Publications

This review article synthesizes current advances in the diagnosis and surgical management of complex compression neuropathies — conditions where nerves are chronically squeezed within tight anatomical tunnels throughout the body. The article covers thoracic outlet syndrome, groin and pelvic nerve entrapments (including pudendal neuralgia), and common peroneal nerve compression, with particular attention to evolving surgical techniques and patient selection criteria. A central theme is the importance of early recognition: subclinical compression — especially at the peroneal nerve — can progress to irreversible nerve damage and foot drop if not treated promptly. The authors also discuss emerging reconstructive strategies such as targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) procedures for patients with refractory nerve pain. This article reflects Dr. Lakhiani's active expertise at the forefront of peripheral nerve surgery.

This conference abstract, presented at the ASPS Annual Meeting, reports outcomes from surgical decompression of the pudendal nerve in patients suffering from chronic pelvic and perineal pain. Pudendal nerve entrapment is a debilitating condition often misdiagnosed for years, and surgical release remains among the most definitive interventions available. The study evaluates pain relief outcomes following decompression, contributing to the evidence base for nerve-targeted surgical approaches to chronic pelvic pain. This work aligns directly with Dr. Lakhiani's multidisciplinary pelvic pain clinic, where he collaborates with physiatrists, urologists, and pelvic floor therapists to provide comprehensive care for patients with pudendal neuralgia.

This study describes a novel surgical technique for simultaneously feminizing the cheekbones and jaw in transgender women during a single operative session — using bone harvested from the reduced mandible to fill the gap created by the zygomatic (cheekbone) osteotomy. In a retrospective review of 17 patients, independent reviewers found a statistically significant improvement in facial femininity scores after surgery, with a low rate of major complications. For patients with gender dysphoria related to masculine facial features, having two procedures performed at once reduces total anesthetic exposure and recovery burden. The authors note that this approach requires careful craniofacial surgical planning, and virtual surgical planning tools (described in a companion paper) enhance precision. This publication reflects the practice's comprehensive approach to gender-affirming facial surgery.

Radiation therapy is increasingly integrated into the care of patients who also require reconstructive plastic surgery — for example, after breast cancer surgery, head and neck cancer, or soft tissue sarcoma — yet the technical details of radiation can be opaque to surgeons without oncology training. This review translates radiation oncology concepts into accessible language for plastic surgeons, covering different delivery modalities, the biology of how radiation damages tissue, and how timing relative to reconstruction affects healing and complication risk. Understanding these principles is critical for selecting the right reconstructive strategy for each patient, because irradiated tissue heals differently and is at higher risk for wound breakdown and implant failure. The article is designed to help surgeons have more informed conversations with their radiation oncology colleagues and improve multidisciplinary planning. Clinically, this knowledge directly informs decisions such as when to use autologous tissue (living flap) reconstruction over implants in previously irradiated breasts.

This case report describes the complex, staged microsurgical reconstruction of a 41-year-old man with advanced gum (gingival) cancer who had undergone radical resection of his lower jaw, leaving him with facial deformity, facial paralysis, and absent sensation. The team performed jaw bone reconstruction using a composite bone-and-skin free flap, restored sensation to the lower lip and chin with a nerve graft, and later transferred a functioning muscle (gracilis) powered by the facial nerve to restore a spontaneous smile. After 4.5 years of follow-up, the patient achieved a symmetrical smile and normal sensation without residual deficits — an exceptional outcome for a case of this complexity. This publication demonstrates the state-of-the-art potential of multistage reconstructive microsurgery to restore both form and function after radical cancer surgery. It was produced in collaboration with Dr. Lakhiani's microsurgical fellowship training program in Taiwan.

Cross-leg flaps are a specialized reconstructive technique used when both lower legs are severely compromised — tissue is transferred from one leg to the other while temporarily bridging them. The traditional teaching is to wait 21 days before dividing the connecting tissue bridge, but this paper challenges whether that time window is always sufficient or even necessary. The authors describe using indocyanine green (ICG) angiography — a real-time fluorescent imaging tool that visualizes blood flow — to objectively assess whether the flap has adequately developed its own blood supply before division is attempted. This approach allows surgeons to make individualized decisions rather than following a fixed calendar, potentially reducing complications. The technique has important implications for patients who cannot safely remain immobilized in a cross-leg position for the standard duration, such as the elderly or medically fragile.

