Scientific Abstract Presentations: Breast Session 8 Saturday, October 17 Sat, Oct 17 10:30 a.m.-12:30 p.m. CDT

Abstract Background: Same-day discharge following deep inferior epigastric perforator (DIEP) flap breast reconstruction is feasible and select groups have reported successful same-day or short-stay protocols. However, limited large-scale data exist describing the frequency of short-stay DIEP flap procedures or supporting the safety of this approach.

Methods: A retrospective cohort study was performed using a de-identified data from an electronic health record collaborative dataset (Epic Cosmos) to identify patients who underwent DIEP flap breast reconstruction between January 2015-2026. Patients were stratified by postoperative length of stay (LOS) into <1 day (same-day discharge) and ≥1–3 days. Cohorts were compared using descriptive statistics and Pearson chi-square testing.

Results: A total of 27,051 DIEP flap reconstructions were identified, of which 786 (2.9%) were discharged at <1 day, and 26,307 (97.1%) had a postoperative LOS of 1–3 days. Mean age was similar between cohorts (<1 day: 43.6 years; 1–3 days: 43.8 years). BMI category differed significantly (p<0.001), with obesity (BMI ≥30) more prevalent among patients admitted for 1–3 days. Unilateral reconstruction (35.4% vs 33.5%, p=0.27) and immediate reconstruction (25.2% vs 27.6%, p=0.12) were similarly distributed between cohorts. Patients with a history of radiation therapy, hypertension, or prior antineoplastic therapy were more frequently admitted for 1–3 days (all p<0.05). Rates of unplanned readmission were comparable between cohorts (4.2% vs 4.0%, p=0.78).

Conclusion: Same-day discharge following DIEP flap reconstruction was not associated with increased unplanned readmissions compared with short inpatient stays. In carefully selected patients, same-day DIEP flap reconstruction may represent a safe and feasible care pathway.

Background: Mastectomy skin flap necrosis (MSFN) threatens reconstruction and often prompts difficult management decisions. While prevention is well studied, evidence guiding treatment after necrosis develops remains limited. The purpose of this study was to systematically evaluate treatment strategies and outcomes for MSFN after immediate breast reconstruction, with emphasis on reconstruction-specific salvage, healing time, and escalation patterns.

Methods: A PRISMA-guided systematic review was performed. Of 1,211 screened studies, eight met inclusion criteria for qualitative and quantitative synthesis. Studies published between 2011 and 2023 reported outcomes for 166 patients and 203 breasts with MSFN. Study designs included four retrospective cohorts, one prospective cohort, and three case reports. Extracted variables included reconstruction modality (autologous vs implant-based), necrosis extent, intervention type, timing of intervention, salvage rate, explantation rate, and time to healing. Due to heterogeneity in reporting and inconsistent patient- versus breast-level analyses, results were synthesized descriptively.

Results: Management strategies included conservative wound care, clinic-based debridement, operative debridement with primary closure, split-thickness skin grafting, skin banking, and hyperbaric oxygen therapy (HBOT). The median reported salvage rate across studies was 96.3% (range 66–100%). Autologous-exclusive cohorts demonstrated preservation of reconstruction in all reported cases, with no total flap loss documented in studies reporting outcomes. However, healing times were variable and in some series prolonged, with mean time to closure exceeding 120 days in patients managed with staged wound care and delayed revision. In contrast, implant-exclusive cohorts demonstrated lower salvage rates, with a weighted salvage of 67.5% and explantation rates up to 34.2%. Larger and full-thickness defects were more likely to require operative intervention, particularly in implant-based reconstruction. Severity grading was inconsistently reported. Only one study utilized a validated necrosis grading system. Reporting units (patient vs breast), timing of escalation, and definitions of salvage varied substantially, limiting cross-study comparison.

Conclusion: Reported salvage rates following MSFN are high overall but differ by reconstructive modality. Autologous reconstruction demonstrates high preservation rates, though frequently with prolonged healing. Implant-based reconstruction is associated with lower salvage and higher explantation once necrosis progresses. Significant heterogeneity in severity classification and outcome reporting limits the development of evidence-based treatment algorithms. Prospective studies incorporating standardized necrosis grading and reconstruction-specific outcome reporting are needed to guide management of this complication.

Background: Large national databases are increasingly used in plastic surgery research to evaluate surgical outcomes. The National Surgical Quality Improvement Program (NSQIP) and TriNetX are commonly utilized platforms with distinct data structures and collection methodologies. As database-driven studies continue to shape the literature, understanding differences between these datasets is essential. This study compares patient characteristics and outcomes between NSQIP and TriNetX among patients undergoing immediate microsurgical breast reconstruction.

Methods: Patients undergoing immediate microsurgical breast reconstruction were identified in NSQIP and TriNetX using CPT code 19364 (free flap/DIEP). Demographics, preoperative comorbidities, and 30-day postoperative complications were extracted. Descriptive and comparative analyses using chi-square testing were performed to assess differences in patient characteristics, comorbidity burden, and complication rates between databases for each reconstructive modality.

Results: For immediate microsurgical breast reconstruction, 11,221 patients were identified in NSQIP and 794 in TriNetX. TriNetX patients demonstrated significantly higher rates of comorbidities including diabetes (13.6% vs 7.3%; p<0.0001), COPD (2.8% vs 0.2%; p<0.0001), CHF (2.6% vs 0.2%; p<0.0001), hypertension (39.7% vs 14.5%; p<0.0001), and smoking (4.8% vs 3.4%; p=0.0335) compared to NSQIP. Complication profiles varied substantially as well. NSQIP demonstrated higher rates of 30-day complications including superficial SSI (6.9% vs 1.4%; p<0.0001), deep SSI (1.1% vs 0%; p=0.0028), and blood transfusion (7.8% vs 1.3%; p<0.0001). Conversely, TriNetX demonstrated higher rates of wound dehiscence (5.3% vs 2.0%; p<0.0001) and DVT (2.0% vs 0.7%; p<0.0001).

Conclusion: NSQIP and TriNetX generate meaningfully different patient cohorts and postoperative outcome profiles in immediate microsurgical breast reconstruction research. TriNetX demonstrated a higher burden of comorbidity, whereas NSQIP reported increased rates of surgical site infection. Conversely, TriNetX suggested higher rates of wound dehiscence and DVT. Compared to the current literature, these results generally show lower complication rates (1), raising important questions regarding the generalizability and comparability of findings derived from each database. As large database research increasingly influences plastic surgery literature, recognizing structural differences and limitations is critical for accurate interpretation.

