The 2025 Plastic and Reconstructive Surgery Breast highlights reflect a specialty in motion, one that is simultaneously reaffirming its foundations and redefining its future. The 2025 highlights illustrate how research on plastic and reconstructive surgery of the breast has matured: our questions are sharper, our tools are more powerful, and our data are more connected than ever. The 10 articles featured in this Editorial, grouped into 3 themes, capture this evolution across the clinical, technical, and population health spectrum. First, investigators are delivering new answers to old questions by re-examining long-standing debates about postradiation breast changes, management of periprosthetic infections, and infection prophylaxis. Second, new technologies and innovations, including new digital tools, therapeutic devices, and techniques, offer answers to new questions, reshaping surgical planning, intraoperative precision, and postoperative outcomes. Finally, the era of big data is transforming population-level understanding of outcomes, equity, and specialty trends, allowing the field to better define value and highlighting issues of broad national and international relevance. NEW ANSWERS TO OLD QUESTIONS Despite decades of progress, some of the most enduring debates in breast reconstruction remain unresolved. These 2025 studies revisited such questions with increased methodological rigor, demonstrating how incremental refinements can meaningfully improve the safety and efficacy of reconstructive breast surgery. “A Quantitative Evaluation of the Effects of Radiation Therapy on the Postsurgical Breast”1 How does radiation affect breast volume? We know that radiation therapy is associated with tissue atrophy and fibrosis, but until now, we have not quantified the anticipated changes with whole or partial breast radiation therapy. Becker et al.1 tackled this longstanding question with a retrospective study of 113 patients (115 breasts) who underwent breast-conserving therapy for T1 tumors. The investigators calculated volumes from serial mammograms and found an average volume loss beyond the lumpectomy specimen of 19.3% and 26.6% at 1 and 5 years after breast-conserving therapy/radiation therapy, respectively. These findings not only provide a useful statistic for patient counseling but also set the stage for future studies exploring the potential impact of oncoplastic reduction and mastopexy on these volume changes. “Management of the Infected Tissue Expander”2 How can surgeons best manage an infected tissue expander? In their retrospective study of 4498 patients (7173 tissue expanders), Nelson et al.2 drew upon a large institutional experience treating 305 patients (338 expanders) with infection to recommend an optimal management pathway for one of the most common and frustrating complications of implant-based breast reconstruction. Finding that 40% of patients with infection who were initially managed by interventional radiology drainage required escalation to surgery, the authors advocate for a practice shift away from interventional radiology and toward early operative intervention, particularly for patients with unfavorable (ie, Gram-negative) periprosthetic culture data. This shift could yield meaningful time and cost savings and improve quality of life for patients, while also stimulating ongoing inquiry into optimal surgical management. “Single-Dose versus 24-Hour Antibiotic Prophylaxis in Reduction Mammaplasty: A Randomized Controlled Trial”3 What is the optimal duration of perioperative antibiotic prophylaxis? There have been several systematic reviews, meta-analyses, and expert panels on this topic in breast surgery, and many of them have concluded that there is “no good evidence.” Veiga et al.3 used a randomized controlled trial study design to provide level 1 evidence about prophylactic antibiotic use in breast reduction. The authors demonstrated no significant difference in surgical-site infection among 146 participants randomized to a single perioperative antibiotic dose with or without continuation for 24 hours postoperatively. This study deserves mention among the 2025 highlights for its rigorous design alone, although study inclusion criteria (eg, body mass index of 19 to 30 kg/m2) and practice patterns (eg, 24-hour perioperative admission permitting blinded intravenous antibiotic dosing) limit study generalizability and reproducibility. TECHNOLOGY AND INNOVATION: ANSWERS TO NEW QUESTIONS Innovation in breast reconstruction is generating answers to entirely new questions, redefining precision and performance in our specialty. The answers emerging from these 2025 studies challenge us to rethink how we prevent complications, overcome shortcomings of existing technologies, and leverage imaging to enhance outcomes. “Prophylactic Local Antibiotics for Tissue Expansion (PLATE) Improve Breast Reconstruction Outcomes”4 In this tri-institutional collaboration, Clark et al.4 demonstrated the utility of prophylactic local antibiotics for tissue expansion (PLATE) using a polymethyl methacrylate disk impregnated with vancomycin and tobramycin, inserted at the time of immediate tissue expander placement and removed at the time of second-stage reconstruction. Among 183 PLATE-treated patients (292 breasts) and 183 control subjects (301 breasts), the authors found significantly fewer infections (4.8% versus 12.6%, P < 0.01) in the PLATE group, illustrating the promise of local antibiotic delivery and the potential for future de-escalation of systemic perioperative prophylactic antibiotics. “Magnetic Resonance Imaging–Conditional Tissue Expanders in Breast Reconstruction: Clinical Outcomes and Radiation Therapy Implications”5 Clemens et al.5 report the results from a retrospective postmarket approval trial of magnetic resonance imaging (MRI)–conditional tissue expanders, a technology designed to limit imaging artifacts and bypass the MRI incompatibility of traditional tissue expanders. Citing their experience with 103 patients (161 expanders) who received MRI–conditional tissue expanders compared with a traditional tissue expander control cohort, the authors report equivalence of reconstructive safety outcomes alongside improvements in radiation dose calculations and delivery. Of note, although not addressed in this study, MRI “incompatibility” is relative; MRI can be performed safely