Plastic and Reconstructive Surgery Highlights: Reconstructive

The year 2024 brought about significant advancements in plastic and reconstructive surgery that are redefining clinical practice and patient care. These advancements include technological breakthroughs, innovative surgical techniques, and pioneering research to counter long-standing surgical dogma, all to enhance functional and aesthetic outcomes and improve overall patient satisfaction. From novel approaches in reconstruction and microsurgery to the integration of artificial intelligence in research, education, and perioperative planning, these developments highlight the progressive trajectory of reconstructive surgery. As part of this special initiative, I have selected 11 outstanding articles from the Plastic and Reconstructive Surgery Reconstructive section that exemplify “what’s hot and what’s new” in the field. These articles represent transformative findings that may alter the way we select patients or manage complex cases, influential trends, and groundbreaking methodologies that have the potential to impact clinical decision-making and future research. Some introduce unique or modified techniques and simplified algorithms for challenging cases, whereas others provide compelling data that challenge long-held surgical practices. The following sections offer a concise analysis of each selected article, exploring the reasons for their inclusion, how they exemplify the cutting edge of reconstructive surgery, whether they have sparked new trends, and how they influence my approach to patient care. By examining these pivotal contributions, valuable insights can be gained into the evolving landscape of reconstructive surgery and the innovations that will shape its future. HEAD AND NECK Challenging the anterolateral thigh (ALT) workhorse flap for tongue reconstruction, Ismail et al. introduced the profunda artery perforator flap as a viable alternative.1 With its inconspicuous donor site and robust perfusion, the profunda artery perforator flap offers an innovative solution for head and neck reconstruction, with demonstrably better swallowing function than the ALT flap. This research has the potential to broaden reconstructive options for oral cancer patients, particularly in thinner patients, improving both functional and aesthetic outcomes. The pilot study by Lerner et al. introduced a cost-effective, 3-dimensionally printed simulation model designed to enhance surgical training for bilobed and banner flaps in Mohs nasal reconstruction.2 By providing an accessible, high-fidelity training tool, the study has tremendous implications for advancing surgical education. The model allows for hands-on practice, improving surgical confidence and technical proficiency while reducing the reliance on live patients or cadavers. This innovative approach to skill acquisition has the potential to revolutionize reconstructive training, making high-quality education more widely available and ultimately leading to better patient outcomes. LOWER EXTREMITY The value of patient-reported outcome measures to assess quality of life following reconstructive surgery has grown over the past decade. The study by Mundy et al.3 validates the LIMB-Q, which was designed to assess functional recovery and quality of life for patients undergoing reconstruction for traumatic lower extremity injuries. As surgeons aim to achieve traditional markers of success, such as viable soft-tissue coverage, this tool refocuses our efforts beyond that and further toward holistic patient-centered care. Establishing the reliability and validity of the LIMB-Q thereby adds this tool to our accepted-standard outcome assessments, influencing future research and clinical practice. Reconstruction of the knee is oftentimes a vexing surgical problem due to the need for durable and dependable soft tissue to cover hardware or bone prominences of the weight-bearing joint. Du et al. present an innovative algorithm and structured approach for utilizing distally based ALT (dALT) flaps for such purposes.4 Preoperative imaging and knowledge of the variable dALT anatomy are paramount, as is a “plan B” option. As previously noted in the Discussion of the article by my colleagues and me,5 surgeons should carefully weigh the risks versus the benefits of the dALT flap against the workhorse gastrocnemius flap or free ALT flap. Nevertheless, this study by Du et al. and the proposed algorithm have allowed us to broaden our armamentarium while providing ways to deal with unexpected intraoperative challenges, making this less commonly used flap a more reliable option for the knee. UPPER EXTREMITY DONOR SITES Reconstructive microsurgery has evolved beyond flap survivability to prioritizing aesthetics and function and minimizing donor-site morbidity. Al-Aroomi et al. compared radial and ulnar forearm free flaps to assess donor-site morbidity and its impact on quality of life.6 Whereas the radial forearm free flap is more widely taught and used, this study highlights the ulnar forearm free flaps as a viable—and potentially preferable—alternative. By emphasizing functional outcomes and