Background: Autologous breast reconstruction after chest-wall radiotherapy (RT) remains challenging because radiation-induced vascular injury may impair flap perfusion and wound healing. Bipedicled deep inferior epigastric perforator (DIEP) flaps anastomosed to two separate recipient systems may provide greater vascular redundancy in this setting. Methods: This retrospective single-center case series, reported according to the PROCESS 2025 guideline, included 26 consecutive women who underwent unilateral bipedicled DIEP flap breast reconstruction in the setting of chest-wall RT between September 2024 and March 2026, with a minimum follow-up of 6 months. Outcomes were total flap loss, flap-related complications, donor-site morbidity, and BREAST-Q scores. Results: One pedicle was anastomosed to the internal mammary vessels and the other to an axillary branch, most often the circumflex scapular artery (18/26; 69.2%). Mean operative time was 7 h 9 min ± 47 min. No total flap loss occurred. One arterial complication (3.8%) involved the internal mammary pedicle, and the flap survived. Abdominal bulge occurred in 5 patients (19.2%). Mean BREAST-Q scores were ≥90 in all domains. Conclusions: In this case series, bipedicled DIEP flap reconstruction was associated with no total flap loss after chest-wall RT, without an apparent increase in early donor-site morbidity. The biological condition of the recipient bed may deserve consideration when selecting flap configuration; larger prospective studies are required to confirm these findings.

Background: In recent years, prepectoral implant-based breast reconstruction supported by acellular dermal matrices (ADMs) has become an increasingly adopted alternative to submuscular techniques. Although this approach can improve patient comfort and aesthetic outcomes, fluid accumulation around the implant remains one of the most frequent and clinically relevant complications. Our unit progressively modified the handling and wrapping of the Braxon^® ADM with the aim of optimizing pocket configuration and reducing seroma formation. Methods: We performed a retrospective analysis of consecutive patients who underwent immediate prepectoral, direct-to-implant breast reconstruction with Braxon^® ADM at our institution between October 2019 and January 2025. Two techniques were compared: a standard full-wrap configuration and a modified approach in which the posterior ADM sheet is trimmed and only anterior coverage is maintained, with fenestrations created in the anterior wall. Clinical data and postoperative complications, including seroma rates, were recorded and compared between groups. Categorical variables were summarized as counts and percentages, and continuous variables as means and standard deviations. The primary comparison between techniques was performed on the presence of at least one postoperative complication using Fisher’s exact test, and odds ratios (OR) with 95% confidence intervals (CI) were calculated where appropriate. A p-value <0.05 was considered statistically significant. Results: A total of 138 direct-to-implant prepectoral reconstructions were included, 90 performed with the standard full-wrap technique and 48 with the modified wrapping approach. The overall complication rate was 27.8% (25/90) in the standard group and 10.4% (5/48) in the new-technique group. Seroma occurred in 8 patients (8.9%) in the standard group and in 1 patient (2.1%) in the modified-technique group. Fisher’s exact test demonstrated a significantly lower overall complication rate in the modified-technique cohort (10.4% vs. 27.8%; p = 0.02; OR 3.31; 95% CI 1.18–9.31), indicating that patients treated with the standard technique had approximately 3.3-fold higher odds of developing at least one complication than those treated with the modified technique. Conclusions: Anterior-only ADM coverage with selective trimming of the posterior sheet and fenestration of the anterior wall appears to reduce complications, particularly seroma, in ADM-assisted prepectoral breast reconstruction. Small technical refinements in ADM handling and pocket configuration, combined with a structured drainage protocol, may substantially improve postoperative outcomes in this setting.