1. ElAbd R, Jabori S, Willey B, El Eter L, Oberoi MK, Singh D. Outcomes of Immediate versus Delayed Autologous Reconstruction with Postmastectomy Radiation: A Meta-Analysis. PRS. 2024 Nov;154(5):851e. doi:10.1097/PRS.0000000000011327

Purpose: Breast symmetry is a critical determinant of aesthetic outcomes in reconstructive and cosmetic breast surgery. However, its evaluation remains largely subjective, with no universally accepted quantitative composite score (1). Existing assessment methods have poor inter-rater agreement or report isolated anthropometric measurements without integrating them into a standardized, multi-domain symmetry index (2,3). Therefore, the objective of this study was to develop a quantitative breast symmetry score incorporating five geometric domains and to evaluate inter-rater agreement of the measurements.

Methods: A breast symmetry metric was developed based on established anthropometric and aesthetic principles (4), as well as clinical judgement. It is comprised of five domains: breast width, inframammary fold (IMF) curvature shape, IMF curvature position, nipple-areolar complex (NAC) shape, and NAC position. Each domain is comprised of multiple linear, angle, or area measurements related to the domain. Domain-level scores were calculated by comparing standardized measurements for the left and right breast, which were then combined into two overall symmetry scores with one from an average of the domains and the second from the area of a radar-plot polygon. Two independent raters applied the metrics to five deidentified postoperative photographs after reduction mammoplasty. Inter-rater agreement was assessed by applying absolute agreement metrics, including mean absolute difference and percent difference.

Results: Absolute inter-rater agreement was high across each of the domains, with mean percent difference ranging from 1.2 to 3.6%. Agreement was strongest for curvature shape (mean: 1.2%, range 0.7%-3%) and breast width (mean: 1.3%, range: 0.4-2.7%), and least strong for curvature position (mean: 3.6%, range: 2.8-3.9%). For the average composite score, inter-rater differences were minimal with a mean absolute difference of 0.85 points and a mean difference of 0.9% (range: 0.9-1.9%). For the radar-plot polygon-based composite score, the inter-rater differences were low with a mean absolute difference of 1.6 points and a mean percent difference of 1.8% (range: 0.2-3.8%).

Conclusion: In this proof-of-concept study, a five-domain, quantitative breast symmetry metric was developed that demonstrates high inter-rater agreement in a pilot cohort The varied percent difference for inter-rater agreement indicates that further refinements in specific domains (such as curvature position), may be necessary for greater precision of the metric. Overall, these findings support the feasibility and reproducibility of an objective, quantitative, and compositive approach to breast symmetry assessment and establish a foundation for human subject comparisons and integration with machine learning based approaches.

References: 1. Monton J, Torres A, Gijon M, et al. Use of Symmetry Assessment Methods in the Context of Breast Surgery. Aesthetic Plast Surg. 2020;44(5):1440-1451. doi:10.1007/s00266-020-01755-6

2. Pham M, Alzul R, Elder E, et al. Evaluation of Vectra® XT 3D Surface Imaging Technology in Measuring Breast Symmetry and Breast Volume. Aesthetic Plast Surg. 2023;47(1):1-7. doi:10.1007/s00266-022-03087-z

3. Isaac KV, Murphy BD, Beber B, Brown M. The Reliability of Anthropometric Measurements Used Preoperatively in Aesthetic Breast Surgery. Aesthet Surg J. 2016;36(4):431-437. doi:10.1093/asj/sjv210

4. Liu YJ, Thomson JG. Ideal anthropomorphic values of the female breast: correlation of pluralistic aesthetic evaluations with objective measurements. Ann Plast Surg. 2011;67(1):7-11. doi:10.1097/SAP.0b013e3181f77ab5

Background: Immediate breast reconstruction is an established component of breast cancer care with demonstrated psychosocial and economic benefits (1,2). Although outpatient reconstruction has expanded, concerns persist regarding its safety across reconstructive modalities. The purpose of this study is to evaluate national trends and compare short-term outcomes of outpatient versus inpatient immediate breast reconstruction using propensity-matched analysis.

Methods: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried for mastectomy and breast reconstruction procedures from 2015–2023. Trends in reconstructive modality, care setting, and length of stay were assessed across three periods: pre-2020, 2020, and post-2020. Inpatient and outpatient cohorts were propensity score matched using age, body mass index, diabetes mellitus, disseminated cancer, chronic steroid use, smoking history, and hypertension. Thirty-day postoperative outcomes were compared.

Results: A total of 118,535 breast reconstructions and 316,895 mastectomies were identified. Outpatient immediate reconstruction increased from 8.3% pre-2020 to 36.3% post-2020 for implant-based reconstruction and from 1.67% to 8.35% for autologous reconstruction. Mean postoperative length of stay decreased significantly over time. In propensity-matched analysis, outpatient reconstruction demonstrated lower rates of 30-day reoperation, hematoma/seroma, and blood transfusion compared with inpatient reconstruction across all time periods (P < 0.001). Rates of surgical site infection, implant removal, wound dehiscence, and serious medical complications were low and comparable between settings. No complication category increased for outpatient autologous reconstruction in the post-2020 period.

Conclusions: Outpatient immediate breast reconstruction has expanded substantially and is associated with equivalent or improved short-term outcomes compared with inpatient reconstruction when applied to appropriately selected patients.

1. Al-Ghazal SK, Sully L, Fallowfield L, Blamey RW. The psychological impact of immediate rather than delayed breast reconstruction. Eur J Surg Oncol. 2000;26(1):17-19. doi:10.1053/ejso.1999.0733
2. Khoo, Andrew M.D.; Kroll, Stephen S. M.D.; Reece, Gregory P. M.D.; Miller, Michael J. M.D.; Schusterman, Mark A. M.D.. A Comparison of Resource Costs of Immediate and Delayed Breast Reconstruction. Plastic and Reconstructive Surgery 101(4):p 964-968, April 1998.

