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Implant-based breast reconstruction (IBBR) remains the most common form of post-mastectomy reconstruction worldwide, offering patients a reliable and accessible option to restore breast contour. Advances in surgical technique, biomaterials, and implant technology have driven rapid evolution in the field, with the dual goals of improving aesthetic outcomes and minimizing patient morbidity. The prepectoral plane has been popularized due to the eliminated risk of animation deformity and reduced postoperative pain. Some concerns remain regarding mastectomy flap thickness and long-term oncologic and aesthetic outcomes. Concurrently, nipple-sparing mastectomy has improved aesthetic results and enabled surgeons to move beyond just restoring breast form and improve functional recovery as well, as demonstrated by surgical efforts aimed at restoring nipple–areolar complex (NAC) sensation. Adjunctive use of biologic matrices and synthetic meshes has broadened reconstructive options, while next-generation implants seek to further enhance outcomes. Balanced against these innovations are important oncologic and systemic safety concerns, including breast implant-related cancers and the ongoing debate over breast implant illness (BII). This review highlights eight current “hot topics” in implant-based breast reconstruction: (1) prepectoral reconstruction, (2) nipple-sparing mastectomy, (3) oncoplastic techniques, (4) nipple–areolar complex (NAC) neurotization, (5) biologic matrices and synthetic meshes, (6) next-generation implants, (7) optimizing aesthetic outcomes, and (8) implant-associated cancer and systemic concerns. Together, these areas define the current landscape of innovation, controversy, and future directions in implant-based reconstruction.

Background: Nipple-sparing mastectomy (NSM), given demonstrated oncologic safety, is widely used for both therapeutic and prophylactic mastectomy. The popularity of NSM has spurred advancements by breast and plastic surgeons, liberalizing the indications for NSM and improving patient and aesthetic reconstructive outcomes. This review explores these developments and establishes up-to-date surgical tenets for successful NSM and reconstruction. Methods: A comprehensive literature review was conducted using the PubMed, Google Scholar, and Cochrane Library databases, focusing on peer-reviewed studies published up to 2024. Articles were selected based on relevance, quantity, and documentation of clinical outcomes and patient satisfaction. Results: NSM is utilized frequently for both invasive breast cancers and prophylactic mastectomy, with expanded criteria for candidacy by breast surgeons. Staged procedures such as adjunct reduction, mastopexy, or nipple delay allow patients with larger or ptotic breasts to undergo NSM with comparable outcomes. Long-term outcome studies have identified important risk factors for complications, including smoking history, higher mastectomy weight, certain medical comorbidities, and suboptimal mastectomy flaps. Evolutions in reconstructive decision making in direct-to-implant and staged tissue expander placement have improved aesthetic results while accounting for poor mastectomy flap quality or adjuvant therapy. Long-term outcomes show NSM remains safe and has comparable rates of local recurrence. Patient-reported outcomes demonstrate satisfaction with NSM, especially in sexual and psychological wellbeing metrics. Conclusions: NSM has been demonstrated to be safe in long-term oncologic outcomes. Its widespread popularity over the past ten years has helped identify methods to improve upon surgical and aesthetic outcomes, including decision-making in reconstruction; considerations for challenging patient-related characteristics such as macromastia, ptosis, and NAC asymmetry; and novel advances in areas such as neurotization.

Patients requiring breast reconstruction following radiation therapy or prior failed autologous breast reconstruction (ABR) or implant-based breast reconstruction (IBBR) represent a challenging cohort and often present with compromised vascularity, scarred anatomy, and subsequent increased rates of complications. In this review, we discuss microsurgical strategies designed to optimize donor tissue in these challenging clinical scenarios, including the use of stacked or bipedicled flaps, and the utility of intraoperative indocyanine green angiography. We also review approaches to alternate recipient vessel selection in the suboptimal chest, and we address specific strategies for the revision setting, like soft tissue support and hybrid reconstruction with ABR and IBBR. By synthesizing the current literature and expert experience, this narrative review provides a practical framework for microsurgeons managing complex breast reconstruction in higher-risk patients.

Background: Zygomatic arch (ZA) fractures are a common facial fracture, and reduction is typically performed blind via a Gillies or Keen approach. Postoperative confirmation of reduction thus requires advanced imaging, which may not be readily available in all settings. Thus, there exists a need for an effective, low-cost imaging paradigm to employ in these clinical scenarios. Herein, we introduce the ultrasonic arch reduction (USA Reduction) for ZA fractures. Methods: All consecutive patients with ZA fractures undergoing a USA Reduction at a single public hospital were reviewed. Patients were operated on by two plastic surgeons. A standard Gillies approach was used in all cases in conjunction with real-time intraoperative ultrasound. All relevant patient data were collected and analyzed. Results: Two patients were included in our study. Patient 1 was a 43-year-old man who was assaulted and sustained a right comminuted zygomatic arch fracture without concomitant trauma. Patient 2 was a 35-year-old man who was hit by a train and sustained a left comminuted ZA fracture in addition to traumatic subarachnoid hemorrhage. Both fractures were successfully reduced under ultrasound guidance in under 1 hour of operating room (OR) time without necessitating the use of postoperative CT. To date, both patients endorse positive postoperative satisfaction with their results. Conclusions: Intraoperative ultrasound is a safe and effective tool for confirming reduction of ZA fractures in a resource-limited practice while obviating the need for additional radiation. Further investigations to standardize the technique and approach will be useful to optimize this intraoperative adjunct.

Background Plastic surgery training has undergone tremendous change and transitioned through many models over the years, including independent, combined, and integrated. This study evaluates how these changes and others have affected plastic surgery applicants' demographics and academic qualifications over the last 30 years. Methods Data on applicant demographics and academic qualifications were extracted from multiple sources including the National Resident Matching Program, the American Association of Medical Colleges, and cross-sectional surveys of plastic surgery applicants for the years 1992, 2005, 2011, and 2022. Data were compared using pairwise χ² goodness of fit tests. Results The sex distribution of plastic surgery applicants changed significantly over the last 30 years: whereas men predominated in 1992 (86% male vs 14% female), by 2011, the distribution was nearly equal (54% male vs 46% female in both 2011 and 2022, P < 0.001). The racial makeup of applicants also changed over time (P < 0.05). White applicants decreased from 73% in 1992 to 55% in 2011, and 53% in 2022. While there was an increase in Asian (7% to > 17% to > 20%) and other (13% to > 14% to > 21%) applicants over time, whereas the proportion of Black applicants remained stagnant (5% to > 6% to > 8%). Applicants with prior general surgery experience declined precipitously over the years: 96% in 1992, 64% in 2005, 37% in 2011, and 26% in 2022 (P < 0.001). When compared with 1992, Alpha Omega Alpha status increased significantly in 2011 (36% vs 12%, P < 0.05) but did not change considerably in 2005 (22%) and 2022 (23%). Research experience increased dramatically over the years, with the proportion of applicants with at least one publication going from 43% in 1992, to 75% in 2005, to 89% in 2011, and to 99% in 2022 (P < 0.001). Applicant interest in academic plastic surgery did not change considerably over the years at roughly ranging from 30% to 50% of applicants (P = ns). Conclusions There has been a shift in the demographics and academic qualifications of plastic surgery applicants over the last 3 decades. Understanding this evolution is critical for reviewing and evaluating the makeup of our specialty, and enacting changes to increase representation where necessary.