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The recent and growing concept of patient and public involvement (PPI) refers to the active participation of patients and/or members of the public in research. It brings benefits to research and clinical practice. PPI offers different points of view, guides healthcare providers toward new research priorities, and ensures that research handles issues which truly matter. This review aims to illustrate the current state of research in the field of breast reconstruction regarding PPI.

A systematic search of PubMed and Embase databases was performed using a search strategy incorporating the following terms: “patient and public involvement”, “public”, “patient”, “community”, “decision”, “involvement”, “participation”, “engagement”, “empower”, “breast”, “surgery”, “reconstruction”. Articles were sought through patient-reported outcomes (PROs) or through their PPI strategy, including the types of involvement (consultation, collaboration, co-production, or user controlled research) and the research stages (identifying and prioritizing, commissioning, designing and managing, undertaking, disseminating, implementing, and evaluating impact) based on the National Institute for Health and Care Research (NIHR) classification. This review focuses on studies that included an explicit PPI strategy and excludes articles that solely presented PROs.

A total of 4738 articles were collected. After removing duplicates and screening, 499 studies were included. 10% (49/499) of the articles described a PPI strategy, while the remaining 90% (450/499) included only PROs. In the 49 articles that adopted a PPI strategy, consultation was reported 42 times, collaboration 15 times, co-production eight times, and user controlled research zero times. Some studies integrated different types of PPI within the same research stage, others included one type of PPI at different stages, or different types across various stages of the research process.

Despite using targeted search terms, only 10% of the articles included our topic of interest. The results show that the least patient-active involvement type predominates, while involvement approaches in which patients share equal status with researchers are rare. Given the ongoing shift toward patient-centered research, greater emphasis on incorporating PPI strategies should be placed in future research projects to ensure credibility of results.

Enhanced Recovery After Surgery (ERAS) pathways have standardized perioperative care in autologous breast reconstruction. However, several biologically relevant domains influencing microvascular stability and wound healing remain inconsistently integrated into clinical practice.

This analysis aims to systematically contextualize emerging perioperative strategies and stratify them according to their level of clinical evidence in autologous microsurgical breast reconstruction.

A structured narrative synthesis of contemporary clinical and translational literature was performed. Perioperative interventions were categorized into five domains: hyperbaric oxygen therapy (HBOT), closed-incision negative pressure wound therapy (ciNPWT), antioxidant and metabolic modulation, protein and carbohydrate optimization, and structured drain management.

Each domain was qualitatively appraised according to the predominant level and consistency of supporting evidence within reconstructive microsurgery.

Evidence stratification demonstrated heterogeneity in the level of clinical validation across perioperative domains in autologous microsurgical breast reconstruction.

Perioperative protein and carbohydrate optimization demonstrate relatively strong clinical support derived from randomized trials and surgical guidelines. ciNPWT and structured drain management show moderate clinical evidence in reducing donor-site morbidity. In contrast, HBOT is supported primarily by small clinical series despite a strong physiological rationale, while antioxidant strategies—including glutathione, vitamin C, and arginine—remain largely grounded in mechanistic and experimental data.

This disparity between biological plausibility and clinical validation highlights a translational gap in reconstructive microsurgery and supports staged integration of perioperative strategies according to their level of evidence.

Together, these findings suggest a progressive shift toward physiology-centered perioperative optimization. This approach may facilitate risk-adapted perioperative pathways tailored to individual patient profiles. Further prospective validation is needed to define structured clinical integration, including potential benefits for long-term functional and patient-reported outcomes with implications for flap predictability.

We applied the concept of augmentation mastopexy in the context of autologous immediate breast reconstruction (AIBR). In this case series we present the indications, clinical and patient reported outcomes of this approach.

Retrospective analysis of prospectively collected data identified the cohort of patients who had an augmentation of the reconstructed breast in AIBR. Patients wishing for larger breast size in bilateral reconstruction or who preferred the larger non-cancerous side were the main indications. The less common reason was to over reconstruct the ladies who will have adjuvant radiotherapy. Our inclusion criteria were patients who received immediate reconstruction with augmentation mastopexy by the senior author between January 2023 and June 2025. Augmentation was defined as a flap weight greater than or equal to 125 grams in relation to the mastectomy weight. Patient demographics, smoking status, oncologic characteristics and post-operative complications and returns to theatre, as well as patient reported outcome measures (BREAST-Q) were analysed.

17 patients met these criteria, including 13 unilateral and 4 bilateral cases. In total, 21 reconstructed breasts were included, 20 of which were reconstructed using deep inferior epigastric perforator (DIEP) flap, and one reconstructed using stacked transverse upper gracilis (TUG) flap. The mean nipple transposition distance in relation to the sternal notch on both breasts was 5.5cm [Range: 2 – 10cm]. The mean augmentation weight was 243.3 grams [Range: 142 – 419g]. Epidermolysis/ superficial mastopexy skin necrosis occured in 43.8%, partial mastectomy flap necrosis in 6.25%, seroma 6.25%, haematoma 6.25%, and surgical site infection was 18.75%. (put numbers rather than percentages please ) There was no return back to theatres and no flap loss. The BREAST-Q satisfaction with breast scored an average of 84.1% (53.8/64) and satisfaction with outcomes scored an average of 80.4% (38.6/48).

