The cross-leg free flap: A systematic review of the literature.

BACKGROUND: Free tissue transfer is a mainstay treatment for lower extremity soft tissue injuries. When the traditional cross-leg flap cannot provide enough coverage, a cross-leg free flap (CLFF) is a limb-saving alternative. The aim of this study is to conduct a systematic review of the literature published on the CLFF. METHODS: We conducted a systematic review of articles describing the CLFF, according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Inclusion criteria included articles with primary data on the CLFF. Exclusion criteria included those describing pedicled cross-leg flaps or lacking complete data. Data analysis was performed using SPSS 29.0. RESULTS: Our review included 28 articles encompassing 130 patients who underwent free tissue transfer. Most were male (63.8%) with a mean age of 32.4 years. Latissimus dorsi was the most common flap type (30.0%), followed by vertical rectus myocutaneous (20.0%). Average flap size was 301.8 cm2 , with trauma in the lower third of the leg being the most common indication (73.1%). The contralateral posterior tibialis was the most common recipient artery (84.1%) followed by the anterior tibialis (9.5%). Complications included amputation (1.4%), partial graft loss, thrombosis, hematoma, prolonged pain, nonunion, and seroma; a forest plot was used to illustrate the low overall adverse events rate. Although bivariate analysis identified age, flap size, type, location, and donor site as variables significantly impacting the incidence of complications (p < .05), this was not sustained in a multivariate logistic regression model. CONCLUSION: The CLFF remains an excellent option for limb salvage when a suitable recipient vessel is unavailable. Our review demonstrates 1.4% flap failure and an acceptable complication rate. While most cases in our review describe muscle flaps, we report a complex case of limb salvage using an unusually large anterolateral thigh flap.

Oncoplastic breast reconstruction: Principles, current techniques, and future directions.

Oncoplastic breast reconstruction has improved esthetic results after breast-conserving surgery with low complication rates and stable oncologic outcomes. Basic principles can be applied across different volume displacement and replacement techniques including restoration of breast shape and symmetry through esthetic incisions while eliminating dead space. Technique selection is guided by several factors including breast size, resection-to-breast ratio, and patient desires. A surgeon familiar with all techniques will allow individualization of treatment and optimization of outcomes.

Surgical Management of Occipital Neuralgia: A Systematic Review of the Literature.

BACKGROUND: Occipital neuralgia (ON) is a primary headache disorder characterized by severe, paroxysmal, shooting or stabbing pain in the distribution of the greater occipital, lesser occipital, and/or third occipital nerves. Both medical and surgical options exist for treating headaches related to ON. The purposes of this study are to summarize the current state of surgical ON management through a systematic review of the literature and, in doing so, objectively identify future directions of investigation. METHODS: We performed a systematic review of primary literature on surgical management for ON of at least level IV evidence. Included studies were analyzed for level of evidence, therapeutic intervention, study design, sample size, follow-up duration, outcomes measured, results, and risk of bias. RESULTS: Twenty-two studies met the inclusion criteria. All 22 studies used patient-reported pain scores as an outcome metric. Other outcome metrics included complication rates (7 studies; 32%), patient satisfaction (7 studies; 32%), quality of life (7 studies; 18%), and analgesic usage (3 studies; 14%). Using the ROBINS-I tool for risk of bias in nonrandomized studies, 7 studies (32%) were found to be at critical risk of bias, whereas the remaining 15 studies (68%) were found to be at serious risk of bias. CONCLUSIONS: Greater occipital nerve decompression seems to be a useful treatment modality for medically refractory ON, but further prospective, randomized data are required.

Comparing outcomes between stacked/conjoined and non-stacked/conjoined abdominal microvascular unilateral breast reconstruction.

