methods Design:  Retrospective cohort study (2017–2022) Patients:  281 total (408 breasts) All patients were primary breast reconstruction and offered both LIFT vs. Ab-FF 70 patients (86 breasts) underwent LIFT 211 patients (322 breasts) underwent Ab-FF (DIEP, MS-TRAM, or SIEA) Outcomes:  Complication rates, reoperations, and BREAST-Q domains at multiple intervals Results Demographics:  LIFT patients were older (56 vs. 53 years; P <0.001) with higher comorbidity index. Ab-FF patients received more adjuvant and neoadjuvant chemo/RTX Operative Time:  LIFT reduced mean OR time by 113 mins (unilateral) and 96 mins (bilateral) Hospital Stay:  LIFT had significantly shorter stays (median 1 vs. 3 days; P <0.001) Complications: Seroma:  Higher in LIFT (19% vs. 4%; P <0.001) Dehiscence & Takebacks:  Lower in LIFT (dehiscence 9% vs. 17%; takebacks 0% vs. 6%; P <0.05) Reoperations and Fat Grafting:  Lower in LIFT (revision 52% vs. 75%; fat grafting 36% vs. 53%; P <0.01) Multivariable Analysis: LIFT independently associated with increased odds of seroma (OR 5.05; P <0.001) LIFT predicted decreased odds of dehiscence (OR 0.37), reoperation (OR 0.37), and fat grafting (OR 0.59) BREAST-Q Outcomes:   Survey response from 116/281 (41%) patients Survey given at 1, 3, 6, and 12 months 96/211 (46%) – Ab-FF 20/70 (29%) – LIFT At 12-month mark there was no statistically significant difference between all domains on BREAST-Q data Ab-FF tended to increase with time Physical wellbeing was lower initially for LIFT patients   Conclusion LIFT offers an effective alternative to Ab-FF with fewer complications, shorter recovery, and comparable satisfaction. It is especially useful for patients in which microsurgery or abdominal flap harvest is not possible.   Strengths and Limitations Strengths:  Comprehensive multivariable analysis Limitations:  Retrospective design, incomplete BREAST-Q follow-up (41% response rate). Captures both revision reconstruction and primary reconstruction Future Directions Prospective, multicenter trials with broader demographic inclusion and long-term follow-up are needed to validate LIFT’s applicability. Clinical Relevance Often considered a salvage option, the LD flap (with fat grafting) enables fully autologous reconstruction without microsurgery, offering comparable patient satisfaction to abdominal free flaps with fewer complications and shorter recovery. These findings suggest LIFT may be underutilized and merits consideration as a first-line option in a broader range of patients.

Authors: Fung E, Godek Mm, Roth JM, Montalmant KE, Yu BZ, Hnderson PW Affiliations: Icahn School of Medicine Mount Sinai Journal: Journal of Plastic, Reconstructive & Aesthetic Surgery, 2025. PMID: 40156946   Key takeaways   TXA reduces postoperative hematoma formation after mastectomy ± reconstruction (2.4% vs 5.5%; OR 0.40; P = 0.001).  TXA shortens drain duration by ~1.2 days and reduces 24-hour drain output by ~42 mL.  No significant effect on seroma or surgical-site infection (SSI).  Safety: no increase in thromboembolism across 947 patients; one pulmonary embolism occurred in controls.  TXA mechanism of action: lysine analogue; indirectly inhibits fibrinolysis (i.e. stabilizes clot) by blocking plasminogen → plasmin activation  Dosing/administration: 1g IV (82%), 1g in 1L irrigation solution (18%)  Contraindications/adverse events: avoid in hypercoagulable patients; may lower seizure threshold and cause visual disturbances  Background   Use of tranexamic acid (TXA) in surgery is increasing; however, existing literature lacks high quality analysis. Outcomes specific to mastectomy and reconstruction require critical analysis to inform standardized protocols.  Objective   Quantify TXA’s effect on hematoma, seroma, SSI, drain output, and drain duration in mastectomy with and without reconstruction.  Methods   Design: PRISMA-guided systematic review and meta-analysis.  Studies: 13 included in final review: RCTs (4), prospective comparative studies (5) and retrospective comparative studies (4) focusing on TXA in setting of mastectomy w/wo breast reconstruction  2,115 patients (44% received TXA)  Setting/procedures: mastectomy ± reconstruction (mastectomy alone (8 studies), autologous (2) or implant-based (3)).  Interventions: TXA via IV (82%) or topical (18%), typically intraoperative (83%); some continued postoperatively; dose varied (0.5-3g; most commonly 1 g).  Endpoints: primary—hematoma and seroma; secondary—SSI, drain output, drain duration, thromboembolic events, explantation.  Statistical approach: Mantel–Haenszel for odds ratios; inverse-variance for mean differences; subgroup analyses by study type, reconstruction type, and route.  Results   Hematoma: 2.4% TXA vs 5.5% control; OR 0.40 (95% CI 0.23–0.70), P = 0.001 .  Seroma: 23% TXA vs 21% control; pooled OR 0.82 (95% CI 0.61–1.10), P = 0.19 .  29% of seromas in TXA required aspiration vs 43% of seromas in control  Subgroup analysis by study type, reconstruction type or route of TXA did not find significant differences between the study and control groups   Drain duration: average drain duration 6.6 ± 5.9 days in the TXA cohort vs 7.6 ± 5.3 days in control (mean difference −1.2, P = 0.03 ).  24-hour drain output: significantly lower with TXA (pooled reduction ~41.8 mL).  SSI: no significant change with TXA.  Thromboembolism: none reported in TXA groups across four studies (n = 947); one pulmonary embolism in controls.  Implant explantation (subset): 8 TXA vs 18 control.    Conclusion   Across mastectomy ± reconstruction, TXA reduces hematoma, shortens drain duration, and lowers early drain output without increasing seroma, SSI, or thromboembolic events.    Strengths & limitations   Largest, most current synthesis focused on mastectomy ± reconstruction.  Consistent hematoma benefit with improved drain-related outcomes.  Heterogeneity in timing, route, and dose; several studies underpowered for secondary endpoints.  Limited adverse-event reporting; need for standardized dosing and safety reporting.    Future directions   Standardize TXA dosing, route, and timing; include flap-specific safety endpoints and cost-effectiveness analyses in future RCTs.    Clinical relevance   For mastectomy ± reconstruction, consider a simple intraoperative TXA regimen (commonly 1 g IV) to reduce hematoma risk and potentially enable earlier drain removal. Counsel that seroma and SSI rates appear unchanged, and screen patients for thrombotic risk before use.

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.