Background: The COVID-19 pandemic caused unprecedented delays in elective surgery, including breast reconstruction, prolonging expander retention beyond recommended timelines. Methods: We retrospectively compared patients who underwent two-stage expander-to-implant reconstruction before the pandemic (2011–2020) and during the pandemic (2020–2022). Clinical outcomes and patient-reported experiences were analyzed, and multivariate regression was used to adjust for confounders. Results: Expander retention was significantly longer in the pandemic cohort (481 vs. 280 days). Capsular contracture around the expander was markedly increased, with pandemic group assignment and prolonged expander retention emerging as independent predictors in multivariate analysis, while overall complication rates were unaffected. Patient-reported outcomes showed more functional limitations but paradoxically higher satisfaction with the definitive implant. Conclusions: Surgical delay selectively increased the risk of expander contracture without raising overall morbidity. Patient-reported findings highlight the dual impact of delay, with both greater burden and a potential “relief effect”.

Background: Venous congestion is a major contributor to complications in DIEP flap breast reconstruction. Beyond superficial venous dominance, the presence or absence of anatomical connections between the superficial and deep venous systems may influence drainage physiology. This study investigates how preoperative CTA and targeted superdrainage impact outcomes over a 25-year period. Patients and Methods: A retrospective analysis was conducted on 208 DIEP flaps performed from 2000 to 2024 at a single center. From 2006, computed tomographic angiography (CTA) was routinely used to evaluate venous anatomy, focusing on the presence, trajectory, and connection of the superficial inferior epigastric vein (SIEV) with the deep system. Superdrainage was performed when superficial venous dominance was evident or drainage was judged insufficient intraoperatively. Primary outcomes included venous congestion, partial necrosis, and reoperations; secondary outcomes included hospital stay and safety of superdrainage. Results: Venous complications decreased significantly after CTA implementation (37.5% vs. 8.0%; p < 0.001). Superdrainage was performed in 40.9% of post-CTA cases, with 90% preoperatively planned based on CTA findings. No complications were associated with second venous anastomosis. Flap outcomes correlated not with perforator number or flap size but with venous drainage physiology. Mean hospital stay was shorter post-CTA (6 vs. 9 days; p < 0.001). Conclusions: Evaluating the anatomical connection between superficial and deep venous systems via CTA enhances venous planning and allows for safer, physiology-driven decisions. In the absence of such connections, intraoperative evaluation remains essential. Drainage physiology—rather than anatomical metrics alone—should guide surgical strategy in DIEP flap reconstruction.

Background: Implant-based breast reconstruction (IBBR) is the most widely used reconstructive strategy after mastectomy, but postoperative infection remains a major complication because it may require reoperation, implant explantation, and reconstructive failure. This study evaluated the incidence, determinants, and clinical burden of infection in a large single-center cohort. Materials and Methods: This retrospective observational study included 1537 reconstructed breasts undergoing post-mastectomy implant-based breast reconstruction. The unit of analysis was the reconstructed breast. Infection was defined clinically by erythema, pain, swelling, or secretion requiring antibiotic treatment, without requiring microbiological confirmation or formal surgical-site-infection criteria; this pragmatic definition reflects the retrospective nature of the study and should be considered when comparing results across studies. Univariate analyses were performed using chi-square, Fisher’s exact, or Mann–Whitney U tests, as appropriate. Independent predictors were assessed by multivariate binomial logistic regression. Results: Postoperative infection occurred in 66 of 1525 reconstructed breasts (4.3%). Among infected breasts, 54 cases (81.8%) required surgery, whereas 12 (18.2%) were managed conservatively. Implant explantation was performed in 82 of 1525 reconstructions (5.4%), and infection accounted for 39 of 74 explantations with available indication data (52.7%). In multivariate analysis, longer operative time remained independently associated with infection (OR 1.005 per minute, 95% CI 1.001–1.010; p = 0.010; corresponding to OR 1.38, 95% CI 1.08–1.77, per 60 min increment). Prepectoral reconstruction was also associated with a higher risk of infection compared with retropectoral reconstruction (OR 2.31, 95% CI 1.03–5.16; p = 0.042). Additional analyses showed that prepectoral reconstruction was more frequently associated with bilateral procedures, nipple-sparing mastectomy, and longer operative time. In unilateral reconstructions, the association between prepectoral reconstruction and infection persisted. Conclusions: Infection after implant-based breast reconstruction remains a clinically relevant source of morbidity and frequently requires further surgery. Longer operative time emerged as the most consistent independent factor associated with infection in the overall cohort. Prepectoral reconstruction was also associated with infection, although this finding should be interpreted cautiously in light of reconstructive context and case selection.

Extremity soft tissue sarcoma resection often results in complex defects requiring reconstruction to preserve function and support multidisciplinary treatment. Propeller flaps have emerged as a local alternative to free flaps in selected cases, but their role in sarcoma reconstruction remains incompletely defined. This systematic review aimed to assess the current evidence on the indications, reconstructive outcomes, and oncologic reporting of propeller flaps in extremity sarcoma reconstruction. A systematic literature search was conducted in PubMed/MEDLINE, Scopus, and the Cochrane Library in accordance with PRISMA 2020. Studies reporting perforator-based propeller flaps after extremity soft tissue sarcoma resection were included. Data were synthesized descriptively because of the heterogeneity of study design, patient populations, and outcome reporting. Nineteen studies were included. Across the published literature, 656 patients were described overall, including 185 propeller flaps used after sarcoma resection. Most reconstructions involved the lower extremity, accounting for more than 95% of reported cases. Flap survival was generally high; among studies providing extractable numerical data, complete flap survival was 92.7% (115/124), total flap loss was 3.8% (2/52), and partial necrosis occurred in 9.6% (5/52) of flaps. Venous congestion was the most frequently reported complication. Oncologic outcomes were inconsistently reported, and comparative recurrence-related data were very limited. Available data suggest that propeller flaps can provide reliable coverage with acceptable complication rates in selected cases. Oncologic outcomes were sparsely and inconsistently reported, and the current literature does not show a clear signal of increased local recurrence; however, the available evidence is insufficient to draw firm conclusions regarding oncologic safety or equivalence compared with other reconstructive strategies. These findings support consideration of propeller flaps as a complementary reconstructive option in carefully selected patients, although higher-quality studies with standardized oncologic outcomes are needed.

Facial vascularized composite allotransplantation (fVCA) is one of the most complex forms of vascularized composite allotransplantation and requires lifelong immunosuppression to ensure graft survival. Despite significant advances in surgical techniques and postoperative care over the past two decades, the true incidence of cutaneous malignancies in fVCA recipients remains poorly characterized due to the limited number of procedures, heterogeneous immunosuppressive protocols, and relatively short follow-up. This narrative review summarizes current evidence on oncologic risk in facial VCA, focusing on the effects of different immunosuppressive regimens and the challenges posed by the high immunogenicity of skin and mucosa. Available data indicate that malignancies, including cutaneous and other neoplasms, occur in approximately 10% of recipients, based on heterogeneous case-series data with immunosuppressive therapies largely extrapolated from solid organ transplantation. Calcineurin inhibitors, corticosteroids, and azathioprine are associated with increased oncologic risk, whereas mycophenolate mofetil and mTOR inhibitors may confer a more favorable profile. Overall, fVCA, unlike solid organ transplantation, is a life-enhancing procedure, highlighting the need for tailored immunosuppressive strategies, rigorous dermatologic surveillance, and further research supported by dedicated registries to better define long-term malignancy risk.