BACKGROUND: Stacked and conjoined free flaps are increasingly utilized in autologous breast reconstruction to augment tissue transfer volume. However, there is a paucity of comparative data on abdominally-based stacked/conjoined versus non-stacked/conjoined flaps. The purpose of this study was to compare ability to match native breast size, complications, recovery, and symmetrizing procedures between these two cohorts in unilateral breast reconstruction. METHODS: A retrospective review of all stacked (two separate hemiabdominal)/conjoined (bipedicled full abdominal) flaps and non-stacked/conjoined (unipedicled hemiabdominal) flaps in unilateral abdominally-based autologous breast reconstructions was performed from 2011 to 2018. Variables including demographics, operative characteristics, complications, and revisions were compared in 36 stacked/conjoined patients versus 146 non-stacked/conjoined patients. RESULTS: The stacked/conjoined cohort had more DIEP flaps (91.7 vs. 65.1%) and the non-stacked/conjoined group more MS-TRAMs (34.2 vs. 6.9%, p = .000). Additionally, non-stacked/conjoined flaps had greater utilization of combined medial and lateral row perforators (p = .000). Mean flap weight was significantly higher than mastectomy weight in stacked/conjoined flaps (+110.7 g) when compared to non-stacked/conjoined flaps (-40.2) (p = .023). Average follow-up was 54.7 ± 27.5 and 54.6 ± 29.3 months, respectively. Stacked/conjoined flaps had lower fat necrosis rates (8.3 vs. 25.4%, p = .039) and had a decreased risk of fat necrosis on multivariable regression analysis (OR 0.278, p = 0.045). There were otherwise no differences in flap, breast, or donor-site complications. Stacked/conjoined flaps also had a lower rate of contralateral breast reduction (p = .041). CONCLUSION: Stacked/conjoined flaps were associated with a lower risk of fat necrosis compared with non-stacked/conjoined flaps and had a lower rate of contralateral symmetrizing reductions in patients undergoing unilateral abdominally-based breast reconstruction.

A Systematic Review and Meta-Analysis of Microvascular Stacked and Conjoined-Flap Breast Reconstruction.

BACKGROUND: Stacked and conjoined (SC) flaps are a useful means of increasing flap volume in autologous breast reconstruction. The majority of studies, however, have been limited to smaller, single-center series. METHODS: A systematic literature review was performed to identify outcomes-based studies on microvascular SC-flap breast reconstruction. Pooled rates of flap and operative characteristics were analyzed. Meta-analytic effect size estimates were calculated for reconstructive complication rates and outcomes of studies comparing SC flaps to non-SC flaps. Meta-regression analysis identified risk factors for flap complications. RESULTS: Twenty-six studies were included for analysis (21 case series, five retrospective cohort studies) for a total of 869 patients, 1,003 breasts, and 2006 flaps. The majority of flaps were harvested from the bilateral abdomen (78%, 782 breasts) followed by combined abdomen-thigh stacked flaps (22.2%, 128 breasts). About 51.1% of flaps were anastomosed to anterograde/retrograde internal mammary vessels (230 breasts) and 41.8% used internal mammary/intraflap anastomoses (188 breasts). Meta-analysis revealed a rate of any flap complication of 2.3% (95% confidence interval: 1.4-3.3%), Q-statistic value p = 0.012 (I 2 = 43.3%). SC flaps had a decreased risk of fat necrosis compared with non-SC flaps (odds ratio = 0.126, p < 0.0001, I 2 = 0.00%), though rates of any flap and donor-site complication were similar. Age, body mass index, flap weight, and flap donor site and recipient vessels were not associated with increased risk of any flap complication. CONCLUSION: A global appraisal of the current evidence demonstrated the safety of SC-flap breast reconstruction with low complication rates, regardless of donor site, and lower rates of fat necrosis compared with non-SC flaps.

Prophylactic nipple-sparing mastectomy in young previvors: Examining decision-making, reconstructive outcomes, and patient satisfaction in BRCA+ patients under 30.

Bilateral prophylactic mastectomies (BPM) in young previvors with high-risk mutations are rising; however, little data on management, therapy timing, and outcomes exist. BRCA+ patients under 30 undergoing BPM from 2006 to 2018 were reviewed. Twenty-two patients aged 23-29 underwent mastectomy 4.2 years after genetic diagnosis. Twelve patients completed surveys, most often citing personal decisions (50%) for undergoing mastectomy and plastic surgeons' recommendations (83.3%) for reconstruction. About 73% of patients completely understood risks/benefits of mastectomy and 63.6% of reconstruction. Patients reported high BREAST-Q Satisfaction and Well-Being scores. Continued educational resource development will optimize shared decision-making in the reconstructive process.

Estimation of Profunda Artery Perforator Flap Weight Using Preoperative Computed Tomography Angiography.

