This Week in Plastic Surgery — May 28, 2026

Welcome to This Week in Plastic Surgery. This week we're covering 9 notable papers spanning advances in complex reconstruction, management of the oncologic patient, and systems-based practice. Let's dive in.

Our first theme covers advances in planning and executing complex reconstructions.

In facial feminization surgery, predicting the soft tissue response to underlying bony work is a persistent challenge. A study in *Plastic and Reconstructive Surgery* provides new, region-specific guidance [2]. Investigators compared preoperative and postoperative CT scans and 3D photographs in 70 patients. They found that the soft tissue-to-bone response ratio varies significantly by facial third. In the gonial region, soft tissue reduction was nearly double the amount of bony reduction, with a ratio of 1.85. In contrast, forehead projection changes were nearly one-to-one, and chin changes were less than one-to-one. Interestingly, factors like BMI, age, and hormone therapy duration did not predict this response within a given region. This work underscores that a uniform surgical plan doesn't work for the entire face and that surgeons must account for these regional differences to achieve desired aesthetic outcomes.

Moving to craniofacial reconstruction, a paper in *Plastic and Reconstructive Surgery Global Open* details a refined technique for total cranial vault remodeling in craniosynostosis [8]. The authors evolved their prior multidirectional cranial distraction osteogenesis, or MCDO, by creating an external frame that encompasses the entire cranial circumference. This allows for global, three-dimensional correction. In their series of 23 patients, the technique effectively corrected various deformities. For example, in patients with scaphocephaly, the cephalic index improved from 68 to nearly 82. In those with brachycephaly, it decreased from 121 to 105. The technique also achieved a mean intracranial volume expansion of over 270 milliliters. This total cranial vault MCDO represents a promising alternative to conventional single-stage remodeling for comprehensive correction of complex synostosis.

Finally, for lower limb reconstruction, a report in *Plastic and Reconstructive Surgery* examines how fixation methods for free fibular flaps influence long-term bone graft hypertrophy, a key factor for weight-bearing [1]. In a retrospective review of 51 patients, the authors compared external fixation with dynamic and locking compression plates. At a mean follow-up of 5.7 years, locking compression plates, or LCPs, were associated with the greatest hypertrophy. Multivariable analysis showed that dynamic compression plates, or DCPs, led to significantly greater hypertrophy compared to external skeletal fixators. Another key finding was that hypertrophy continued to progress significantly beyond the two-year mark, especially in patients younger than 20. This suggests that for lower limb reconstruction with fibulas, internal plate fixation is superior for promoting hypertrophy, and the graft continues to adapt and strengthen over the long term.

Our next theme focuses on optimizing outcomes for the oncologic patient, addressing the collateral damage of cancer treatment.

Chronic pain after amputation is a major source of disability. A study in *Plastic and Reconstructive Surgery* provides important long-term data on the effectiveness of targeted muscle reinnervation, or TMR, and regenerative peripheral nerve interface, or RPNI [3]. Researchers compared 54 oncologic amputees who received TMR or RPNI with a historic cohort of 25 patients who did not. At a follow-up of at least 10 months, the TMR/RPNI group reported significantly lower residual limb pain and phantom limb pain. For example, the median phantom limb pain score was 0 in the treatment group versus 4 in the control group. The TMR/RPNI cohort also had significantly reduced use of opioids and benzodiazepines, though their use of gabapentin was higher, indicating a successful shift toward non-opioid analgesics. This study provides strong evidence for the durable, long-term benefits of physiologic nerve reconstruction in reducing pain and opioid dependence in this population.

Breast cancer-related lymphedema is another common and costly complication. A paper in *Plastic and Reconstructive Surgery* asks if immediate lymphatic reconstruction, or ILR, is a cost-effective prevention strategy [6]. Using a decision tree model from a payer perspective, the authors compared ILR to prospective surveillance and no specific intervention. The results were clear: both surveillance and ILR were cost-effective compared to doing nothing. While ILR was the most expensive option up front, it also provided the greatest health benefit in terms of quality-adjusted life years. The incremental cost-effectiveness ratio for ILR was just over $1,600 per QALY, a figure far below the typical willingness-to-pay threshold. This economic analysis provides a strong argument for integrating preventive microsurgical approaches like ILR into standard multidisciplinary breast cancer care.

