This Week in Plastic Surgery — May 14, 2026

Welcome to This Week in Plastic Surgery. This week we're covering 9 notable papers spanning advances in complex reconstruction, new insights into keloid and migraine pathophysiology, and system-level improvements in perioperative care. Let's dive in.

Advances in Complex Reconstruction We begin this week in the realm of complex reconstruction, with four papers exploring breast, lymphatic, lower extremity, and chest wall procedures.

Starting with breast reconstruction, a study in *Plastic and Reconstructive Surgery* compared two approaches for implant support in prepectoral direct-to-implant, or DTI, reconstruction [9]. Investigators retrospectively compared outcomes in patients who received total anterior implant coverage with acellular dermal matrix, or ADM, alone versus those who received complete implant coverage with both ADM and a resorbable mesh, GalaFLEX. The study included 170 breasts in the ADM-alone group and 168 in the combined ADM plus GalaFLEX group. At 6 months, the group receiving the combined support had a significantly lower rate of implant malposition, at 1.8 percent compared to 7.1 percent in the ADM-alone group. Survival analysis suggested the risk of malposition was over seven times higher with ADM alone. Interestingly, despite the difference in malposition, the rate of revision surgery was similar between groups. From a cost perspective, the index operating room costs were significantly lower in the combined ADM and GalaFLEX cohort.

Moving from the breast to the axilla, a paper in the *Journal of Plastic, Reconstructive & Aesthetic Surgery* examined national trends and safety of prophylactic lymphovenous bypass, or LVB, performed at the time of axillary lymph node dissection [4]. Using the American College of Surgeons NSQIP database from 2013 to 2022, the authors analyzed nearly 62,000 cases, of which about 1 percent included a concurrent LVB. They found that the adoption of prophylactic LVB has increased dramatically, showing a 14.6-fold rise over the decade. When looking at 30-day outcomes, the LVB group had slightly higher rates of any postoperative complication, deep vein thrombosis, and superficial surgical site infection. However, rates of reoperation and deep infections were comparable. Furthermore, on multivariate analysis, performing an LVB trended toward a decreased risk of reoperation. The authors conclude that despite some increased short-term risks, the expanding national use of LVB suggests it is becoming an integrated part of breast cancer care.

Shifting to the lower extremity, another study in *JPRAS* provides guidance on a challenging scenario: free flap reconstruction after recent vascular intervention [8]. This two-center matched cohort study compared 34 patients who had a free flap within 100 days of a vascular procedure, most commonly angioplasty, to 34 matched controls. As expected, operative time was significantly longer in the vasculopathic patients. While overall flap success was high, there was a trend toward more flap-related complications in the intervention group, with a success rate of 88 percent versus 100 percent in controls, though this difference was not statistically significant. The most critical finding was that all four flap losses occurred in the subgroup where the microvascular anastomosis was performed on the same vessel that had been previously stented or angioplastied. This translated to a nearly 29 percent failure rate in that specific scenario, a statistically significant finding. Despite these challenges, the ultimate limb salvage rate was identical between groups at over 94 percent. The takeaway is that while free flap reconstruction is feasible and successful in these high-risk limbs, surgeons should be wary of using the previously intervened vessel for the anastomosis.

Finally in our reconstruction theme, a case report from *Plastic and Reconstructive Surgery Global Open* describes a novel, single-stage solution for transmasculine patients with pectus excavatum seeking chest masculinization [1]. The surgeons performed a combined mastectomy and chest wall reconstruction on a 33-year-old patient, using a bilateral inferiorly pedicled adipocutaneous flap based on anterior intercostal artery perforators. This autologous tissue was used to fill the sternal depression of the funnel chest deformity. At one-year follow-up, the patient had a satisfactory masculinized chest contour with complete correction of the deformity, avoiding the need for implants or multiple procedures.

New Insights into Pathophysiology Next, we turn to the basic science bench, with three papers offering new perspectives on the drivers of keloids and migraine.

Two papers from the journal *Burns* provide complementary insights into keloid formation. The first study establishes impaired branched-chain amino acid, or BCAA, catabolism as a metabolic hallmark of keloids [6]. Through an integrated analysis of transcriptomic datasets and clinical samples, researchers found a systemic downregulation of the genes responsible for breaking down BCAAs. This leads to an accumulation of these amino acids, particularly leucine, in both the circulation and the keloid tissue itself. In vitro experiments confirmed that leucine drives keloid fibroblast proliferation and extracellular matrix deposition, a phenotype that could be reversed by pharmacologically enhancing BCAA catabolism. This identifies a potential new therapeutic target for this difficult-to-treat condition.