BACKGROUND: Given the relatively small size of thigh-based flaps and the possible necessity for a multiflap reconstruction, it is imperative to arrive at an accurate estimation of flap weight during preoperative planning. It was our objective to develop a novel technique for the preoperative estimation of profunda artery perforator (PAP) flap weight. METHODS: All patients that underwent transverse PAP flap breast reconstruction at two institutions were retrospectively reviewed. Subcutaneous tissue thicknesses were measured on axial computed tomography angiography scans at several predetermined points. The distance from the inferior gluteal crease to the PAP was also recorded. Linear regression was used to estimate flap weight. RESULTS: A total of 18 patients (32 flaps) were analyzed. The median intraoperative flap weight was 299 g (interquartile range [IQR]: 235-408). The parsimonious model (R 2 = 0.80) estimated flap weight using the Eq. 77.9x + 33.8y + 43.4z - 254.3, where x is subcutaneous tissue thickness (cm) at the lateral border of long head of the biceps femoris at a level 4.5 cm caudal to the inferior gluteal fold, y is distance (cm) from the inferior gluteal fold to the dominant PAP, and z has a value of 1 if the patient was scanned in the supine position or 0 if prone. The aforementioned formula yielded a median estimated flap weight of 305 g (IQR: 234-402) and a median percent error of 10.5% (IQR: 6.1-16.2). CONCLUSION: The authors demonstrate a simple and accurate formula for the preoperative estimation of transverse PAP flap weight for breast reconstruction.

Optimizing the Mastectomy Flap to Improve Aesthetic Outcomes.

The aesthetics of breast reconstruction inherently rely on both the ablative and reconstructive procedures. Mastectomy flap quality remains one of the most critical factors in determining the success of a reconstruction and its aesthetic outcome. Maintaining the segmental perfusion to the nipple and skin envelope during mastectomy requires preserving the subcutaneous tissue superficial to the breast capsule. Because this layer of tissue varies in thickness among different patients and within each breast, anatomic dissection along the appropriate planes is required rather than a "one-size-fits-all" mentality. A team-based approach between the breast surgeon and plastic surgeon will optimize both the ablative and reconstructive procedures while engaging in a process of shared decision-making with the patient. Preoperative clinical analysis and utilization of imaging to assess individual breast anatomy will help guide mastectomies as well as decisions on reconstructive modalities. Critical assessment of mastectomy flaps is paramount and requires flexibility to adapt reconstructive paradigms intraoperatively to minimize the risk of complications and provide the best aesthetic result.

The Effects of Perioperative Tamoxifen Therapy on Microvascular Flap Complications in Transverse Rectus Abdominis Myocutaneous/Deep Inferior Epigastric Perforator Flap Breast Reconstruction.

BACKGROUND: Tamoxifen is an important adjunct therapy in breast cancer treatment; however, it has been implicated in increasing microvascular flap complications. Current recommendations on stopping tamoxifen are conflicting and do not address tamoxifen therapy that is continued perioperatively. The purpose of this study is to determine whether tamoxifen taken at the time of free transverse rectus abdominis myocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flap breast reconstruction affects thrombotic complication rates. METHODS: A retrospective review of microvascular breast reconstruction with TRAM/DIEP flaps over the last 20 years was carried out at a single institution. Patients were divided into 2 cohorts: those receiving tamoxifen at the time of reconstruction (tamoxifen cohort) and those not taking tamoxifen (control). Demographic information, procedural characteristics, and rates of microvascular flap complications were compared. RESULTS: Forty-three patients (56 flaps) received tamoxifen at the time of microvascular breast reconstruction, and 185 patients (267 flaps) did not. Patients in the tamoxifen cohort had a lower mean age of 48.9 years (P = 0.013). A greater percentage of patients in the tamoxifen cohort had preoperative radiation (P < 0.0001) and chemotherapy (P = 0.018) and underwent delayed reconstruction (P < 0.0001). There were no significant differences between the 2 cohorts with regard to flap complications including both arterial and venous thrombosis, flap failure, and other local flap complications. CONCLUSIONS: Patients receiving tamoxifen during TRAM/DIEP flap breast reconstruction did not have increased rates of flap thrombosis or failure; therefore, stopping tamoxifen prior to these procedures may not be necessary.

The National Ambulatory Medical Care Survey: PAs and NPs in outpatient surgery.

