After studying this article, the participant should be able to: 1. Define the indications, benefits, and drawbacks of thigh-based flap donor sites for breast reconstruction. 2. Recognize the differences between popular thigh-based flaps and the utility of each. 3. Understand the anatomy of thigh-based free flaps, including their landmarks, vascular pedicles, and techniques of flap harvest. 4. Manage donor-site healing and complications. Thigh-based free flaps have become a popular flap option for autologous breast reconstruction. Critiques of thigh-based flaps include inadequate flap volume and donor-site concerns, such as poor appearance, sensory changes, and problematic healing; however, refinements in surgical technique have led to more predictable outcomes. The purpose of this article is to review the advantages and disadvantages of the various thigh-based free flaps for breast reconstruction, including gracilis myocutaneous, profunda artery perforator, and lateral thigh perforator flaps. Practical pearls for flap harvest and optimization of aesthetic results are provided.

Validating national trends in breast reconstruction hospital price variation: A detailed analysis of a state market.

Breast symmetry plays a key role in breast reconstructive surgery. In the healthy population, volume asymmetry is common. This study aimed to better understand how breast symmetry is perceived and to compare subjective estimation with objective measurements of breast symmetry in the healthy participants. A retrospective cross-sectional study included healthy participants who underwent VECTRA 3-dimentional breast imaging. Breast volume measurements were obtained using the VECTRA system. Five plastic surgeons and five laypersons assessed volume symmetry subjectively. Of 209 healthy participants, 100 were randomly selected for assessment. Mean left and right breast volumes were 636.8 cc and 664.8 cc, respectively, with a mean relative volume difference of 16.0% (SD 12.7). No clear threshold of relative breast volume difference was found in which the majority of plastic surgeons or laypersons defined breast asymmetry. Even with large volume differences quantified by 3D VECTRA measurement, breasts were perceived as symmetrical by both plastic surgeons and laypersons. Inter-observer agreement was poor for both groups (Fleiss' kappa: surgeons 0.23; laypersons 0.30). Agreement with 3D measurements regarding the larger breast was low (surgeons: accuracy 53.8%, Cohen's kappa 0.08; laypersons: accuracy 48.6%, Cohen's kappa -0.07). Subjective assessments of breast symmetry by both experts and laypersons poorly correlate with objective 3D imaging volume measurements. Symmetry perception likely extends beyond volume alone, influenced by factors such as breast shape, projection, and nipple position. While 3D imaging provides reliable volume measurements and preoperative consultations, it alone may not enhance patient satisfaction regarding perceived symmetry. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Immediate breast reconstruction with perforator flaps after breast-conserving surgery: A case series

Free adipomuscular diagonal upper gracilis flap as volume replacement for reconstruction of partial breast defect in the medial upper quadrant.

Microsurgical breast reconstruction with deep inferior epigastric perforator (DIEP) flaps has become increasingly popular. While surgeons undergo rigorous training, it is believed that plastic surgeons continue to refine and enhance their performance through independent practice. This study evaluates the effect of surgeon experience on clinical outcomes in DIEP flap breast reconstruction. A retrospective review was conducted on consecutive DIEP flap procedures performed by a single surgeon from fellowship completion in 2013 to 10 years of independent professional practice in 2023. Patients were categorized into "early" and "late" groups, separated by a midpoint surgery date (July 30, 2018). Statistical analyses included student's t-tests, chi-squared analysis with Fisher's exact test, and multivariable regressions controlling for comorbidities. The study included a total of 1,182 DIEP flaps in 632 patients, with 238 in the early group and 394 in the late group. The late group had a lower mean body mass index (28.83 vs. 29.98, p = 0.004), prevalence of hypertension (26.6% vs. 35.3%, p = 0.021), and prevalence of diabetes (7.9% vs. 14.3%, p = 0.010) than the early group. After controlling for potential confounders, the late group was independently associated with decreased length of stay (incidence rate ratio [IRR] = 0.611, p < 0.001) and fewer revision surgeries (IRR = 0.689, p < 0.001). This large, single-surgeon series demonstrates that even with extensive initial training, plastic surgeons continue to evolve their surgical outcomes through accumulated experience. These findings emphasize the importance of consistent volume over time in achieving optimal results in microsurgical breast reconstruction.