Prior breast irradiation is a well-recognized risk factor for postoperative complications following breast surgery. Prior radiation induces long-term microvascular and fibrotic changes that may increase complication risk in subsequent breast surgery. Although reduction mammoplasty has been performed in previously irradiated breasts, existing evidence is derived primarily from small retrospective series, and the influence of radiation timing on postoperative morbidity remains incompletely defined. This study sought to evaluate whether recency of radiation influences postoperative morbidity following reduction mammoplasty. A retrospective cohort study was conducted using the TriNetX Research Network. Patients undergoing reduction mammoplasty were identified and stratified by history of breast radiation occurring prior to index surgery defining exposure. Propensity score matching (1:1) was performed based on age, race, BMI, diabetes, smoking status, hypertension, chronic kidney disease, chemotherapy exposure, and breast cancer diagnosis. Primary outcome was any postoperative complication. Thirty-day outcomes and extended postoperative outcomes were evaluated. Secondary outcomes included seroma/hematoma, dehiscence, scarring, surgical site infection, fat necrosis, return to the operating room, and hospital readmission. Subgroup analyses were performed based on timing of radiation exposure (≤1 year, 1–5 years, >5 years prior to surgery). In the 30-day analysis (n=2022 per group), overall complication rates were similar between cohorts (4.45% vs 3.81%, p=0.30). However, patients with history of radiation experienced significantly higher seroma/hematoma rates (9.20% vs 5.44%, p<0.0001). Over the full post-operative period (n=2153 per group), patients with prior radiation demonstrated a modest increased overall postoperative complications compared to non-radiated controls (19.9% vs 16.9%, p=0.0106), driven primarily by higher rates of seroma/hematoma (RR 1.28, p<0.0001) and fat necrosis (RR 1.33, p=0.0049). Temporal analysis revealed a recency-dependent effect, revealing the greatest risk among patients undergoing reduction within 1 year of radiation (24.97% vs 20.22%, p=0.0318). In the 1–5-year subgroup, overall complication rates were not significantly different; however, rates of seroma/hematoma (p=0.001), scarring(p=0.0212), and fat necrosis (p=0.0028) were elevated. No significant differences were observed among patients with radiation exposure >5 years prior to surgery. Prior breast irradiation is associated with increased postoperative morbidity following reduction mammoplasty, with timing of exposure differentially affecting risk. Early complications are primarily driven by seroma and hematoma formation, while longer-term morbidity is greatest in the first several years after radiation. Beyond 5 years, complication rates approximate those of non-radiated patients. These findings suggest temporal modulation of radiation-associated risk and may inform surgical timing and preoperative counseling.

Background: Oncoplastic breast surgery (OPS) is a form of breast conservation surgery (BCS) that has been shown to be a safe and effective treatment for breast cancer (1) (2). OPS includes both volume displacement (VD) and volume replacement (VR) techniques which allow for oncologic resection while preserving aesthetic outcomes (3). This study aims to evaluate advanced oncoplastic approaches that combine oncoplastic approaches using multiple pedicles and techniques to address complex reconstructive needs following BCS.

Methods: Patients undergoing OBS using at least dual pedicles were retrospectively reviewed from January 2023 to December 2025. Primary outcomes included oncologic safety and postoperative complication rates. Secondary outcomes included surgical complications, delay in adjuvant therapy, recurrence, mortality, and utilization of reconstructive techniques and adjunctive technologies.

Results: A total of 135 patients (139 breasts) underwent BCS with advanced oncoplastic reconstruction using at least a dual-pedicle technique. Median age was 59.0 years (IQR 51.5–66.0), and median body mass index was 30.1 kg/m² (IQR 26.0–35.0). Common comorbidities included hypertension (36.0%) and diabetes (8.6%). Median postoperative follow-up was 13.3 months (IQR 3.3–22.8). The most common primary cancer type was invasive ductal carcinoma (54.7%), followed by ductal carcinoma in situ (18.7%). Median tumor size was 1.5 cm (IQR 0.8–2.2). Positive margins occurred in 7.9% of cases, and 5.8% experienced a delay in adjuvant therapy. There were no cases of local recurrence or breast cancer–specific mortality during follow-up. One patient (0.7%) had evidence of metastatic disease, and all-cause mortality was 1.4%. Indications for advanced oncoplastic reconstruction included patient preference (51.1%), large area of disease or defect (28.8%), multicentric disease (10.1%), and tumor involvement of the nipple–areolar complex (NAC) (10.1%). Of the combined reconstructive approaches, the most frequently involved pedicle was the inferior pedicle in combination with another pedicle (66.2%). Sentinel lymph node biopsy was performed in 79.9% of patients. Adjunctive technologies included intraoperative indocyanine green angiography in 65.5% and closed incision negative pressure wound therapy in 96.4%. Overall postoperative complications occurred in 17.3% of patients, most commonly wound dehiscence (6.5%) and infection (5.8%). No cases of flap failure or nipple loss were observed.

Conclusion: Advanced oncoplastic breast surgery that combines multiple pedicles and techniques for reconstruction of complex defects are feasible and oncologically safe in selected patients undergoing BCS. These approaches address a range of indications, including large areas of disease, multicentric tumors, tumor involvement of the NAC, and patient preference, without compromising margin status or short-term oncologic outcomes. Complication rates were comparable to published outcomes, supporting the role of combined oncoplastic strategies in complex breast reconstruction.

1. Campbell EJ, Romics L. Oncological safety and cosmetic outcomes in oncoplastic breast conservation surgery, a review of the best level of evidence literature. Breast Cancer (Dove Med Press) 2017;9:521-30. 10.2147/BCTT.S113742

2. Chatterjee A, Gass J, Patel K, Holmes D, Kopkash K, Peiris L, Peled A, Ryan J, El-Tamer M, Reiland J. A Consensus Definition and Classification System of Oncoplastic Surgery Developed by the American Society of Breast Surgeons. Ann Surg Oncol. 2019 Oct;26(11):3436-3444. doi: 10.1245/s10434-019-07345-4. Epub 2019 Apr 11. PMID: 30977016.

3. De La Cruz L, Blankenship SA, Chatterjee A, et al. Outcomes After Oncoplastic Breast-Conserving Surgery in Breast Cancer Patients: A Systematic Literature Review. Ann Surg Oncol 2016;23:3247-58. 10.1245/s10434-016-5313-1

Introduction

Long-term maintenance of breast projection and preservation of the inferior pole's shape have historically been some of the most difficult challenges in Wise-pattern reduction mammoplasty and augmentation-mastopexy. Chronic gravitational load of breast parenchyma progressively stretches the skin envelope, leading to the bottoming-out deformity and cephalad migration of the nipple-areolar complex. (1) Traditional techniques commonly depend on parenchymal pillars or skin-based support that frequently fail over time due to the mechanical stress. (2) Therefore, we have developed a new technique called 'Dermal Croisé': a unique surgical modification that utilizes excess inframammary tissue to create an autologous crisscross dermal hammock. This technique functions as a structural internal sling to provide structural support to the breast footprint and shields the skin from being stretched while restoring the breast's fascial support system to its normal state.

Surgical Technique

During preoperative marking of the inframammary fold (IMF), two opposing triangular islands, each 8–10 cm in length, are outlined, extending from the pillar bases to the breast borders. Each area is then completely de-epithelized, forming large dermal-adipose flaps. Following parenchymal resection and pedicle mobilization, each flap is elevated 1.5–2 cm in thickness. The distal end of each flap is secured with long-term absorbable sutures to the deep subcutaneous fascia to cross over each other, creating an overlapping, double-vector suspension sling that reinforces the lower pole. (Figure)

Results

In an initial clinical series of 40 patients with a mean follow-up of 12 months, the technique was successfully implemented with no major complications such as flap necrosis, infection, or implant exposure. The anatomical fixation of the breast by the anchored flaps not only prevented the caudal parenchymal migration but also secured the contour of the upper pole. The clinical application of the Dermal Croisé design allowed for the distribution of tension to be significantly altered; by attaching the weight of the breast to the chest wall and closing the layers of fascia, forces acting on the skin edges have been reduced. Tension-shielding on the skin edges was especially apparent at the T-junction, allowing for improved wound closure and long-term stability of the breast projection.