BACKGROUND: This study aimed to determine the prevalence and occupational characteristics of physician assistants (PAs) and nurse practitioners (NPs) in outpatient surgical subspecialty clinics. METHODS: The 2007 and 2008 National Ambulatory Medical Care Survey (NAMCS) databases were queried for the number and characteristics of office visits seen by different provider types (PAs or NPs, physicians, or both) in various surgical subspecialties. RESULTS: More than 250 million weighted sample visits were analyzed. PAs or NPs were involved in 5.9% of visits, though the percentage of patients seen by them alone (1.1%) was significantly lower (P<0.0001). PAs and NPs were more likely to be involved in pre- or postoperative visits, and often saw the same diagnoses alone as physicians only. The most common procedures performed by PAs and NPs varied according to subspecialty. CONCLUSIONS: PAs and NPs have a minor prevalence in the ambulatory surgical workforce during the time period studied. Further integration of these providers into the outpatient setting may help optimize efficiency in ambulatory surgical care.

Implications for human adipose-derived stem cells in plastic surgery.

Adipose-derived stem cells (ADSCs) are a subset of mesenchymal stem cells (MSCs) that possess many of the same regenerative properties as other MSCs. However, the ubiquitous presence of ADSCs and their ease of access in human tissue have led to a burgeoning field of research. The plastic surgeon is uniquely positioned to harness this technology because of the relative frequency in which they perform procedures such as liposuction and autologous fat grafting. This review examines the current landscape of ADSC isolation and identification, summarizes the current applications of ADSCs in the field of plastic surgery, discusses the risks associated with their use, current barriers to universal clinical translatability, and surveys the latest research which may help to overcome these obstacles.

Single-lumen and multi-lumen poly(ethylene glycol) nerve conduits fabricated by stereolithography for peripheral nerve regeneration in vivo.

BACKGROUND: The use of nerve conduits to facilitate nerve regrowth after peripheral nerve injury is limited to defects less than 3 cm. The purpose of this study is to determine the capability of novel single and multi-lumen poly(ethylene glycol) (PEG) conduits manufactured by stereolithography to promote peripheral nerve regeneration. MATERIALS AND METHODS: Eight Sprague Dawley rats with sharp transection injuries of the sciatic nerve were randomly assigned to receive single-lumen or multi-lumen PEG conduits to bridge a 10-mm gap. Sciatic nerve and conduit samples were harvested after 5 weeks, and axon number, myelin thickness, fiber diameter, and g-ratio were analyzed. The contralateral intact nerve was also harvested for comparison. RESULTS: Partial nerve regeneration was observed in three out of four single-lumen conduits and one out of four multi-lumen conduits. Axon number in the single-lumen regenerated nerve approached that of the contralateral intact nerve at 4,492 ± 2,810.0 and 6,080 ± 627.9 fibers/mm(2), respectively. The percentage of small fibers was greater in the single-lumen conduit compared with the intact nerve, whereas myelin thickness and g-ratio were consistently greater in the autologous nerve. Axon regrowth through the multi-lumen conduits was severely limited. CONCLUSION: Single-lumen stereolithography-manufactured PEG nerve conduits promote nerve regeneration, with regenerating axon numbers approaching that of normal nerve. Multi-lumen conduits demonstrated significantly less nerve regeneration, possibly due to physical properties of the conduit inhibiting growth. Further studies are necessary to compare the efficacy of the two conduits for functional recovery and to elucidate the reasons underlying their differences in nerve regeneration potential.

"Strategic sequences" in adipose-derived stem cell nerve regeneration.

BACKGROUND: Peripheral nerve injuries (PNI) are a major source of morbidity worldwide. The development of cellular regenerative therapies has the potential to improve outcomes of nerve injuries. However, an ideal therapy has yet to be found. The purpose of this study is to examine the current literature key points of regenerative techniques using human adipose-derived stem cells (hADSCs) for nerve regeneration and derive a comprehensive approach to hADSC therapy for PNI. METHODS: A literature review was conducted using the electronic database PubMed to search for current experimental approaches to repairing PNI using hADSCs. Key search elements focused on specific components of nerve regeneration paradigms, including (1) support cells, (2) scaffolds, and (3) nerve conduits. RESULTS: Strategic sequences were developed by optimizing the components of different experimental regenerative therapies. These sequences focus on priming hADSCs within a specialized growth medium, a hydrogel matrix base, and a collagen nerve conduit to achieve neuromodulatory nerve regeneration. hADSCs may exert their neuroregenerative influence through paracrine effects on surrounding Schwann cells in addition to physical interactions with injured tissue. CONCLUSIONS: hADSCs may play a key role in nerve regeneration by acting primarily as support for local neurotrophic mediation and modulation of nerve growth rather than that of a primary neuronal differentiation agent.