Written during Dr. Lakhiani's microsurgical fellowship in Taiwan, this perspective piece uses the metaphor of learning to make dumplings — where each step is standardized for reproducibility — to argue that structured, protocol-driven training is essential for producing competent microsurgeons. Microsurgery demands extraordinary precision, and the stakes of technical errors are high: a flap failure can mean a lost limb. The authors contend that standardized training frameworks, rather than purely apprenticeship-based models, produce safer and more consistent outcomes for patients. This commentary contributes to a growing conversation in surgical education about how to teach the most technically demanding procedures reliably. It reflects Dr. Lakhiani's commitment to advancing microsurgical training alongside his clinical work.

When wounds fail to heal after orthopedic procedures on the lower leg (such as knee or ankle surgeries), there is often an unrecognized reason: the blood supply to that part of the leg is compromised. This study of 64 patients who required free tissue transfer after orthopedic wound breakdown found that nearly half (47%) had major arterial abnormalities on preoperative imaging — and in a quarter of cases, the diseased artery corresponded precisely to the angiosome (blood supply zone) of the non-healing wound. Identifying vascular disease beforehand allowed some patients to receive endovascular (catheter-based) repair before reconstruction, improving outcomes. Despite the complexity of this patient population — 77% had bone infection (osteomyelitis) and 39% had diabetes — the free flap survival rate was 92% and 89% of patients maintained their limb. This work demonstrates the critical importance of vascular imaging before any attempt at soft tissue reconstruction after failed orthopedic surgery.

While most attention in lower extremity free flap planning focuses on the arterial blood supply, this study investigates whether examining the venous system before surgery also matters. In 57 consecutive patients, preoperative venous duplex ultrasound found venous insufficiency (leaky vein valves) in 39% and undiagnosed deep vein thrombosis (blood clot) in 7% — findings that directly changed how recipient veins were selected for microsurgical connection. Venous thrombosis is a leading cause of free flap failure, so identifying it early allows anticoagulation treatment before surgery. Despite the high-risk nature of this patient population, the flap success rate was 98.3% and nearly 90% of patients were able to walk in the community at follow-up. This study helped establish the venous component of the Georgetown Protocol — a systematic preoperative vascular workup that significantly improved outcomes in complex lower extremity reconstruction.

This comprehensive review describes the measurable anatomical differences between male and female faces — including differences in skull shape, forehead height, orbital bossing, nose size, cheekbone prominence, lip fullness, jaw width, and chin projection — that form the scientific foundation for gender-affirming facial surgery. The authors outline a structured method for analyzing a patient's facial proportions before surgery to identify which features require modification and to set realistic expectations for the outcome. This framework is critical for transgender patients pursuing facial feminization or masculinization procedures, where the goal is to bring facial appearance into harmony with gender identity rather than simply altering individual features in isolation. The paper has become a reference for the growing subspecialty of gender-affirming facial surgery, reflecting Dr. Lakhiani's expertise in this field.

Surgeon fatigue is a well-documented patient safety risk, particularly in specialties requiring sustained concentration and fine motor precision — conditions that define microsurgery and peripheral nerve surgery. This review synthesizes current evidence on how fatigue impairs surgical performance and proposes practical, deliberate strategies for managing it during long or complex operations. Key techniques include careful preoperative case planning to maximize team efficiency, scheduled intraoperative breaks timed to natural pauses in the procedure, and cultivating self-awareness of one's own fatigue state. The authors note that the reluctance to take breaks — driven by concern about extending case time — is itself a fatigue-related cognitive error. This work has practical implications for patient safety and for the wellness of surgeons who regularly perform multi-hour reconstructive procedures.

For decades, microsurgeons were trained to avoid caffeine around the time of free flap surgery, based on the theoretical concern that caffeine causes blood vessel spasm and could compromise the microsurgical anastomosis. This paper challenges that longstanding dogma by reviewing the available physiological and clinical evidence on caffeine's actual vascular effects. The authors argue that in standard doses, caffeine does not cause meaningful vasospasm in the caliber of vessels used in microsurgery, and that restricting caffeine from surgeons performing multi-hour operations may itself impair performance by increasing fatigue and reducing concentration. This is a practical, clinically relevant contribution to the "surgeon wellness" literature — making the case that evidence, rather than habit, should guide operating room policies.