Conclusion

The Dermal Croisé represents a fundamental paradigmatic shift from a skin-dependent method of shaping the breast to a structural, fascia-supported method of breast shaping. Through the utilization of existing, vascularized, autologous tissue, a cost-free suspension system guaranteeing long-term lower pole definition can be developed. This pedicle-independent modification directly addresses recurrent ptosis and wound dehiscence, providing a reproducible and robust solution for the two most common pitfalls in aesthetic and reconstructive breast surgery.

References

1. Ramanadham SR, Johnson AR. Breast lift with and without implant: a synopsis and primer for the plastic surgeon. Plast Reconstr Surg Glob Open. 2020;8(10):e3057.
2. Wagner RD, Gologorsky RC, Kunjummen JJ, et al. Longevity of ptosis correction in mastopexy and reduction mammaplasty: a systematic review of techniques. JPRAS Open. 2022;34:1-9.

Background: Wise pattern mastectomy has emerged as a popular alternative to transverse pattern mastectomy for patients with moderate-to-severe breast ptosis and macromastia. Although previous reports have evaluated short-term complications, relatively few studies have presented objective data on reconstructive outcomes (e.g., patient satisfaction, revision rates) after completion of Wise pattern mastectomy with two-stage reconstruction. In this study, we compared complication and revision rates among patients with breast ptosis and macromastia undergoing Wise pattern versus transverse pattern skin-sparing mastectomy with immediate two-stage implant-based breast reconstruction.

Methods: In this single-center retrospective cohort study, female patients with a diagnosis of breast cancer or high genetic risk for breast cancer (e.g., BRCA mutation) who underwent skin-sparing mastectomy with immediate tissue expander placement from 2019 to 2023 at the University of Michigan were identified for possible inclusion. The study sample was refined to include only patients with Regnault grade II or III ptosis and no history of breast surgery. Patients who failed to complete two-stage implant-based breast reconstruction were excluded, Bivariate analyses were conducted to compare Wise pattern and transverse pattern mastectomy cohorts. Multivariable logistic regression models were constructed to evaluate factors independently associated with minor and major complications. Additionally, multivariable logistic regression and ordinal logistic regression models were used to evaluate factors associated with primary and subsequent revision operations.

Results: A total of 200 patients met the inclusion criteria, with 125 and 75 patients in the transverse pattern and Wise pattern groups, respectively. No differences in neoadjuvant or adjuvant chemotherapy, radiation therapy, or endocrine therapy were identified between groups. The Wise pattern group demonstrated significantly greater mastectomy weights compared to the transverse pattern group (646+327 g vs. 443+275 g, p<0.001). Moreover, the Wise pattern group showed a higher rate of prepectoral implant placement (81.3% vs. 56.8%, p<0.001) and larger tissue expander size (549+152 cc vs. 490+138 cc, p=0.005) compared to the transverse pattern group. In multivariable analysis, Wise pattern mastectomy was not associated with minor complications and was associated with decreased odds of major complications (OR 0.285, 95% CI 0.120-0.679, p=0.005). Moreover, Wise pattern mastectomy was associated with decreased odds of undergoing breast revision (OR = 0.247, 95% CI 0.117-0.523, p<0.001) and decreased odds of a higher number of total revisions on ordinal logistic regression (OR = 0.231, 95% CI 0.110-0.487, p<0.001).

Conclusions: For patients with moderate-to-severe breast ptosis and macromastia undergoing immediate two-stage implant-based breast reconstruction, Wise pattern mastectomy was associated with a comparable complication rate after first-stage tissue expander placement and lower revision rate after second-stage tissue expander-to-breast implant exchange. These results support the safety and efficacy of Wise pattern mastectomy in patients with breast ptosis and macromastia. Prospective multicenter studies incorporating patient-reported outcome measures are warranted.

Background: Enhanced recovery after surgery (ERAS) protocols and nerve blocks are well-established adjuncts for perioperative pain control in breast surgery. This study aimed to compare the efficacy of combining both pre-operative ERAS and blocks versus either modality alone in patients undergoing tissue expander-based breast reconstruction.

Methods: We conducted a retrospective review of breast cancer patients who underwent tissue expander-based breast reconstruction from January 2019 to 2021 at a single institution. Patients were categorized into two groups: (1) ERAS medications and block versus 2) either ERAS medications or block. Post-operative pain scores, post-operative narcotic use [measured in morphine milligram equivalents (MME)], block-related complications, surgical complications, and 30-day readmission rates were compared between the two cohorts.

Results: Ninety-eight patients underwent tissue-expander based breast reconstruction. Of these patients, 37 received either pre-operative ERAS medications or a nerve block and 61 patients received both modalities. The ERAS + Block group received significantly less narcotics post-operatively compared to the single-modality group [2mg (IQR: 0-7.5mg) vs 7.5mg (IQR: 3.5-18mg), p < 0.05 ]. While overall pain scores did not differ significantly between groups, the trajectories of pain differed significantly (p<0.05). There were no block-related complications. No significant differences were observed in complication rates or 30-day readmission.

Conclusion: The combination of pre-operative ERAS medications and nerve blocks in tissue expander-based breast reconstruction significantly reduced post-operative opioid consumption compared to either modality alone. While overall pain scores were similar, the differing trajectories of pain over time suggest enhanced pain control dynamics with combined therapy. This multimodal approach should be highly considered to enhance patient comfort and optimize perioperative pain management in breast reconstruction.