long-term complications, the findings challenge conventional preferences and encourage surgeons to broaden their flap selection criteria, ensuring a more balanced approach to function, aesthetics, and patient satisfaction. LYMPHEDEMA Lymphedema continues to pose a persistent challenge for reconstructive surgeons, as there are few durable treatment options available for advanced stages of disease. Karlsson et al. provide an impressive follow-up of 5 years, supporting the safety and sustained efficacy of liposuction for advanced lymphedema, through volume reduction and improved patient-reported outcomes.7 All complications were minor and related to compression garments. Their study reinforces the importance of surgery in addressing this debilitating condition, and it emphasizes the advantages of a multidisciplinary approach, which includes physiotherapy and postoperative compression garments to maximize and maintain optimal reduction. Their findings will support the wider adoption of liposuction as a treatment for chronic advanced lymphedema, and they have undoubtedly inspired further research into quality-of-life assessments, both independently and in conjunction with other physiologic lymphatic procedures. Jeong et al. provide compelling evidence supporting axillary vein decompression as an essential adjunct in advanced lymphedema management.8 By demonstrating that perivascular scar release may improve outcomes after lymphovenous anastomosis, this study fills a critical gap in lymphedema treatment and research. The mechanism of action is based on a reduction of venous pressure in the peripheral vein, thereby increasing pressure gradients to more effectively allow lymphatic fluid drainage into the venous system. This offers a more definitive surgical solution for severe cases, setting a new standard in surgical lymphedema management. SPINE Prior research underscores the benefit of prophylactic paraspinous muscle flaps for patients undergoing spinal surgery to prevent wound complications.9 The implication in oncologic patients who have had prior chemotherapy and radiation, debulking tumor resection, or multiple prior spine operations for metastases is less understood. Dalton et al. provide compelling evidence supporting the use of muscle flaps as a preventive strategy in such patients, showing a reduction in wound complication rates and hardware loss.10 Complications in these patients may delay subsequent systemic and radiation therapies, thereby impairing disease control and survival. At my institution, this study has propelled our multidisciplinary efforts to offer muscle flaps prophylactically and routinely for all spine procedures. ABDOMEN AND PELVIS Plastic surgeons often use body mass index (BMI) thresholds to guide patient management. In their meta-analysis, Laspro et al. examined the impact of BMI on risk stratification in panniculectomy.11 They observed that higher BMI increases complication risk, yet the effect is nonlinear, with diminishing marginal risk beyond 33.2 to 35 kg/m². The authors emphasize the importance of considering BMI, but alongside other factors, such as age and tobacco use, for a more comprehensive approach to patient selection and risk mitigation. This evidence-based perspective could shape future insurance guidelines and eligibility criteria, reinforcing that BMI alone should not serve as an absolute exclusion criterion. Asaad et al. present a comprehensive analysis of the vertical rectus abdominis myocutaneous flap for pelvic reconstruction in 546 patients at a single institution.12 Their findings reveal a 9.9% postoperative hernia rate, with no protective effect from component separation or mesh use. Rather than use a routine prophylactic approach, I will tailor mesh use to cases with excessive tension or when fascia cannot be reapproximated. The authors also highlight refinements in flap harvesting, particularly fascia-sparing techniques, which undoubtedly minimize donor-site morbidity and enhance recovery. With a favorable complication profile, the vertical rectus abdominis myocutaneous flap remains the cornerstone for reconstructing complex and large perineal defects. CONCLUSIONS The selected articles exemplify the dynamic progress in reconstructive surgery, spanning innovative algorithms, novel surgical techniques, risk stratification methods, quality-of-life considerations, and outcome measures. Each contribution not only reflects current advancements but also signals future directions in patient care and surgical refinement. Whether through the validation of patient-reported outcomes, the development of novel flap algorithms, or the refinement of existing surgical approaches, these studies highlight the ever-evolving nature of reconstructive surgery. By incorporating these findings into clinical practice, surgeons can safely push the boundaries of innovation in an evidence-based manner, ultimately enhancing patient outcomes and shaping the future of reconstructive surgery. DISCLOSURE Dr. Azoury receives royalty payments from Wolters Kluwer for UpToDate articles and consulting payments from Integra Life Sciences and Johnson & Johnson.