This technical report describes using virtual surgical planning (VSP) — a digital preoperative simulation technology borrowed from orthognathic (jaw) surgery — to guide a critical component of facial feminization: the frontal sinus setback. In female anatomy, the forehead sits more posteriorly and the bone above the eyes is smoother, without the bony prominence (bossing) seen in many male foreheads. VSP allows surgeons to design custom cutting guides that ensure precise, reproducible bone cuts at the exact depth and angle planned on the computer model, reducing intraoperative guesswork. This application to gender-affirming craniofacial surgery represents an important technical advance, improving the accuracy of forehead contouring and reducing the risk of inadvertently entering the frontal sinus. The technique is particularly valuable in complex cases where the frontal sinus is large or unusually shaped.

Infected vascular bypass grafts — synthetic tubes used to bypass blocked arteries in the leg — are among the most challenging wounds a reconstructive surgeon faces, because standard muscle flap closure often fails in the setting of ongoing infection. This case report describes using negative pressure wound therapy with intermittent instillation (NPWTi) with the antibiotic rifampin to salvage such a wound after a muscle flap had already failed. By cycling antibiotic solution directly through the wound cavity under negative pressure, the authors achieved sustained wound control and eventual closure without requiring graft removal. This is clinically significant because prosthetic vascular graft infections carry very high morbidity and mortality, and graft removal can threaten the limb's blood supply. The case illustrates an innovative salvage strategy that may spare patients more extensive surgery.

Diabetic foot ulcers that fail to heal despite standard wound care have historically led to major amputation; this study demonstrates that microsurgical free tissue transfer can serve as a durable limb-saving alternative. In 29 consecutive patients at a specialized limb salvage center, free flap surgery achieved a 93% flap survival rate and preserved the limb in 79% of patients — with 86% regaining the ability to walk in the community. Patients who ultimately required amputation did so for reasons unrelated to flap failure (recurrent infection, pain, or ischemia), underscoring that the surgery itself performs well. Functional outcomes were measured using a validated patient-reported scale (LEFS), yielding an average score consistent with community-level ambulation. These results support the use of free tissue transfer as a first-line limb preservation option rather than a last resort, fundamentally reshaping how complex diabetic foot wounds are managed at specialized centers.

Charcot neuroarthropathy is a progressive bone and joint destruction caused by diabetic nerve damage, often resulting in severe deformity and non-healing wounds of the foot and ankle. This case report describes using a vascularized medial femoral condyle (MFC) free flap — which carries both bone and overlying skin on its own blood supply — to reconstruct a bony defect created by resection of the first metatarsophalangeal joint in a diabetic patient. Unlike bone grafts, vascularized bone brings its own circulation, dramatically improving healing in the hostile environment of the diabetic foot. The long-term follow-up documents sustained healing and function, demonstrating that this demanding microsurgical approach can achieve durable reconstruction even in one of the most challenging patient populations. This paper expands the reported applications of the MFC flap into diabetic limb salvage surgery.

Free tissue transfer for chronic lower extremity wounds is typically a patient's last option before amputation, making preoperative planning exceptionally important. This study evaluated the usefulness of preoperative arteriography (detailed X-ray imaging of leg arteries) in 57 patients undergoing 59 free flap operations. Nearly 68% of patients had significant arterial abnormalities on imaging, including vessel stenosis, occlusion, or absence — and in 27.5% of cases, endovascular (catheter-based) intervention was required before microsurgery could be safely performed. In 15% of patients, the imaging detected peripheral vascular disease that had not been previously diagnosed. Despite this high-risk population, the flap survival rate was 98.3% and 89.8% of patients maintained community ambulation at follow-up. The authors established that routine preoperative arterial imaging substantially improves patient selection, allows for vascular optimization before surgery, and contributes to the exceptional outcomes achieved in this setting.

Poland's sequence is a rare congenital condition characterized by underdevelopment or absence of the pectoralis major muscle and related chest wall structures, often presenting with breast asymmetry or absence. This case report documents the unexpected discovery of partial Poland's syndrome at the time of mastectomy for breast cancer in the opposite breast — a situation that significantly complicates reconstruction planning because the surgeon must address both the cancer defect and the underlying congenital chest wall anomaly. The report highlights the importance of recognizing this condition before or during surgery, as standard reconstructive approaches may be inadequate or technically inappropriate when the underlying chest anatomy is abnormal. It also illustrates that Poland's sequence can remain undiagnosed well into adulthood, discovered only incidentally during surgery for another condition.

