Immediate breast reconstruction increasingly aims to balance oncologic safety and aesthetic outcomes. Two common mastectomy incisions are transverse and inframammary fold (IMF). While the IMF incision offers nipple preservation and aesthetic incision placement, it may pose a technical challenge for breast surgeons, potentially increasing complication rates. This study compares early postoperative outcomes associated with IMF incision within nipple-sparing mastectomy (NSM) and transverse incision within skin-sparing mastectomy (SSM) in the setting of direct-to-implant (DTI) reconstruction. Retrospective analysis of 221 consecutive patients (282 breasts) who underwent mastectomy and DTI reconstruction at a single tertiary medical center (2017–2023). Reconstructed breasts were categorized by incision type as IMF or transverse. Postoperative complications were analyzed using univariate analyses and multivariable generalized estimating equation (GEE) logistic regression, accounting for clustering of bilateral reconstructions. Of 282 breasts, 193 underwent skin-sparing mastectomy through a transverse incision and 89 nipple-sparing mastectomy through an IMF incision. While overall complication rates were not statistically different (22.5
Immediate breast reconstruction (IBR) is increasingly used in the surgical treatment of breast cancer, and evidence suggests that scar quality and satisfaction with reconstruction are closely linked. Research on long-term scar quality is scarce. We investigated whether incisional negative pressure wound therapy (iNPWT) improves long-term scar outcomes compared with conventional dressing. We conducted a prospective follow-up of a randomized controlled trial (RCT) comparing iNPWT with conventional dressing. Differences in scar quality between the two groups, assessed with the Patient and Observer Scar Assessment Scale (POSAS 3.0) four years postoperative, were calculated. Longitudinal changes in scar quality from one to four years were evaluated, using linearly rescaled POSAS 2.0 and 3.0 scores (0–100 scale) to enable numerical comparison across versions, as well as the correlation between patient-reported scar satisfaction and satisfaction with reconstruction. Twenty patients were included. No significant difference in scar quality was found between iNPWT and conventional dressing at 4-year follow-up. We found a significant difference in observer-reported scar quality from one to four years with decreases in general satisfaction (-13.89 points, p < 0.001) and sum score (-6.48 points, p = 0.006) on a 0-100 scale, independent of treatment group. No difference between groups and minimal difference in patient-reported outcomes. A strong correlation between scar satisfaction and satisfaction with reconstruction was found (ρ = 0.62, p = 0.0021). No evidence of iNPWT improving long-term scar quality following implant-based IBR compared to conventional dressing was found. Given the substantially higher cost of iNPWT and the absence of evidence regarding long-term scar benefit, its routine use for the purpose of scar optimization alone may not be justified. Scar quality continued to change beyond one year postoperatively, and scar satisfaction was strongly correlated with overall satisfaction with reconstruction, underscoring the clinical importance of long-term scar outcomes. Level III, therapeutic study.
Optimal timing of wound closure in reconstructive surgery remains debated. Although early closure can improve outcomes, practices vary due to differences in wound assessment, surgical approach, and institutional constraints. With increasing healthcare pressures, establishing consensus on wound closure timing is essential to improve patient outcomes and system efficiency. Thirty international experts from plastic and reconstructive surgery, trauma, burns, and maxillofacial surgery met in June 2025 to discuss three topics: (1) Ideal timing for wound closure; (2) Clinical and economic benefits of early wound closure; (3) Barriers to achieving early wound closure. Statements were drafted from plenary and breakout discussions, refined by a writing group, and circulated to participants for structured feedback. Consensus was defined as unanimous endorsement, with disputed statements revised until consensus was achieved. The field of soft tissue reconstruction (a shared indication among the board of experts) was used to exemplify the application of the consensus conclusions. The group agreed that when wound bed viability, patient stability, and surgical planning criteria are met, early wound closure reduces infection risk, scarring, systemic complications, and hospital stay. It also shortens rehabilitation, improves quality of life, and lowers healthcare costs. Conversely, delayed closure is associated with poorer tissue quality, excessive scarring, higher complication rates, and increased treatment costs. Barriers include variability in assessing wound readiness, reconstructive pathway heterogeneity, and institutional or logistical constraints (e.g., operating room access, staffing, unavailability of modern technology). Early wound closure, when clinically appropriate, is an effective and economically sustainable strategy that improves patient- and system-level outcomes. Achieving this requires updated practice patterns, adoption of new techniques, and institutional support to overcome barriers. Level V: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
Venous congestion is a major cause of failure after digital replantation, yet the optimal number of venous anastomoses remains unclear. This study evaluated the association between venous anastomoses number and digit survival. A systematic review and meta-analysis using PRISMA 2020 guidelines included digit survival stratified by venous anastomosis number (0, 1, or ≥ 2). Odds ratios and risk differences were pooled using random-effects models; survival rates for each stratum were calculated descriptively. Nineteen studies comprising 3,177 digits met the inclusion criteria; 15 of 19 studies (2,690 digits) were included in quantitative synthesis. Pooled survival rose stepwise across strata: 77
Reconstructive microsurgery is resource-intensive, with prolonged operative times, specialised staffing and vigilant postoperative monitoring. LEAN methodology can improve efficiency but remains constrained by manual observation and retrospective audit. Artificial intelligence (AI) may support more continuous performance analysis across the microsurgical value stream. This narrative review integrates conceptual framework development and research agenda setting to examine how AI-enabled measurement could complement LEAN methods in perioperative microsurgical care. Evidence is synthesised across five domains: LEAN in plastic surgery; AI in microsurgical planning; machine-learning prediction of operative duration; computer-vision workflow analysis; and AI-based flap surveillance. Three perioperative AI–LEAN interfaces are proposed. First, machine-learning duration prediction can inform Heijunka-informed capacity planning. Second, computer vision can supply activity data for intraoperative value-stream mapping. Third, hyperspectral imaging combined with machine learning can support an early-warning layer for flap malperfusion. These technologies are not ready for autonomous deployment; rather, they define a staged research programme for developing continuously measured, adaptive quality-improvement systems. Future research should prioritise prospective validation, standardised taxonomies, health-economic evaluation, equity, workforce impact and human factors. Not gradable.