Ultrasound in Microsurgery: Current Applications and New Frontiers.

Ultrasound has revolutionized reconstructive microsurgery, offering real-time imaging and enhanced precision allowing for preoperative flap planning, recipient vessel identification and selection, postoperative flap monitoring, and lymphatic surgery. This narrative review of the literature provides an updated evidence-based overlook on the current applications and emerging frontiers of ultrasound in microsurgery, focusing on free tissue transfer and lymphatic surgery. Color duplex ultrasound (CDU) plays a pivotal role in preoperative flap planning and design, providing real-time imaging that enables detailed perforator mapping, perforator suitability assessment, blood flow velocity measurement, and, ultimately, flap design optimization. Ultrasound also aids in recipient vessel selection by providing assessment of caliber, patency, location, and flow velocity of recipient vessels. Postoperatively, ultrasound enables real-time monitoring of flap perfusion, providing early detection of potential flap compromise and improved flap survival rates. In lymphatic surgery, ultra-high frequency ultrasound (UHFUS) offers precise mapping and evaluation of lymphatic vessels, improving efficacy and efficiency by targeting larger dilated vessels. Integrating ultrasound into reconstructive microsurgery represents a significant advancement in the utilization of imaging in the field. With growing accessibility of devices, improved training, and technological advancements, using ultrasound as a key imaging tool offers substantial potential for the evolution of reconstructive microsurgery.

Prepectoral versus Subpectoral Breast Reconstruction after Nipple-sparing Mastectomy: A Systematic Review and Meta-Analysis.

Background: Implant-based breast reconstruction after nipple-sparing mastectomy (NSM) presents unique benefits and challenges. The literature has compared outcomes among total submuscular (TSM), dual-plane (DP), and prepectoral (PP) planes; however, a dedicated meta-analysis relevant to NSM is lacking. Methods: We conducted a systematic review of studies on immediate breast reconstruction after NSM using TSM, DP, or PP prosthesis placement in PubMed, Embase, and Cochrane databases. In total, 1317 unique articles were identified, of which 49 were included in the systematic review and six met inclusion criteria for meta-analysis. Pooled descriptive outcomes were analyzed for each cohort for all 49 studies. Fixed-effects meta-analytic methods were used to compare PP with subpectoral (TSM and DP) reconstructions. Results: A total of 1432 TSM, 1546 DP, and 1668 PP reconstructions were identified for descriptive analysis. Demographics were similar between cohorts. Pooled descriptive outcomes demonstrated overall similar rates of reconstructive failure (3.3%-5.1%) as well as capsular contracture (0%-3.9%) among cohorts. Fixed-effects meta-analysis of six comparative studies demonstrated a significantly lower rate of mastectomy flap necrosis in the PP cohort compared with the subpectoral cohort (relative risk 0.24, 95% confidence interval [0.08-0.74]). All other consistently reported outcomes, including, hematoma, seroma, infection, mastectomy flap necrosis, nipple -areola complex necrosis, and explantation were comparable. Conclusions: A systematic review of the literature and meta-analysis demonstrated the safety of immediate prepectoral breast reconstruction after NSM, compared with submuscular techniques. Submuscular reconstruction had a higher risk of mastectomy flap necrosis, though potentially influenced by selection bias.

Neuromodulatory nerve regeneration: adipose tissue-derived stem cells and neurotrophic mediation in peripheral nerve regeneration.