Background: Facial rejuvenation increasingly uses techniques targeting the Superficial Muscular Aponeurotic System (SMAS) to achieve natural and durable outcomes. Advances in anesthesia, especially tumescent local anesthesia (TLA), have enhanced the safety and recovery of complex aesthetic procedures. This study presents a 10-year retrospective evaluation of SMAS plication facelift with platysmaplasty and submental liposuction under TLA, focusing on safety, efficacy, and patient satisfaction. Methods: Between January 2012 and December 2022, 80 consecutive ASA I–II patients (mean age 56.3 ± 4.8 years, BMI 23.4 ± 2.1 kg/m ² ) underwent SMAS plication facelift with midline platysmaplasty and neck liposuction under TLA. The anesthetic solution consisted of 25 mL 2% lidocaine, 8 mEq sodium bicarbonate, and 1 mL epinephrine in 1000 mL saline, yielding a final concentration of 0.049% lidocaine with 1:1,000,000 epinephrine. Mean total lidocaine dose was 100 ± 5 mg (1.4 ± 0.07 mg/kg). Mild sedation with diazepam 0.05–0.25 mg/kg was administered as needed. Median follow-up was 28 months (IQR 24–36). Results: The mean infiltrated volume was 200 ± 30 mL per patient. No conversions to general anesthesia occurred. Complication rate was 10%, including hematoma (2.5%), seroma (1.25%), dystrophic scarring (3.75%), transient paresthesia (1.25%), and pixie ear deformity (1.25%). No infections or anesthesia-related events were recorded. Patient-reported satisfaction averaged 4.01/5, with high satisfaction regarding postoperative pain management. Conclusion: This ten-year case series demonstrates TLA as a safe and effective alternative to general anesthesia for SMAS plication facelift in selected patients. The technique provides adequate analgesia, supports precise dissection with less bleeding, and minimizes postoperative edema and ecchymosis, leading to quicker recovery and improved patient comfort and satisfaction. Level of Evidence IV: 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 .

Background: Breast augmentation is traditionally performed under general anesthesia, but tumescent local anesthesia (TLA) offers advantages in terms of rapid recovery and reduced risks. This study presents the largest European series on the use of TLA for breast augmentation, analyzing the cumulative results of 16 years of experience. Methods: A multicenter retrospective analysis was conducted on 1644 consecutive patients (982 subglandular and 662 subpectoral) between 2008 and 2024. All procedures were performed under TLA with conscious sedation without the use of general anesthesia. The tumescent solution consisted of 25 mL of 2% lidocaine, 8 mEq of sodium bicarbonate, and 1 mL of epinephrine (1 mg/1 mL) in 1000 mL of 0.9% saline solution. Infiltration protocols differed between groups: the subglandular approach utilized a single-plane technique (mean 589 mL per breast), whereas the subpectoral approach required a two-stage process (pre-fascial and retromuscular) with a higher mean volume (770 mL per breast). Intraoperative parameters, complication rates, and patient-reported outcomes (BREAST-Q) were analyzed. Statistical comparisons between the two surgical planes were performed using Independent Samples T-tests. Results: The procedure was successfully completed under TLA in 100% of cases, with no conversions to GA. The subpectoral approach was associated with significantly higher mean operating times (141 ± 11.2 min vs. 90.3 ± 11 min; p < 0.001) and TLA solution volumes (770 ± 16.1 mL vs. 589 ± 53.6 mL; p < 0.001). The overall major complication rate was 4.74%, with a significantly higher incidence of hematoma in the subpectoral group compared to the subglandular group (3.51% vs. 1.83%; p = 0.015). Regarding severe capsular contracture (Baker III–IV), although a slightly higher incidence was observed in the subpectoral cohort compared to the subglandular group (2.11% vs. 1.22%), this difference was not statistically significant (p = 0.155). Patient satisfaction via Breast-Q was high, with dissatisfaction exclusively linked to implant dislocation. Conclusions: This 16-year cumulative analysis validates TLA as a safe, effective, and reproducible alternative to general anesthesia for both subglandular and subpectoral breast augmentation. While the subpectoral plane entails longer surgical times and a slightly higher risk of minor complications, the TLA protocol ensures excellent pharmacological safety and rapid functional recovery, supporting its use in modern outpatient surgical settings.