This brief communication examines the practical and safety implications of integrating consumer voice-controlled AI assistants (such as Amazon Alexa) into the operating room environment. As these devices become ubiquitous, surgeons and operating room staff have increasingly encountered them in workspaces adjacent to or within the OR, raising questions about sterility, distraction, ambient sound, and patient privacy. The authors discuss the potential benefits — hands-free information retrieval, music control, timer functions — alongside meaningful risks including inadvertent activation, HIPAA privacy concerns from always-on microphones, and the distraction of interrupted operating room workflow. This paper reflects the team's broader interest in operating room efficiency and the integration of technology into surgical practice, areas where small design choices can have outsized impact on patient outcomes.

Microsurgeons routinely sustain prolonged neck flexion, static posture, and the weight of heavy magnification loupes during operations lasting many hours — a recipe for chronic cervical spine injury. This article synthesizes emerging evidence that surgeon musculoskeletal strain is a significant occupational hazard, then presents practical ergonomic strategies to reduce it: table height adjustments, loupes and headlight positioning, armrest configuration, and intraoperative stretching. Beyond individual wellness, this is a patient safety issue: a surgeon operating under chronic pain or fatigue performs differently than one in an optimized physical state. The paper is part of a body of work by Dr. Lakhiani and colleagues focused on the human factors that affect surgical performance and long-term surgeon health. It is particularly relevant to specialties with long operative times, such as microsurgery and peripheral nerve reconstruction.

"Operative flow" refers to the state of smooth, efficient, and intuitive surgical performance that experienced surgeons describe as being "in the zone." This communication articulates the concept of operative flow within the context of plastic surgery and presents deliberate strategies for achieving and sustaining it during complex procedures. The authors draw on cognitive psychology and surgical human factors research to argue that case preparation, team briefing, standardized protocols, and anticipation of the next operative step are all modifiable factors that determine whether a surgical team operates fluidly or haltingly. Disruptions to flow — from equipment failures, unexpected findings, or team communication breakdowns — are a meaningful source of operative complications. Understanding and optimizing operative flow has direct implications for patient safety and surgical efficiency, particularly in long reconstructive cases.

Distracted walking — using a smartphone while walking — is an increasingly recognized cause of pedestrian injuries, yet it receives far less regulatory attention than distracted driving despite being a growing public health burden. This study analyzed pedestrian trauma data to characterize the epidemiology of smartphone-related walking injuries: who is affected, how severely, and what types of injuries result. The surgical team at a Level I trauma center was uniquely positioned to observe the downstream consequences of this behavior, including fractures, lacerations, and injuries requiring reconstruction. The findings make the case for public health messaging, urban design changes, and potentially legislative interventions to address distracted pedestrian behavior. A companion piece in Plastic and Reconstructive Surgery (PMID 29965926) specifically examined the reconstructive burden of these injuries.

This companion communication to the Journal of Trauma paper presents the reconstructive plastic surgery perspective on smartphone-related pedestrian trauma — specifically the types and complexity of injuries that require plastic surgical intervention after distracted walking accidents. From a trauma surgeon's vantage point, these injuries are distinct from typical pedestrian-vehicle collisions and often involve ground-level impacts, hand and facial trauma, and soft tissue lacerations. The article calls attention to this underappreciated injury mechanism and its implications for emergency and reconstructive care. Both papers together make a case for treating distracted walking with the same seriousness as distracted driving from a public health and injury prevention standpoint.

Patients with cleft lip frequently have residual nasal asymmetry requiring staged correction — typically during the "intermediate" phase in late childhood or early adolescence before definitive rhinoplasty in adulthood. Iliac crest cartilage (rib cartilage from the pelvis) has been used as a structural graft for this purpose, but its quality changes significantly with age as the cartilage ossifies and becomes less workable. This study examines how the utility and behavior of iliac crest cartilage grafts varies with patient age, arguing that timing is a critical variable in surgical planning. The practical implication is that if this graft source is desired, surgery should occur before the patient matures past the optimal window. The title's play on "use it or lose it" reflects the authors' insight that waiting too long may eliminate this reconstructive option entirely.