Rounding out this theme, a systematic review and meta-analysis in *Plastic and Reconstructive Surgery Global Open* tackles the difficult question of autologous breast reconstruction timing relative to post-mastectomy radiation therapy, or PMRT [9]. The analysis of 12 studies confirmed what many clinicians observe: immediate reconstruction in the setting of planned PMRT leads to significantly higher rates of complications like fat necrosis, fibrosis, and flap contracture, resulting in worse aesthetic outcomes. In contrast, delaying the flap reconstruction until after radiation is completed is associated with fewer complications and better cosmetic results. Importantly, flap survival itself did not differ between immediate and delayed approaches. The authors also noted a flap-specific difference, with DIEP flaps having substantially lower rates of fat necrosis compared to TRAM or latissimus dorsi flaps in the irradiated setting. This reinforces the common practice of favoring a delayed approach for patients requiring PMRT.

Our final group of papers looks at practice optimization and systems of care.

We’ll start with a framework from a CME article in *Plastic and Reconstructive Surgery* on the diagnosis and treatment of vascular anomalies [4]. This review synthesizes the current, multidisciplinary approach, emphasizing the ISSVA classification system, the molecular pathways that are now targets for medical therapies like sirolimus, and the use of imaging like Doppler ultrasound to differentiate high-flow from slow-flow lesions. It serves as a valuable guide to the systematic management of these complex conditions.

Applying a systematic approach to perioperative care, a study in the *Annals of Plastic Surgery* evaluated medical therapies to improve wound healing after surgery for hidradenitis suppurativa [7]. This retrospective review of 194 cases found that certain medications were associated with shorter times to documented healing. Specifically, perioperative trimethoprim-sulfamethoxazole, preoperative cephalexin, and perioperative spironolactone were all linked to faster healing progress. In a finding that could change practice, routine intraoperative cultures, which were taken in 28 percent of cases, had very limited clinical utility and were not significantly associated with the choice of postoperative antibiotics. This suggests an opportunity to streamline care by focusing on beneficial medical therapies while de-emphasizing routine intraoperative cultures.

Finally, a study in *Plastic and Reconstructive Surgery* uses geospatial analysis to map access to registered replantation centers across the United States [5]. The findings highlight significant gaps in care. Using a 6-hour travel time radius, the study found that 13.3 percent of the United States population lacks access to a registered hand trauma center. Even when extending the travel window to 12 hours, 7.6 percent of the population remains uncovered. The distribution is uneven, with states like Nevada, Montana, and Kansas having no registered centers, while major metropolitan hubs are well-served. This work quantifies a major barrier to surgical care and underscores the need for strategies to reduce travel times and increase access, particularly in rural areas.

If you only have time for one paper this week, make it the study on TMR and RPNI for oncologic amputees in *Plastic and Reconstructive Surgery* [3]. It provides crucial long-term, comparative evidence that these nerve reconstruction techniques durably reduce chronic pain and opioid dependence, supporting their routine use in this population.

Here are the key takeaways from this week in Plastic Surgery.

First: For lower limb free fibula flaps, internal plate fixation, especially with LCPs, promotes more bony hypertrophy than external fixation. Hypertrophy continues for years, particularly in younger patients [1].

Second: In breast cancer patients requiring post-mastectomy radiation, delayed autologous reconstruction is associated with fewer complications and better aesthetic outcomes than immediate reconstruction, though flap survival is similar. Consider DIEP flaps, as they appear to have lower rates of fat necrosis in this setting [9].

Third: For oncologic amputees, physiologic nerve reconstruction with TMR or RPNI provides sustainable, long-term reductions in both residual and phantom limb pain, and significantly lowers opioid use compared to no nerve treatment [3].

Fourth: In facial feminization surgery, the soft tissue response to bony work is region-specific. The gonial angle shows an amplified soft tissue reduction of nearly two-to-one, while the forehead is closer to one-to-one. Plan your osteotomies accordingly [2].

Fifth: For hidradenitis suppurativa surgery, consider perioperative trimethoprim-sulfamethoxazole or spironolactone to potentially speed healing, and question the routine use of intraoperative cultures, which showed limited clinical utility in guiding antibiotic choice in this study [7].

That's your roundup for This Week in Plastic Surgery. The full transcript and references are available on the episode page in your AudioScholar library. This is an AI-curated summary — for clinical decisions, always consult primary sources and current guidelines. See you next week.