Experiences and challenges in implant based breast reconstruction decision making among young breast cancer patients: A qualitative study.

Breast-conserving surgery (BCS), mastectomy alone (MA), and mastectomy with immediate breast reconstruction (IBR) offer similar oncologic outcomes in early-stage breast cancer, leading patients to base decisions on nononcologic factors such as chest wall discomfort, tightness, and functional limitations. The authors' primary objective was to evaluate the effects of these operations on quality of life using the BREAST-Q Physical Well-Being: Chest subscale. The secondary objective was to assess the impact of different radiation regimens on chest physical well-being. A retrospective review of stage 0 to III breast cancer patients who underwent BCS, MA, or IBR from 2015 to 2019 was conducted. The primary outcome was change in Physical Well-Being: Chest BREAST-Q scores from the preoperative period to 1-year postoperatively. A minimal important difference greater than or equal to 4 points indicated clinical significance. Of 517 patients, 202 underwent BCS, 125 underwent MA, and 190 underwent IBR. BCS patients demonstrated the highest decline of 15.3 points (89.1 to 73.8; P < 0.001) followed by MA with 12.7 points (76.6 to 63.9; P < 0.001). IBR had the smallest decline of 3.7 points (78.0 to 74.3; P = 0.022). A total of 262 radiation patients experienced a mean decline of 15.2 points (84.6 to 69.4; P < 0.001), with the regional node irradiation with boost group exhibiting the greatest decline of 21.5 points (88.5 to 67.0; P < 0.001). BCS patients, despite higher baseline scores, experienced the greatest decline, whereas IBR patients had the smallest. In addition, greater radiation intensity and extent correlated with larger declines. Integrating minimal important difference into clinical practice ensures that patient-reported outcomes capture changes that are meaningful to patients, guiding treatment decisions.

Prepectoral direct-to-implant (DTI) breast reconstruction is currently the most widely used implant-based reconstruction method, which often utilizes an acellular dermal matrix (ADM)-assisted approach. There are two primary methods for applying ADM: full coverage of the implant and anterior tenting, where only the front is covered. Despite the widespread use of these techniques, comprehensive studies comparing their outcomes are lacking. This study aimed to conduct a thorough head-to-head comparison of the outcomes of the two methods. We reviewed patients who underwent prepectoral DTI breast reconstruction with ADM between January 2021 and April 2022. The patients were divided into two groups on the basis of the preference of the attending surgeon: full coverage and anterior tenting. Postoperative complications and esthetic outcomes were compared and analyzed. A total of 304 patients (363 cases) were analyzed: 295 in the full-coverage group and 68 in the anterior tenting group. The baseline characteristics were generally similar between the two groups. Overall complications did not show significant differences, whereas the capsular contracture rate was significantly lower and detected later in the full-coverage group, which remained significant even after adjusting for other factors, including radiotherapy. The esthetic scores were similar between the groups; however, rippling was significantly less frequently observed in the anterior tenting group. Our findings indicate that both methods of applying the ADM yield comparable outcomes, each with its own advantages and disadvantages. Selection of an appropriate method based on a specific situation can lead to optimal outcomes.