When the skin and soft tissue break down over a total knee replacement, the prosthesis may become exposed and infected — a catastrophic complication that can lead to device loss and amputation. This retrospective review of 30 patients examines which factors determined whether the knee implant and limb could be salvaged. Early referral to reconstructive surgery was among the most important factors: patients seen sooner had dramatically higher rates of device and limb preservation. Tobacco use and a long delay from original joint replacement to wound presentation both independently worsened outcomes. The study compared simple closure, local muscle flaps, and free tissue transfer — with limb salvage rates of 66%, 92%, and 75% respectively — emphasizing that technique selection must match wound severity. This work supports a multidisciplinary model of care in which reconstructive surgeons are involved early in complex periprosthetic wound management.

Critics of limb salvage surgery often ask: does saving the limb actually result in a functioning limb? This study directly addresses that question by using a validated patient-reported outcome measure — the Lower Extremity Functional Scale (LEFS) — to measure real-world function in 39 patients after free tissue transfer for chronic wounds. The average LEFS score corresponded to "Stage 4" function: independent community ambulation, defined as the ability to walk and perform daily activities outside the home without assistance. Crucially, this functional level was significantly higher than that of matched patients who underwent below-knee or above-knee amputation, providing concrete evidence that limb salvage leads to better functional outcomes than amputation. Age was the primary factor associated with reduced functional recovery, a finding useful for counseling older patients about realistic expectations. These data help justify the investment of complex microsurgical limb salvage in appropriately selected patients.

Skin grafting of the glans penis is technically challenging because the glans is a rounded, curved structure with few good contact surfaces for traditional bolster dressings — which are needed to hold a graft firmly in place while it heals. This technical report describes the "Lotus Petal" technique: a creative application of negative pressure wound therapy (the VAC device) as a form-fitting bolster that conforms to the irregular surface geometry of the glans, maintaining uniform pressure and graft contact. The technique addresses a common problem in urological and reconstructive surgery — reconstruction of the glans after excision of benign or malignant lesions — with a simple, adaptable solution using a device already widely available in most hospitals. Techniques like this illustrate how reconstructive surgeons solve practical problems that arise at the intersection of surgical specialties.

DIEP flap breast reconstruction is one of the most demanding microsurgical procedures, in which abdominal tissue is moved to the chest as a living flap using tiny blood vessels. When the primary perforator vessel supporting the flap is found to be inadequate or damaged during surgery, the flap risks partial or total loss — a devastating complication. This case report describes a supermicrosurgical rescue technique: bypassing directly from the main arterial pedicle of the flap to an adjacent small perforator vessel to restore adequate blood flow. Supermicrosurgery refers to anastomosis of vessels measuring 0.3–0.8 mm in diameter — at the absolute limit of human technical capability with current instrumentation. The technique demonstrates how advanced microsurgical skills can convert an intraoperative crisis into a successful reconstruction, and highlights the value of having multiple vascular strategies available when operating in this demanding setting.

This dramatic case report documents a rare but life-threatening sequence of events: septic shock following prostate biopsy required high-dose vasopressors (drugs that constrict blood vessels to maintain blood pressure), which in turn caused ischemic gangrene of the extremities. The patient faced possible quadruple amputation. The team employed a methodical strategy — allowing clear tissue demarcation, serial debridement, hyperbaric oxygen therapy, negative pressure wound therapy — followed by bilateral free tissue transfer to both lower limbs, ultimately achieving bilateral transmetatarsal amputations with free flap reconstruction and a walking, functional patient at long-term follow-up. The case illustrates that even catastrophically injured limbs may be salvageable with multidisciplinary coordination, staged surgical planning, and advanced reconstructive expertise. It has important implications for how intensivists and reconstructive surgeons should collaborate in managing vasopressor-induced peripheral ischemia.

This invited editorial discussion accompanies a study examining how a patient's insurance type (private vs. Medicare/Medicaid) affects the likelihood of needing revisional surgery after breast reconstruction. In these discussion pieces — a hallmark of peer-reviewed surgical journals — a senior surgeon provides expert commentary contextualizing the original findings, acknowledges methodological considerations, and draws out the broader clinical implications. Dr. Lakhiani and Dr. Song use this forum to address the systemic and access-related factors that may drive disparities in reconstructive outcomes, and to discuss what surgeons and healthcare systems can do to mitigate these effects. The piece reflects engagement with health equity as an important dimension of reconstructive surgical practice.

