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

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

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

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.