In the traditional ordering model, plastic surgeons often request 3-4 different sizes of implants, tissue expanders (TEs), and sizers per procedure and order duplicates as backup. This can result in large orders, ranging from 15 to 32 items, with most of the materials remaining unused and ultimately being shipped back to the manufacturer. This study aims to quantify the costs incurred by shipping materials used in breast augmentations and reconstructions. A model was constructed to tabulate annual shipping costs, built upon key inputs for annual ordering volumes and shipping rates that were obtained through secondary sources (e.g., courier websites, American Society of Plastic Surgery [ASPS] statistics data), as well as implant/TE sizes and weights. Extreme and conservative scenarios of ordering behavior were simulated in the model to deduce an expected range and most realistic median figure of annual shipping costs. In the base case scenario where three sizes were ordered for all cases using overnight shipping, the total shipping costs for 2023 were $125.3 million. Compared with this, choosing ground shipping for three sizes cost $34.5 million (72.5% less), while ordering four sizes with overnight shipping cost $173.4 million (38.4% more). Implant/TE shipping costs are significant and can total tens to hundreds of millions of dollars depending on the shipping type and total sizes ordered. These costs are handed down to multiple stakeholders in the healthcare system, including physician practices, implant companies, and patients. The results of this study may encourage the use of more cost-efficient methods to decrease overall waste.

Reply: Immediate Hybrid Breast Reconstruction: Dual-Plane Approach Using Prepectoral Implants and Retropectoral Fat Grafting.

Evaluating the Efficacy and Utility of Preoperative Computed Tomography Angiography in Perforator Flap Surgeries: A Systematic Review and Meta-Analysis.

Umbilical Inset Incision Type Influences Abdominal Donor Site Healing in Autologous Breast Reconstruction.

A Primer for Radiation Oncologists on Plastic and Reconstructive Surgery: Key Concepts and Principles.

ASO Visual Abstract: Comprehensive Analysis of Full Coverage Versus Anterior Tenting Techniques for ADM Application in Prepectoral DTI Breast Reconstruction.

Breast reconstruction (BR) following mastectomy is one component of comprehensive breast cancer care; however, its educational emphasis, accessibility, and cultural context vary across health systems, particularly in middle-income countries. Understanding how future physicians perceive BR within the local epidemiologic and health-system landscape is necessary to guide proportionate and culturally responsive medical education. This study assessed knowledge, awareness, perceptions, and attitudes toward BR among Jordanian medical students, with the aim of identifying educational gaps and barriers to practice. A national cross-sectional study was conducted among clinical-year medical students (years 4-6) from six Jordanian universities using a validated, self-administered questionnaire. A validated, self-administered questionnaire was distributed electronically via institutional mailing lists and verified student communication platforms. The survey was developed following expert review and piloting for clarity and cultural appropriateness. Data were analyzed descriptively to evaluate students' educational exposure, knowledge, confidence, and perceptions regarding BR. Of 391 respondents, 69.6% were female and all universities were represented. While 79% reported prior teaching on breast cancer, only 21% attended lectures specifically on BR, and 20.2% observed a procedure. Most rated their knowledge as basic (58.8%), with only 1.3% reporting advanced knowledge. Confidence in counseling patients was limited, with 7.2% feeling very confident. Awareness of key aspects varied: 42.2% recognized both immediate and delayed reconstruction, 55% knew both implant and autologous options, and 57.3% were unsure about insurance coverage. Reported barriers included financial cost (85.2%), lack of awareness (68.3%), and cultural or religious sensitivity (> 60%). Despite this, 88.7% agreed BR improves quality of life, and 75.7% supported greater curricular emphasis, with 68.3% seeking additional training. Jordanian medical students demonstrate supportive attitudes toward BR but significant educational and systemic gaps remain. Strengthening BR education and addressing cultural and financial barriers are essential to empower future physicians in promoting patient-centered cancer care.