The thigh is one of the most common sites for harvesting tissue used in reconstructive free flaps — including the anterolateral thigh (ALT), gracilis, and rectus femoris flaps — but patients rightly worry about what is left behind at the harvest site. This systematic review pooled data from 116 published articles representing over 4,500 flap harvests, making it the most comprehensive analysis of thigh donor-site morbidity to date. The most common problems were numbness in the outer thigh (up to 36%), contour depression, and wound healing issues — but serious complications were rare, and most patients tolerated the donor site well. Importantly, only rectus femoris flap harvest resulted in a significant measured loss of leg strength (21% reduction), while other thigh flaps preserved function. This data is directly applicable to surgical planning conversations: helping patients understand and consent to the realistic trade-offs of donor site harvest before deciding on a reconstructive approach.

After harvesting a DIEP flap from the abdomen for breast reconstruction, closing the abdominal donor site traditionally requires surgical drains to prevent fluid buildup (seroma). This study evaluated whether barbed progressive tension sutures — a type of self-locking suture that holds the deeper tissue layers together without knots — could eliminate the need for abdominal drains. In a comparison of 75 patients across three closure techniques, the drain-free barbed suture group had a 0% seroma rate and no significant difference in wound healing or dehiscence compared to groups managed with drains. Eliminating abdominal drains has meaningful quality-of-life implications: patients can mobilize more freely after surgery, experience less tethering and discomfort, and achieve earlier independence at home. This was among the early studies validating drain-free abdominal closure after DIEP flap harvest.

This large retrospective study of 282 free flap reconstructions for traumatic upper extremity injuries sought to identify which patient and injury factors predict worse outcomes. Over a 25-year period at a specialized center, the overall results validated the safety of early free tissue transfer, even in the setting of severe trauma. Injuries located at or above the elbow, and those with open fractures, carried significantly higher rates of infection and bone complications — but not higher rates of flap loss itself. The most important predictors of flap failure were the most severe fracture type (Gustilo IIIC), the need for extra vein grafts to bridge vessel gaps, and the requirement for revision of the anastomosis during the initial operation. Importantly, timing of reconstruction — whether performed within 24 hours or after a week — did not significantly change the risk of flap loss, providing surgeons with flexibility in scheduling complex traumatic cases.

Sickle cell trait — having one copy of the sickle cell gene rather than two — is generally considered a benign carrier state with minimal clinical consequences. This paper challenges that notion in the specific context of microsurgical free tissue transfer, where abnormal red blood cell behavior in low-oxygen, low-flow conditions (which occur around microsurgical anastomoses) may pose real risks. The authors present evidence that sickle cell trait patients may have elevated rates of microthrombotic complications during and after free flap surgery, and argue that surgeons should be aware of this diagnosis and take appropriate precautions, including perioperative optimization and choice of anesthetic technique. The message — "not just a trait" — is a call to take this genetic status seriously in the high-stakes setting of microsurgical reconstruction, where thrombosis of a 1-2mm vessel can cause total flap loss.

This reply letter responds to reader correspondence regarding the authors' earlier systematic review on DIEP flap vascular anatomy (PMID 25347657), specifically addressing the question of how many perforators are needed for a reliable flap and what to do when the primary perforator is found to be inadequate at the time of surgery. The correspondence focuses on perforator salvage strategies — techniques for rescuing a flap when the dominant vessel is not sufficient. This type of published exchange represents the highest level of expert peer dialogue in the surgical literature, reflecting active engagement with the research community and contributing nuanced technical guidance that benefits surgeons encountering intraoperative complications.

The DIEP flap — which uses abdominal tissue to reconstruct the breast — has become one of the gold standard procedures in breast reconstruction, but its success depends on identifying reliable perforator vessels that carry adequate blood supply. This systematic review of 60 studies synthesizes all published descriptions of DIEP flap vascular anatomy, characterizing how perforators originate from the deep inferior epigastric artery, course through or around the rectus abdominis muscle, and supply the overlying skin. The review categorizes perforators as musculocutaneous (passing through muscle) or extramuscular, and identifies which types are most desirable for harvest based on ease of dissection and predictability. Understanding this anatomy helps surgeons select the safest, most reliable perforator during the dissection phase and reduces the risk of flap complications. This paper became a widely referenced resource for surgeons performing DIEP flap breast reconstruction.