It is safe and feasible to offer augmentation mastopexy approach in the context of AIBR in the indications stated. BREAST-Q showed high patient satisfaction. Clinical outcomes were satisfactory.

With autologous breast reconstruction operations last 7 hours or more, surgeons across the world are keen to ensure a high degree of efficiency. In our breast reconstruction unit we aimed to improve workflow by implementing change at both the microscopic and macroscopic levels.

We conducted a retrospective review of operation notes for all free-flap breast reconstructions undertaken in the department in a 24-month period. 103 anastomoses in 91 patients were identified from an internal database. Flap ischaemia times were grouped into interrupted or continuous frontwall suture techniques. In bilateral cases, each anastomosis was considered separately. Using the same database we compared deviation from a planned 8:30am start and operation lengths across 60 patients undergoing delayed reconstruction over 66 months. Two patients were excluded where technical difficulties led to operative times >=10 hours.

67 anastomoses (65%) used an interrupted technique (mean ischaemia time of 53m, range 26-104). 36 (35%) anastomoses used a continuous technique (mean ischaemia time of 35m, range 19-56). Mann-Whitney U test showed shorter ischaemia times in the continuous group (p<=0.01). Excluding cases involving on-table re-anastomosis did not alter the findings (mean interrupted ischaemia time 55m, mean continuous ischaemia time 27m, p<=0.01). We found a reduced rate of on-table redo in the continuous group (5.5%) compared to the interrupted group (19.4%) but this was not significant (Chi-squared 3.61, p=0.0575). Flap failure rates between the groups were equivocal (2.98% interrupted, 2.77% continuous).
Examining start times and lengths of 58 operations gave a mean operation time of 436m and mean delay from 8:30 of +5:20s. We found a positive correlation between the deviation from a planned 8:30 start time and length of operation (Spearman’s rho = 0.346, p <=0.01). Simple linear regression showed that each 1m delay resulted in an additional 1m24s (140%) to operation length, irrespective of anaesthesia or patient transfer time.

In searching for a greater efficiency within our breast reconstruction lists, we identified key factors at the microscopic and macroscopic level. Starting the day promptly can foster an efficient theatre mentality, and by shifting to a continuous anastomotic technique we can safely limit ischaemia time without worsening flap failure rates.

Autologous breast reconstruction with a deep inferior epigastric perforator (DIEP) flap has high success rates; however, venous congestion can compromise flap viability. The benefit of routinely performing a second venous anastomosis remains uncertain.

We conducted a retrospective cohort study of DIEP flap breast reconstructions performed at a single academic center between 2015 and 2023. Flaps were categorized by venous configuration (single vs dual venous anastomoses). The primary outcome was total flap loss. Secondary outcomes included partial flap loss, venous complications, fat necrosis, hematoma, infection, wound dehiscence, take-back surgery, and at least one postoperative complication. Multivariable logistic regression explored factors associated with postoperative morbidity.

A total of 349 DIEP flaps were analyzed (288 single-vein; 61 dual-vein). Total flap loss was rare (0.9%) and did not differ between groups (0.7% vs 1.6%, p=0.439). At least one complication occurred in 29.8% of flaps, with no significant difference between venous configurations (27.8% vs 39.3%, p=0.073). Rates of venous events, fat necrosis, infection, hematoma, wound dehiscence, and take-back surgery were comparable. Partial flap loss was more frequent in dual-vein reconstructions (19.7% vs 9.7%, p=0.027), and operative time was longer (597.0 [533.0–684.0] vs 502.0 [454.0–582.5] minutes, p<0.001). On multivariable analysis, hypertension was independently associated with ≥1 complication (adjusted OR 2.40, 95% CI 1.27–4.40, p=0.007), whereas venous configuration was not.

In routine practice, dual venous anastomosis was preferentially used in more complex DIEP flap reconstructions and was not associated with lower rates of flap loss or overall complications.

Breast reconstruction is an integral component of guideline-based breast cancer treatment. Autologous breast reconstruction, such as the DIEP flap, can improve the patients’ quality of life.
While scientific attention often focuses on the initial breast reconstruction, there is frequently a subsequent desire for additional procedures aimed at aesthetic optimization. Knowledge of the frequency and types of secondary procedures provides important insight into the reconstructive path and is essential for informed decision-making in patients considering autologous breast reconstruction.
The aim of this study is to investigate the timing, type, and extent of secondary procedures following autologous breast reconstruction.

This study is a retrospective analysis of approximately 450 patients who underwent autologous breast reconstruction as well as their subsequent procedures between 2014 and 2024 at an outpatient center in XX (Praxis YY) certified by the XY Society of Plastic, Reconstructive, and Aesthetic Surgery.

Typical adjustments of both the reconstructed breast and the contralateral side include balancing breast or flap reduction, mastopexy, lipofilling, and scar correction. Secondary surgeries at the donor site include scar correction, especially Dog Ear revisions. Nipple reconstruction and areola tattooing were considered as additional reconstructive steps. Furthermore, the analysis also accounted for the patient’s prior course, including the type of reconstruction, mastectomy type, as well as complications of the initial procedure.

Our results demonstrate that autologous breast reconstruction represents a multi-step reconstructive path, in which the initial procedure is frequently followed by secondary interventions to optimize shape and symmetry.

In conclusion, this study provides insight into the reconstructive path following initial autologous breast reconstruction, offering crucial information for realistic patient counseling, planning and care.