Background: Socioeconomic disparities in breast reconstruction are well described; however, it remains unclear whether inequities are driven primarily by insurance status or broader structural factors. We evaluated the independent and interactive effects of neighborhood deprivation and payer type on plastic surgery consultation and reconstruction after mastectomy. Methods: A retrospective cohort study was conducted using Epic Cosmos from January 2014 to December 2024. Adult patients undergoing mastectomy were identified. Outcomes included PRS encounter and receipt of reconstruction. Patients were stratified by Area Deprivation Index (ADI) quartile and insurance category. Multivariable logistic regression adjusted for age (<50, 50–64, ≥65 years). Interaction between ADI and insurance was assessed using likelihood ratio testing. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were reported. Results: A total of 287,419 patients underwent mastectomy. Increasing neighborhood deprivation was independently associated with lower likelihood of PRS encounter and reconstruction. Compared with the lowest ADI quartile, patients in the highest quartile had reduced odds of PRS encounter (OR 0.59, 95% CI 0.57–0.61, p<0.001) and reconstruction (OR 0.65, 95% CI 0.63–0.67, p<0.001) after age adjustment. Insurance status was also independently associated with access; Medicare (PRS OR 0.46; reconstruction OR 0.41, both p<0.001) and Medicaid (PRS OR 0.82; reconstruction OR 0.83, both p<0.001) were associated with lower odds compared with commercial coverage. A consistent and monotonic decline in consultation and reconstruction was observed across increasing ADI quartiles within each insurance category. Interaction between ADI and insurance was statistically significant for both outcomes (p<0.001). Proximity to an NCI-designated cancer center modestly increased consultation but did not eliminate disparities. Conclusions: Neighborhood deprivation independently influences access to breast reconstruction across all payer types. These findings suggest that structural barriers beyond insurance coverage, such as transportation burden, financial toxicity, and community-level access constraints, may drive persistent inequities in reconstructive care.

Background: The deep inferior epigastric perforator (DIEP) free flap is the gold standard for autologous breast reconstruction. Our group previously described the purse-string DIEPplasty technique, a flap-reshaping approach using a polydioxanone suture placed in the Scarpa's fascial layer in a purse-string fashion to convert typically triangular abdominal-based flaps into a more circular, implant-like shape prior to inset. Historically, suture-based shaping techniques were thought to increase fat necrosis and fluid collections. The purpose of this study was to compare post-operative outcomes and revision burden between patients who underwent purse-string DIEPplasty and those who did not.

Methods: We conducted a retrospective review of bilateral DIEP flaps performed by a single primary surgeon within an academic co-surgeon model. Patients were grouped by use of purse-string DIEPplasty. Demographics, comorbidities, timing of reconstruction, and perforator number were collected. Recipient-site outcomes included infection, seroma, hematoma, wound complications, fat necrosis, and mastectomy skin flap necrosis. All patients had minimum 6 months of follow-up. Analyses were performed at the per-breast level, treating each breast as an independent observation. To account for clustering in bilateral reconstructions, generalized estimating equations with a binomial distribution and logit link were used. A multivariable model adjusting for perforator count assessed the independent association between DIEPplasty and fat necrosis. Results are reported as odds ratios (OR) with 95% confidence intervals (CI). Revision procedures were analyzed using Poisson regression, reported as incidence rate ratios (IRR). Statistical significance was set at p < 0.05.

Results: Between March 2022 and March 2025, 127 patients underwent 254 bilateral DIEP flaps; 80 patients (160 breasts, 63.0%) received DIEPplasty. Mean age was 48.8 ± 10.3 years and mean BMI was 29.6 ± 4.9 kg/m². Groups did not differ in age, BMI, comorbidities, or timing of reconstruction (all p > 0.05). Delayed reconstruction rates were similar (71.3% vs 74.5%, p = 0.84). DIEPplasty flaps had more total perforator vessels than controls (5.0 ± 1.1 vs. 4.2 ± 1.3, p < 0.01), as well as individually on the left (2.5 ± 0.7 vs 2.1 ± 0.9, p < 0.01) and right (2.5 ± 0.7 vs 2.2 ± 0.8, p = 0.03) hemi-flaps. There were no differences in postoperative complications on univariate or cluster-adjusted analyses. After adjusting for perforator count, DIEPplasty was not associated with increased fat necrosis (OR 2.02, CI 0.89–4.57, p = 0.09), and perforator number was not independently predictive (OR 1.00, CI 0.73–1.38, p = 0.99). Overall, 73.2% of patients underwent elective revision surgery and 55.9% underwent fat grafting. DIEPplasty was associated with a lower rate of elective revision procedures (IRR 0.68, CI 0.49–0.95, p = 0.02), while fat grafting rates were similar (IRR 0.83, CI 0.54–1.26, p = 0.37). However, DIEPplasty patients required significantly less fat graft volume (194.0 ± 250.9 mL vs 299.7 ± 286.9 mL, p = 0.03).

Conclusion: Purse-string DIEPplasty did not increase recipient-site complications and was associated with reduced revision burden and lower fat grafting volume. These findings support DIEPplasty as a safe and effective flap-shaping technique in autologous breast reconstruction.

Background: The Southeastern United States has among the highest obesity rates nationally, with a disproportionate burden among Black women.[1] Elevated body mass index (BMI) has been associated with increased wound complications after reduction mammoplasty in national database studies.[2,3] However, regional data from high-obesity populations remain limited. We evaluated the association between BMI and postoperative outcomes at a Southeastern academic plastic surgery center.

Methods: We performed a retrospective analysis of 128 patients undergoing bilateral reduction mammoplasty between June 2024 and December 2025. Patients were stratified into four BMI groups: <30 (n=24), 30–35 (n=38), 35–40 (n=32), and >40 (n=34). Outcomes included wound infection, wound breakdown, hematoma or seroma, resection weight, operative time, and procedural re-intervention.

Results: Mean BMI was 35.8kg/m², and 26.6% of patients had BMI >40. Wound breakdown occurred in 16.7% of patients with BMI <30, 26.3% in the 30–35 group, 43.8% in the 35–40 group, and 70.6% in patients with BMI >40 (p<0.001). Most events were superficial dehiscence at the inframammary fold or T-junction and were managed with local wound care. Each one-unit increase in BMI increased the odds of wound breakdown by 16% (OR 1.16, 95% CI 1.08–1.25; p<0.001). Wound infection increased from 12.5% to 26.5% across groups but was not statistically significant (p=0.24). Hematoma or seroma occurred in 14.8% overall and was not associated with BMI (p=0.92). Return to the operating room rose from 0% to 14.7% across BMI groups without statistical significance (p=0.09). Resection weight increased with BMI (p<0.001), and operative time differed modestly (p=0.014).

Conclusion: Increasing BMI was strongly associated with wound breakdown and greater resection weight, findings expected in higher-BMI populations. Despite increased wound events, most complications were superficial and conservatively managed. Importantly, patients across BMI groups appear to achieve similar symptomatic relief, prompting ongoing prospective evaluation of patient-reported satisfaction independent of wound outcomes.