Anatomical terminology is often assumed to be structurally precise and historically stable. However, the anterior thoracic region demonstrates significant semantic transformation across time. In classical Latin, pectus referred broadly to the chest without sexual specification. In modern English, the term "breast" predominantly denotes the female mammary gland. This study investigates how a structurally stable anatomical region underwent progressive linguistic gendering. A qualitative historical-anatomical analysis was conducted integrating: (1) philological examination of classical Latin and Greek texts, including the Aeneid; (2) review of medical writings attributed to Hippocrates and Galen to assess early structural differentiation between thorax and mammary gland; (3) comparative analysis of medieval to 19th-century anatomical atlases to evaluate visual and terminological separation of thoracic and mammary structures; and (4) conceptual review of contemporary clinical framing in thoracic trauma and breast reconstruction. No human subjects were involved. Classical terminology (pectus, stēthos) denoted the anterior thorax without inherent sexual coding, while mastos specified mammary tissue. Renaissance dissection reinforced structural separation between thoracic wall and glandular appendage. Despite increasing anatomical precision, vernacular English progressively narrowed "breast" toward female mammary meaning. Modern anatomical standards maintain structural neutrality, but linguistic asymmetry persists in clinical and cultural discourse. The thorax has remained anatomically stable, whereas its linguistic representation has undergone gender-specific specialization. The transition from pectus to "breast" illustrates how anatomical regions may acquire cultural coding independent of structural change.

The aim of breast reconstruction after mastectomy is to improve quality of life and patient satisfaction, but cost-effectiveness of different reconstruction techniques remains uncertain due to methodological limitations in existing studies. High-quality trial-based economic evaluations are therefore needed. This study aimed to compare the quality of life and cost outcomes of patients randomized to different delayed breast reconstruction techniques based on previous receipt of radiotherapy. A single-site randomized controlled trial (GoBreast; NCT03963427) including women aged 18-60 undergoing delayed breast reconstruction was conducted. Patients without previous radiotherapy were randomized to either thoracodorsal flap with implant (TD) or two-stage expander (EXP), while patients with previous receipt of radiotherapy were randomized to either latissimus dorsi with implant (LD) or deep inferior epigastric artery perforator (DIEP) flap. Outcomes included health-related quality of life (HRQoL) (by SF-6D utilities), re-operations, and direct/indirect costs over long-term follow-up. Among patients without previous radiotherapy (n = 75), EXP had slightly lower direct healthcare costs, but higher indirect costs, and generated a statistically significant positive change in HRQoL utility value (0.06 (0.02;0.9)) and fewer re-operations (2.34 vs 4.73) during a mean follow-up of 12.9 years. Among patients who had received radiotherapy (n = 25), there were no statistically significant differences in HRQoL utility scores or total costs, but a higher re-operation rate for LD as compared to DIEP. Among patients without previous radiotherapy, EXP yielded superior HRQoL and fewer re-operations compared to TD. In patients with previous receipt of radiotherapy, DIEP reconstruction was associated with fewer re-operations and comparable costs compared to LD.

Mapping Breast Cancer Care Patterns in FARO Member Countries: A Survey.

Wise pattern mastectomy has emerged as a popular alternative to transverse pattern mastectomy for patients with moderate-to-severe breast ptosis and macromastia. However, there is a knowledge gap regarding reconstructive outcomes. In this study, we compared complication and revision rates among patients with breast ptosis undergoing Wise pattern versus transverse pattern skin-sparing mastectomy with immediate two-stage implant-based breast reconstruction. In this single-center retrospective cohort study, female patients with Regnault grade II or III breast ptosis who underwent skin-sparing mastectomy with immediate tissue expander placement from 2019-2023 were included. Bivariate analyses were conducted to compare Wise pattern and transverse pattern mastectomy cohorts. Multivariable analyses were performed to evaluate complication and revision rates. A total of 200 patients met the inclusion criteria, with 125 and 75 patients in the transverse pattern and Wise pattern groups, respectively. 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). For patients with moderate-to-severe breast ptosis undergoing immediate two-stage implant-based breast reconstruction, Wise pattern mastectomy was associated a similar complication profile and reduced revision burden compared with transverse pattern mastectomy. Prospective multicenter studies incorporating patient-reported outcome measures are warranted.