with traditional tissue expanders using specialized protocols, though there can be in-plane rotation of the expander that can cause mild chest pressure or discomfort as well as an imaging artifact. This technology offers meaningful advancement by improving imaging fidelity, patient experience, and overall safety when MRI is required in the setting of expanders. Looking ahead, this study provides a preview of the next generation of tissue expander technology, with similar devices currently under development by major manufacturers. “The GalaFLEX ‘Empanada’ for Direct-to-Implant Prepectoral Breast Reconstruction”6 With the resurgence of prepectoral and direct-to-implant reconstruction and the declining use of textured implants due to safety concerns, control of the breast pocket has become a key challenge. By wrapping an implant in a poly-4-hydroxybutyrate scaffold (GalaFLEX Lite), Karp et al.6 effectively converted a smooth round implant into an “implant with tabs” or a “temporarily textured implant,” given the resorbable nature of poly-4-hydroxybutyrate. This novel application may reduce material-related costs compared to techniques using biologic matrices in prepectoral direct-to-implant reconstruction, given that GalaFLEX Lite is generally positioned at a lower list price per unit area of material relative to comparator biologics, such as AlloDerm Select contour matrix. However, incremental savings could be offset by the amount of scaffold required and will vary based on institution-specific pricing. Downstream outcomes, particularly around the authors’ hypothesized lower seroma rate, will be needed to complete the value analysis. “Ingress Time as a Metric for Indocyanine Green Angiographic Evaluation of Skin Flap Perfusion in Immediate Implant-Based Reconstruction”7 Indocyanine green (ICG) angiography has markedly improved our ability to evaluate mastectomy skin flap perfusion, yet many surgeons still find themselves holding the SPY handheld imaging device and wondering, “at what point has enough time passed?” This article by Lee et al.,7 a quantitative evaluation of ICG ingress time (ie, the time for ICG to cover the entire mastectomy skin flap), answers this question, suggesting that a time of greater than 70.5 seconds is predictive of mastectomy skin flap necrosis with 82% sensitivity, 84% specificity, and 83% accuracy. The authors astutely note a positive predictive value of 49%, meaning that only half of patients who screen positive by this metric will develop full-thickness necrosis, underscoring the importance of clinical judgment in its application. Even so, the study delivers a valuable, standardized reference point for performing and interpreting ICG angiography in practice. BIG DATA With the growth of national claims and registry datasets, breast reconstruction research has entered a population-scale era. Recent studies harness these resources to derive insight from variation on topics such as surgeon competition, specialty practice patterns, and reconstructive outcomes. “Impact of Regional Surgeon Competition on Use, Cost, and Outcomes of Breast Reconstruction in the United States”8 In this elegant health services study, Fahmy et al.8 used a decade of MarketScan commercial claims data to show that regions with greater plastic surgeon competition are associated with higher rates of breast reconstruction and lower out-of-pocket costs. Importantly, the authors calculated a reconstructive surgeon–specific Herifndahl-Hirschman Index, a standard economic measure of market concentration, to quantify local competition within metropolitan statistical areas. During a time of health system consolidation, this work provides timely evidence that preserving competition among reconstructive surgeons may enhance affordability, access, and equity in postmastectomy care. “Assessing the Shift: Increasing Rates of Immediate Breast Reconstruction by Nonplastic Surgeons—Insights from a Nationwide Analysis”9 Kilmer et al.9 used PearlDriver national claims data to explore shifting patterns in surgeon specialty participation in breast reconstruction. The authors evaluated 80,031 implant-based breast reconstructions and 10,518 oncoplastic reductions performed from 2010 to 2021 among patients with a previous orthopedic diagnosis, offering evidence that general surgeons are performing an increasing share of immediate implant-based breast reconstruction and oncoplastic procedures, even in regions with adequate access to plastic surgeons. Findings from studies using other national datasets (eg, MarketScan, National Surgical Quality Improvement Program) have not always mirrored this trend, underscoring how differences in the “big data” source, cohort and variable definition, coding strategy, and timeframe can yield divergent conclusions. These discrepancies underscore the importance of transparent methodology, as produced by the authors of this study, and independent validation to strengthen reproducibility in reconstructive health services research. “Risk Prediction of Implant Loss following Implant-Based Breast Reconstruction: A Population-Based Study”10 This nationwide study uses the Dutch Breast Implant Registry to develop and validate a practical risk prediction model for implant loss following breast reconstruction. Drawing on 5260 cases, Blok et al.10 identified 4 key predictors—body mass index, smoking, radiation therapy, and prepectoral placement—and converted them to an accessible clinical tool for individualized risk estimation. Beyond its immediate clinical utility, this work highlights the power of national, mandatory registries to generate high-quality, complete, real-world data and serves as a model for how population-level surveillance can drive quality improvement. Collectively, these 10 studies illustrate a field that is advancing through evidence and innovation. They not only showcase the progress of the past year but also spark the next generation of research questions that will sustain ongoing years of discovery and improvement in breast reconstruction. DISCLOSURE The author has no financial interest in any of the products, devices, or drugs mentioned in this article. disclaimer The content is solely the responsibility of the author and does not necessarily represent the views or opinions of Memorial Sloan Kettering Cancer Center.
Danielle H. Rochlin (Wed,) studied this question.