References 1. Centers for Disease Control and Prevention. Adult Obesity Prevalence Maps. Updated 2023. Accessed January 2026. https://www.cdc.gov/obesity/data/prevalence-maps.html 2. F Fischer JP, Cleveland EC, Shang EK, Nelson JA, Serletti JM. Complications following reduction mammaplasty: a review of 3538 cases from the 2005-2010 NSQIP data sets. Aesthet Surg J. 2014 Jan 1;34(1):66-73. doi: 10.1177/1090820X13515676. Epub 2013 Dec 13. PMID: 24334499. 3. Nelson JA, Fischer JP, Chung CU, West A, Tuggle CT, Serletti JM, Kovach SJ. Obesity and early complications following reduction mammaplasty: an analysis of 4545 patients from the 2005-2011 NSQIP datasets. J Plast Surg Hand Surg. 2014 Oct;48(5):334-9. doi: 10.3109/2000656X.2014.886582. Epub 2014 Feb 10. PMID: 24506446.

Background Cyclin-dependent kinase (CDK) 4/6 inhibitors such as Abemaciclib, Palbociclib and Ribociclib, are approved for use primarily in hormone receptor-positive, HER2-negative advanced and metastatic breast cancer (1). CDK4/6 inhibitors enforce G1 cell-cycle arrest, thereby preventing progression of cells through mitosis (2). The impact on wound healing is not fully understood. Currently there is no evidence available on outcomes in autologous free tissue transfer in patients on CDK4/6 inhibitors. This study investigates the impact of peri-operative CDK4/6 inhibitors on postoperative complications after deep inferior epigastric perforator (DIEP) breast reconstruction.

Method We present a retrospective, consecutive cohort series of all unilateral DIEP breast reconstruction patients operated between January 2024 and January 2026 at our institution. Patients undergoing delayed and immediate DIEP reconstruction were included. Patients were excluded if they began CDK4/6 inhibitors only after their DIEP reconstruction surgery.
Data was collected for demographic information, oncologic profile, chemo- and radiotherapy, and complications. The primary outcome was documentation of major complication (Clavien-Dindo Grade ≥ III) or any complication (any deviation from the normal postoperative course). Statistical comparisons were performed using Chi-square (or Fisher's exact) tests for categorical variables and the independent samples t-test for continuous variables.

Results The study included 232 patients, 9 of whom (4%) underwent peri-operative CDK4/6 inhibitor therapy at the time of DIEP reconstruction. The median age of all patients was 51 years. Among surgical risk factors, 41 patients (18%) were obese (BMI ≥ 30), 16 (7%) had a smoking history, and 5 (2%) had diabetes. CDK4/6 inhibitors administered were; Abemaciclib (n=6), Ribociclib (n=2) and Palbociclib (n=1), and patients were recommended a median of 2 weeks, 2.5 and 1 week off treatment pre-operatively, respectively. CDK4/6 inhibitors were restarted when patients were fully healed, at a median of 2 weeks post-operatively. There were no oncological ill-effects related to the temporary cessation of treatment.
Patients who received CDK4/6 inhibitors were more likely to have undergone previous chemotherapy (67% vs. 27%) and radiotherapy (78% vs 24%) compared to those who did not receive CDK4/6 inhibitors (p<0.05). Pre-operative haemoglobin, white cells, neutrophil and lymphocyte count were all significantly lower in CDK4/6 inhibitor patients (p<0.05). Major complications were rare in both the CDK4/6 inhibitor and the non-CDK4/6 inhibitor groups (0% vs 2.2%, p = 1). No partial or complete free flap losses occurred. There were no minor complications in CDK4/6 inhibitor patients compared with 24 (11%) in non-CDK4/6 inhibitor patients, although this did not reach significance (p = 0.6).

Conclusion This is the first series of peri-operative CDK4/6 inhibitor safety in autologous free tissue transfer. We advocate for judicious coordination between the surgical and medical oncology teams around temporary cessation of treatment, with consideration of peri-operative iron transfusion and prophylactic antibiotics given the medication's myelosuppressive effect. CDK4/6 inhibitors were not associated with higher surgical complication rates after DIEP breast reconstruction at our institution, and as such they appear safe in free tissue transfer in this early series. Larger, multi-centre studies are needed to assess the risk profile of peri-operative CDK4/6 inhibitors in more diverse patient populations.

References 1. Johnston SRD, Toi M, O'Shaughnessy J, et al. Abemaciclib plus endocrine therapy for hormone receptor-positive, HER2-negative, node-positive, high-risk early breast cancer (monarchE): results from a preplanned interim analysis of a randomised, open-label, phase 3 trial. Lancet Oncol. 2023 Jan;24(1):77-90.

2. Cazenave MG, Elahi L, Mahiou K, Bonneau C, Ammendola O, Benoit L. How should we manage abemaciclib in the peri-operative period during secondary breast reconstruction: balancing oncologic benefit and surgical safety. Breast. 2026 Feb;85:104683.

Purpose: Infection remains a major complication in implant-based reconstruction following mastectomy (1). Standard prevention strategies, including perioperative antibiotics and antiseptic irrigation, have shown limited success. While prophylactic absorbable antibiotic beads have demonstrated efficacy in orthopedic and trauma settings, and chlorhexidine irrigation has been proposed as an effective antimicrobial against biofilm formation, their combined use in implant-based reconstruction remains underexplored. This study aims to evaluate whether combining absorbable antibiotic beads with peri-prosthetic intracorporeal chlorhexidine washes reduces infection and reconstructive loss.

Methods: This retrospective cohort study included patients undergoing primary implant-based breast reconstruction with partial subpectoral tissue expanders over a two-year (2024-2025) period at a single institution. All reconstructions incorporated a contoured, perforated acellular dermal matrix (ADM) as an inferior pole sling, with the inferior border of the pectoralis major sewn to the ADM to create a retromuscular pocket. Two postoperative drains were routinely placed in the prepectoral space. The experimental group received biodegradable calcium sulfate antibiotic beads (1g vancomycin, 240mg gentamicin) placed in the pocket at the time of expander insertion, followed by scheduled peri-prosthetic intracorporeal chlorhexidine washes performed weekly during postoperative clinic visits for the first four weeks. The control group underwent the same reconstructive technique without antibiotic beads or prophylactic chlorhexidine washes over a two-year (2021-2022) period at the same institution. Both groups had expanders placed in the same fashion, with ADM and postoperative drains, and received perioperative and post-operative prophylactic antibiotics.

Results: A total of 177 patients (294 breasts) were included. Over a two-year period, 64 patients (105 breasts) underwent implant-based breast reconstruction with dual prophylaxis using absorbable antibiotic beads and scheduled peri-prosthetic chlorhexidine washes, while 113 patients (189 breasts) served as historical controls. The average age was 58.50 years, the mean BMI was 29.30, and the mean mastectomy weight was 783.43g. There were no statistically significant differences in age, BMI, or mastectomy weight between groups (p > 0.05, t-test).