Peripheral nerve injury requiring nerve gap reconstruction remains a major problem. In the quest to find an alternative to autogenous nerve graft procedures, attempts have been made to differentiate mesenchymal stem cells into neuronal lineages in vitro and utilize these cellular constructs for nerve regeneration. Unfortunately, this has produced mixed results, with no definitive procedure matching or surpassing traditional nerve grafting procedures. This review presents a different approach to nerve regeneration. The literature was reviewed to evaluate current methods of using adipose-derived stem cells (ADSCs) for peripheral nerve regeneration in in vivo models of animal peripheral nerve injury. The authors present cited evidence for directing nerve regeneration through paracrine effects of ADSCs rather than through in vitro nerve regeneration. The paracrine effects rely mainly, but not solely, on the elaboration of nerve growth factors and neurotrophic mediators that influence surrounding host cells to orchestrate in vivo nerve regeneration. Although this paradigm has been indirectly referred to in a host of publications, few major efforts for this type of neuromodulatory nerve regeneration have been forthcoming. The ADSCs are initially "primed" in vitro using specialized controlled medium (not for neuronal differentiation but for sustainability) and then incorporated into a hydrogel base matrix designed for this purpose. This core matrix is then introduced into a natural collagen-based nerve conduit. The prototype design concepts, evidence for paracrine influences, and regulatory hurdles that are avoided using this approach are discussed.

Modern Approaches to Implant-Based Breast Reconstruction.

The modern approach to implant-based breast reconstruction encompasses an evolution in surgical techniques, patient selection, implant technology, and use of support materials. Successful outcomes are defined by teamwork throughout the ablative and reconstructive processes as well as appropriate and evidence-based utilization of modern material technologies. Patient education, focus on patient-reported outcomes, and informed and shared decision-making are the key to all steps of these procedures.

Microsurgery in oncoplastic breast reconstruction.

Oncoplastic breast reconstruction has allowed for the optimization of oncologic and reconstructive outcomes after breast-conserving surgery (BCS). Volume replacement procedures in oncoplastic reconstruction most commonly utilize regional pedicled flaps, though several studies have reported benefits to free tissue transfer for oncoplastic partial breast reconstruction in the immediate, delayed-immediate and delayed settings. Microvascular oncoplastic breast reconstruction is a useful technique in the appropriate patients with small-to-medium size breasts and larger tumor-to-breast ratios who desire to preserve breast size, those with a paucity of regional breast tissue and patients that wish to avoid chest wall and back scars. Several free flap options for partial breast reconstruction exist, including superficially-based abdominal flaps, medial thigh-based flaps, deep inferior epigastric artery perforator (DIEP) flaps and thoracodorsal artery-based flaps. However, special consideration should be given to preserving donor sites for potential future total autologous breast reconstruction with any flap choice that should be tailored to individual recurrence risk. Aesthetically placed incisions should take recipient vessel access into consideration which include the internal mammary vessels and perforators medially, and then intercostal, serratus branch and thoracodorsal vessels laterally. The utilization of a thin strip of lower abdominal tissue based on the superficial abdominal circulation allows for a well-concealed donor site with minimal morbidity and preservation of the abdominal donor site if future total autologous breast reconstruction is needed. Optimizing outcomes requires a team-based approach to appropriately design recipient and donor-site considerations while individualizing tumor and patient-specific plans.

The Free Superficially Based Low-Abdominal Mini Flap for Oncoplastic Breast Reconstruction.

SUMMARY: Volume replacement in oncoplastic breast reconstruction most commonly uses pedicled flaps. In thin patients with small breasts, free-tissue transfer may be better suited to preserve breast size. Evidence on microvascular oncoplastic reconstruction is limited, and reconstruction has often required sacrifice of potential future donor sites. The free superficially based low-abdominal mini (SLAM) flap uses a narrow strip of lower abdominal tissue based on superficial perfusion of the abdominal wall that is anastomosed to chest wall perforators to preserve the ability to perform future abdominally based autologous breast reconstruction. Five patients underwent reconstruction with SLAM flaps for immediate oncoplastic reconstruction. Their mean age was 49.8 years, and their mean body mass index was 23.5. Tumor location was most commonly in the lower outer quadrant (40%). Average lumpectomy weight was 30 g. Two flaps were based on the superficial inferior epigastric artery, and three, on the superficial circumflex iliac artery. Recipient vessels included internal mammary perforators (40%), serratus branch (20%), lateral thoracic vessel branch (20%), and lateral intercostal perforators (20%). All patients underwent radiation therapy without delay and maintained volume, symmetry, and contour at an average period of 11.7 months after surgery. There were no cases of flap loss, fat necrosis, or delayed wound healing. The free SLAM flap allows for immediate oncoplastic breast reconstruction in thin, small-breasted patients with limited regional tissue without sacrificing future potential donor sites for autologous breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.