Composite Achilles tendon defects — involving loss of both the tendon and overlying skin — represent one of the most functionally devastating reconstructive challenges in lower extremity surgery. This conference abstract reports on a novel strategy using combined free tissue transfer to simultaneously restore tendon continuity (using a "neo-tendon construct") and provide durable soft tissue coverage. The primary outcome of interest was functional recovery, specifically the ability to walk and the patient's subjective satisfaction with the result. The work addresses a gap in the literature by reporting patient-reported outcomes rather than only surgical success rates, recognizing that a flap that survives but leaves the patient unable to walk has not achieved its goal. This study reflects the team's focus on function as the true endpoint of limb salvage reconstruction.

Long-standing dogma in reconstructive surgery held that traumatic wounds should be covered within 72 hours to minimize infection and complications. This systematic review — one of the most comprehensive analyses of its kind — examined 15 studies covering all published timing categories from emergency surgery (within 24 hours) through delayed reconstruction (after 3 weeks). The key finding was that no timing window was consistently superior: rates of flap loss, infection, and bone non-healing did not significantly differ based on when surgery was performed. However, earlier reconstruction was associated with shorter hospital stays and lower costs. This evidence gives surgeons and patients flexibility in planning complex reconstructions around optimal clinical conditions rather than arbitrary time pressures, a clinically meaningful liberalization of practice. It also provided a methodological template for subsequent systematic reviews in reconstructive microsurgery.

Capsular contracture — the painful, distorting hardening of scar tissue around a breast implant — is the most common complication of implant-based breast reconstruction, affecting up to 16% of patients and often recurring after conventional treatment. This paper describes a novel technique using acellular dermal matrix (ADM, a processed biological tissue scaffold) to completely envelop the implant — both the lower and upper poles — rather than the partial coverage used in prior reports. In 11 patients with 16 treated breasts, including four with history of prior contracture, no patient developed recurrent contracture at up to 18-month follow-up, with only one implant lost to infection. The authors propose that complete ADM coverage modifies the biology of the implant-tissue interface in a way that prevents the inflammatory cascade responsible for contracture. This technique offers a promising option for patients whose contracture has been resistant to standard approaches.

Flexor tendon repairs in the hand are notoriously prone to failure, and knots in the suture are a known weak point — they can slip, create bulk that catches in the tendon sheath, and provoke inflammation. This biomechanical cadaver study compared a traditional four-strand repair using standard braided suture with a knotless four-strand repair using a larger-diameter barbed suture that locks without knots. The knotless barbed suture repairs were significantly stronger on load-to-failure testing (52N vs. 42N) while maintaining equivalent resistance to gap formation at the repair site — the most clinically important failure mode. These results suggest that eliminating knots and using a larger-caliber suture can improve the structural integrity of hand tendon repairs, which is relevant to achieving earlier active mobilization after surgery and reducing re-rupture rates. This study contributed to the growing evidence base supporting barbed suture in hand surgery.

The anterolateral thigh (ALT) flap — a workhorse of reconstructive microsurgery used worldwide for head and neck, lower extremity, and trunk reconstruction — is renowned for its anatomical variability, which makes it technically challenging. This systematic review of 44 studies (covering nearly 3,000 flap dissections) is a landmark reference characterizing that variability in rigorous, pooled fashion. Key findings include the precise prevalence of different perforator origins, the frequency of septocutaneous versus musculocutaneous perforators, and the incidence of absent perforators (1.8%) — a situation requiring an alternative plan. A previously undescribed "musculoseptocutaneous" perforator type was identified in anatomical studies and warranted formal description. This paper became a standard reference for surgeons planning ALT flap surgery, helping them understand the range of anatomy they may encounter and prepare accordingly to avoid intraoperative surprises.

The latissimus dorsi is the largest muscle in the back and a commonly used source of tissue for breast and chest wall reconstruction — but harvesting the entire muscle carries significant donor site consequences including seroma, weakness, and contour defect. This study investigated a muscle-sparing variant based on the descending branch of the thoracodorsal artery, combining cadaver dissection, 3D CT angiography, and five clinical cases to characterize its vascular territory and reliability. The authors found that the descending branch supplies a comparable cutaneous area to the transverse branch, and that substantial collateral flow between branches allows harvest of a larger skin paddle than expected from a single vessel. In clinical use, all five flaps survived without complication. This work validated the muscle-sparing latissimus dorsi as a reliable free flap that substantially reduces donor site morbidity — an important advance for patients who need back tissue for reconstruction but cannot afford muscle weakness.