The infection rate was 8.57% (9/105) in the dual prophylaxis group, significantly lower than 20.10% (38/189) in the control group (p < 0.01, chi-square analysis). Total reconstructive loss occurred in 0.95% (1/105) of the prophylaxis group compared to 14.90% (27/189) of controls (p < 0.01, Fisher's exact test). Among reconstruction losses, 0% of breasts in the prophylaxis group were lost due to infection, compared to 11.64% (22/189) in the control group, while 0.95% (1/105) of prophylaxis group breasts were lost due to soft-tissue failure. Reoperation for infection was performed in 2.86% (3/105) of breasts in the prophylaxis group, with 6 successfully salvaged nonoperatively and 3 salvaged with surgical washout (100%).

Conclusion: Our preliminary results demonstrated lower infection rates and reduced reconstructive loss with the combined use of prophylactic absorbable antibiotic beads and scheduled peri-prosthetic intracorporeal chlorhexidine washes. These findings suggest that dual local prophylaxis may serve as an effective adjunct for infection prevention in breast cancer patients. However, further studies are needed to validate their impact.

References: 1. Kenna DM, Eveler K. Absorbable Antibiotic Beads Prophylaxis in Immediate Breast Reconstruction. Plast Reconstr Surg. 2018;141(4):486e-492e. doi:10.1097/PRS.0000000000004203

Introduction Venous thromboembolism (VTE) remains a significant source of morbidity following breast cancer surgery. This study evaluated the association between hospital length of stay (LOS) and VTE risk after microsurgical breast reconstruction. Secondary objectives included identifying additional risk factors for VTE. Method Patients undergoing microsurgical breast reconstruction were identified from the ACS-NSQIP database (2016–2022). VTE incidence was assessed across postoperative LOS categories (days 1–4 and ≥5) using Cochran–Armitage trend testing and chi-square analyses. Restricted cubic spline modeling to identify a clinically relevant risk threshold. Multivariable logistic regression was performed to identify independent predictors of VTE. Results: A total of 13,285 patients were included (mean age 51.0 ± 9.7 years; mean BMI 29.9 ± 5.3 kg/m²), of whom 169 (1.3%) developed VTE. VTE incidence increased with LOS (0.6%, 0.5%, 0.9%, 1.0%, and 3.0% for days 1–4 and ≥5, respectively; p < 0.001). Patients with LOS >4 days had a significantly higher VTE rate compared with those with LOS ≤4 days (3.0% vs. 0.9%, p < 0.001). On multivariable logistic regression, increased body mass index (BMI) (OR 1.07, CI 1.04–1.09) and longer LOS (OR 1.06, CI 1.03–1.10) were independently associated with increased risk of VTE. Postoperative wound infection, operative time, and preoperative serum sodium demonstrated modest associations. Conclusion: VTE risk increased with hospital length of stay, with a clinically relevant increase beyond postoperative day four. Elevated BMI further amplifies this risk. These findings may inform postoperative risk stratification and discharge planning.

Introduction Outpatient aesthetic breast surgery, including breast augmentation, mastopexy, and reduction mammaplasty, has become one of the most frequently performed procedures in contemporary plastic surgery.¹ Despite its high prevalence and patients' increasing expectations for a rapid and safe recovery, there are currently no international guidelines specifically addressing enhanced recovery pathways for aesthetic breast surgery. This lack of standardization results in marked variability in perioperative practice, with relevant differences in preoperative preparation, anesthetic management, analgesia, drain use, and discharge criteria. Concurrently, emerging evidence indicates that the application of enhanced recovery principles in aesthetic breast surgery is associated with reduced postoperative pain, decreased opioid consumption, faster functional recovery, and lower healthcare costs, without an increase in complications.² The aim of this study is to integrate the available evidence and propose a standardized clinical enhanced recovery protocol for outpatient aesthetic breast surgery.

Materials and Methods A narrative synthesis was conducted based on a systematic review of the literature identifying clinical studies addressing the implementation of structured perioperative protocols in aesthetic breast surgery.³–¹⁰ In parallel, an institutional protocol was developed drawing on recommendations from established enhanced recovery programs and evidence extrapolated from reconstructive breast surgery and other surgical specialties. By integrating both sources, a standardized clinical pathway was designed and organized into three phases, preoperative, intraoperative, and postoperative, incorporating interventions aimed at attenuating the physiological stress response to surgery, optimizing analgesic control, promoting early mobilization, and enabling safe same-day discharge (Figure 1).

Results: Proposed Protocol

Preoperative Phase: This phase includes a structured surgical evaluation, anesthetic risk stratification (ASA classification), systematic nutritional assessment, and optimization of lifestyle factors (smoking and alcohol cessation, body mass index control). Comprehensive preoperative education, both verbal and written, is provided, informed consent is delivered in advance, and preventive multimodal analgesia is prescribed. Shortened fasting and preoperative oral carbohydrate loading are recommended in selected patients to reduce insulin resistance and dehydration.

Intraoperative Phase: General anesthesia using total intravenous anesthesia (TIVA) with an opioid-sparing approach is recommended, combined with multimodal prophylaxis for postoperative nausea and vomiting. Regional analgesia is achieved with PECS I or PECS II interfascial blocks depending on the procedure, supplemented by local infiltration with long-acting anesthetics. Goal-directed fluid therapy is employed to maintain a near-zero fluid balance. Intraoperative normothermia is prioritized, and routine drain use is minimized in favor of external compression systems.

Postoperative Phase: Early mobilization within the first postoperative hours and early resumption of oral intake are encouraged. Analgesia is maintained with a multimodal regimen based on acetaminophen, nonsteroidal anti-inflammatory drugs, and gabapentinoids, reserving opioids for rescue therapy. Thromboprophylaxis is prescribed according to individual risk stratification. Structured follow-up is implemented, including early postoperative telephone contact and an in-person visit within the first postoperative week.

Expected Outcomes Available evidence supports that these components are associated with reduced postoperative pain, lower analgesic requirements, decreased nausea and vomiting, accelerated functional recovery, high patient satisfaction, and reduced utilization of hospital resources, while maintaining low complication rates.

Conclusion The integration of enhanced recovery principles into outpatient aesthetic breast surgery enables the establishment of a standardized, reproducible, and patient-centered clinical pathway. This protocol represents a practical proposal to optimize safety, perioperative experience, and healthcare efficiency. Prospective studies are required to validate its clinical and economic impact, as well as patient satisfaction outcomes, and to support the development of future guidelines specific to aesthetic breast surgery.

Background: Early recovery after abdominally based autologous breast reconstruction is influenced by complex pain experiences across donor and recipient sites, yet the relative contributions of baseline pain characteristics, inpatient pain burden, and reconstruction timing to early patient-reported outcomes remain poorly defined. This study aimed to characterize early postoperative pain trajectories and functional impact, and to evaluate whether baseline pain characteristics and/or inpatient pain burden independently influence early BREAST-Q quality-of-life outcomes.