The second paper in *Burns* uses single-cell RNA sequencing to dissect the fibroblast heterogeneity within keloids [7]. This analysis identified four distinct fibroblast subpopulations, with one type, mesenchymal fibroblasts, being predominantly increased. Within this group, a subset of senescent fibroblasts marked by the protein TNFRSF9 was identified. These TNFRSF9-positive senescent fibroblasts appear to represent a mature stage of fibroblast differentiation and, crucially, were found to strongly interact with neural cells. This finding provides a potential mechanistic link between the fibrotic and neural components of keloid pathology, opening another possible avenue for targeted therapy.

Rounding out this section, a study in *JPRAS* leveraged the large National Institutes of Health 'All of Us' Research Program database to investigate nonclinical factors associated with receiving procedural care for refractory migraine [2]. Among over 23,000 patients with migraine, about 2 percent received treatments like chemodenervation or nerve-targeted surgery within a year of diagnosis. The key finding was that after adjusting for age, sex, and race, the factors significantly associated with receiving procedural care were patient-reported. These included higher perceived psychosocial stress, frequent emotional withdrawal, and negative patient-provider interactions. The authors suggest this doesn't point to access disparities, but rather that these psychosocial factors are likely a reflection of higher disease burden and care complexity in patients who escalate to procedural therapies.

System-Level Improvements in Perioperative Care Finally, we look at two studies aimed at improving outcomes at a system level, one in burn care and the other in pediatric craniofacial surgery.

First, a powerful study from a tertiary burn center in Taiwan, published in *Burns*, evaluated the impact of a standardized burn protocol for preventing acute kidney injury [5]. The protocol, implemented in 2015, emphasized goal-directed fluid resuscitation, early albumin administration, and proactive initiation of renal replacement therapy, or RRT. Comparing the pre- and post-protocol eras, the researchers found that RRT utilization was more than halved, dropping from about 43 percent to 20 percent. The impact on survival was even more striking: 28-day mortality fell from nearly 29 percent to under 3 percent, and overall hospital mortality plummeted from 48 percent to just 8 percent. After robust statistical adjustment, the post-protocol era was associated with a 76 percent reduction in the hazard of death. This study highlights the profound survival benefit of a standardized, proactive approach to managing renal function in major burns.

Our last paper, from *JPRAS*, explores the use of machine learning to support preoperative planning for pediatric craniosynostosis surgery [3]. Using data from over 8,000 patients in the NSQIP Pediatric database, investigators developed and validated models to predict both the risk of perioperative transfusion and the required volume. Their classification model, which predicts the probability of needing a transfusion, achieved a mean area under the curve of 0.77, indicating good predictive ability. A second model designed to predict transfusion volume had a median absolute error of about 7 milliliters per kilogram. The authors propose that such a tool, after external validation, could support individualized blood product preparation and guide the selective use of cell salvage systems, optimizing resource use for these complex cases.

Editor's Pick If you only have time for one paper this week, make it the study from *Burns* on a standardized protocol for acute kidney injury in major burns [5]. The reported mortality reduction is profound, and it underscores the immense impact that protocolized, proactive care can have on outcomes in our most critically ill patients.

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

First, in prepectoral direct-to-implant breast reconstruction, combining a resorbable mesh like GalaFLEX with ADM may reduce malposition rates and lower costs compared to using ADM alone for total coverage [9].

Second, prophylactic lymphovenous bypass during axillary dissection is becoming more common. While associated with a small increase in certain 30-day complications like DVT, it does not appear to increase reoperation rates and may even reduce them [4].

Third, for lower limb free flaps in patients with recent revascularization, outcomes are generally good, but surgeons should be cautious. Anastomosing to the previously intervened vessel carries a high risk of flap failure, approaching 30 percent in this series [8].

Fourth, in major burn care, implementing a standardized protocol with goal-directed resuscitation and early, proactive renal replacement therapy can dramatically reduce both RRT utilization and mortality [5].

Finally, emerging basic science continues to point toward new targets for keloids, including metabolic pathways involving branched-chain amino acids and specific senescent fibroblast populations that interact with neural cells [6, 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.

This is an automated summary generated by artificial intelligence, which can make mistakes. Always review the original source materials.