Methods: We conducted a prospective observational study of adults undergoing abdominally based breast reconstruction. Participants completed baseline and two-week post-discharge pain scores and BREAST-Q modules, as well as daily surveys on postoperative days 1-3 assessing pain intensity (0-10), location, quality, and functional impact. Clinical variables included demographics, laterality, timing, and inpatient opioid use in morphine milligram equivalents. Data were analyzed using descriptive statistics, repeated-measures analyses, paired comparisons, and multivariable models, with significance set at p<0.05.

Results: Thirty-three female patients are enrolled, with complete pain and BREAST-Q data available for 26 patients included in the analytic cohort (mean age, 50.6 ± 12.4 years); most underwent bilateral (88%) and delayed (62%) reconstruction. Postoperative baseline pain scores were significantly higher than preoperative values across overall, abdominal, and chest domains (all p<0.001). Delayed reconstruction patients demonstrated higher baseline chest and overall pain compared with immediate reconstruction (p<0.05), though two-week pain outcomes did not differ by timing of reconstruction. At two weeks, pain remained most frequently localized to the donor site (n=12), followed by the recipient site (n=7) and back (n=4). Inpatient opioid utilization declined from the first postoperative day onward, while overall pain demonstrated a gradual downward trend without significant change across timepoints (p=0.265). Donor-site pain remained greater than recipient-site pain at each postoperative day (all p<0.01). Greater inpatient pain burden and opioid utilization correlated with higher two-week donor-site pain (r ≈ 0.48-0.51, p<0.05), while higher baseline pain demonstrated an inverse association with postoperative pain change (r ≈ -0.57 to -0.66, p<0.01). BREAST-Q analysis demonstrated declines in psychosocial well-being (Δ = -10.8, p=0.038) with no significant change in sexual well-being or breast satisfaction. Chest (Δ = +13.7, p=0.012) and abdominal physical well-being (Δ = +36.1, p<0.001) improved postoperatively. Immediate reconstruction, compared with delayed reconstruction, demonstrated greater improvements in chest (Δ +34.6 ± 16.6 vs +0.85 ± 15.4, p<0.001) and abdominal physical well-being (Δ +53.1 ± 11.2 vs +29.2 ± 22.0, p=0.018), and delayed reconstruction remained independently associated with lower postoperative chest and abdominal physical well-being in baseline-adjusted models. Inpatient pain burden and opioid utilization were not independently associated with early BREAST-Q outcomes after adjustment for multiple comparisons.

Conclusion: Early recovery after abdominally based autologous breast reconstruction is characterized by donor-site–dominant pain despite declining opioid use. Baseline pain characteristics and reconstruction timing influenced early physical well-being, whereas inpatient pain burden did not independently predict BREAST-Q recovery. These findings highlight patient-specific baseline factors and surgical context, rather than acute inpatient pain intensity alone, as key determinants of early quality-of-life recovery and support individualized perioperative strategies beyond pain intensity-focused management.

Breast cancer-related lymphedema affects 30-47% of patients following axillary dissection (1), with lymphatic microsurgical preventive-healing approach (LYMPHA) demonstrating reduction from 14.1% to 2.1% in non-irradiated patients (2). Single-tracer lymphatic mapping for the LYMPHA limits comprehensive visualization of upper extremity lymphatic drainage territories. We propose a novel triple-dye protocol addressing this limitation through spatially distinct multi-zone mapping and real-time patency confirmation.

We performed LYMPHA using a standardized triple-dye protocol in consecutive patients undergoing axillary lymph node dissection (ALND) for breast cancer. The protocol employs sequential subdermal injection of indocyanine green (1mL) into hand web spaces, fluorescein yellow (1mL) into volar and dorsal forearm locations, and isosulfan blue (1mL) into proximal and distal upper arm sites, creating spatially distinct visualization zones throughout the upper extremity drainage territories. Intraoperative identification uses sequential microscope lens switching with IR-800 (800 nm), yellow fluorescence (560 nm), and standard visualization modes to confirm drainage from the hand, forearm, and upper arm, respectively. Microsurgical anastomosis was predominantly performed using lymphatic coupler-assisted invagination technique, with real-time patency confirmed through direct dye-flow visualization.

Between April 2021 and May 2023, 214 consecutive patients underwent triple-dye LYMPHA at the time of ALND. 83% received adjuvant radiation, a recognized lymphedema risk factor (3), with a median of 12 lymph nodes removed per case (IQR 9-18).

Invagination/telescoping was the dominant anastomotic technique (N=162, 76%), followed by end-to-end (N=32, 15%) and end-to-side (N=9, 4.2%). The thoracodorsal vein was the most common recipient vessel (61% of anastomoses). One to two anastomoses were performed in 70% of cases and three or more in 30%. Dye-specific technical challenges included absence of yellow fluorescence in 9% of cases and green fluorescence in 3.3%, confirming that no single injection site guarantees visualization of all drainage territories. Complications included infection (15%), wound healing delay (12%), seroma (9.8%), hematoma (3.3%), and prolonged drain placement (2.3%).

The triple-dye LYMPHA protocol provides three operative advantages over single-tracer techniques: 1) spatially comprehensive lymphatic mapping across the full upper extremity drainage territory, 2) tracer redundancy compensating for documented individual injection site failure rates, and 3) objective real-time anastomotic patency verification. Dye-specific failure rates approaching 10% in the forearm and 4% in the hand within our series confirm that multi-tracer redundancy is operatively beneficial. This protocol establishes a standardized, reproducible framework for prophylactic lymphatic surgery with built-in intraoperative quality assurance. The effectiveness of lymphedema prophylaxis was not assessed as part of this investigation.

References: 1. Deldar R, Spoer D, Gupta N, et al. Prophylactic Lymphovenous Bypass at the Time of Axillary Lymph Node Dissection Decreases Rates of Lymphedema. Ann Surg Open. 2023;4(2):e278. Published 2023 May 2. doi:10.1097/AS9.0000000000000278 2. Johnson AR, Kimball S, Epstein S, et al. Lymphedema Incidence After Axillary Lymph Node Dissection: Quantifying the Impact of Radiation and the Lymphatic Microsurgical Preventive Healing Approach. Ann Plast Surg. 2019;82(4S Suppl 3):S234-S241. doi:10.1097/SAP.0000000000001864 3. Weinstein B, Le NK, Robertson E, et al. Reverse Lymphatic Mapping and Immediate Microsurgical Lymphatic Reconstruction Reduces Early Risk of Breast Cancer-Related Lymphedema. Plast Reconstr Surg. 2022;149(5):1061-1069. doi:10.1097/PRS.0000000000008986