The international exchange of knowledge has long driven surgical innovation and advanced reconstructive techniques worldwide. In this regard, few have shaped modern plastic surgery as profoundly as Dr. Isao Koshima of Japan, whose 1989 publication laid the technical foundation for the development of the deep inferior epigastric perforator flap by Dr. Robert J. Allen.1 Still, particularly in our field, we are guided not only by such established gold standards but also by adaptability to individual patient needs and a comprehensive shared decision-making process shaped by unique anatomical, biological, and sociocultural considerations. Visits to institutions abroad offer an ideal opportunity to reflect on this principle and explore how colleagues worldwide address their specific clinical demands. A recent observership at the Cancer Institute of the Japanese Foundation for Cancer Research (JFCR) showed what this meant in practice. As a senior resident at the University Hospital Muenster, Germany, I appreciated the chance to observe how oncoplastic surgery is performed at Japan’s largest microsurgical center. Beyond surgical excellence, I was intrigued by how their approach was tailored to the characteristics of the local patient population. Patients tended to be younger, possibly reflecting earlier cancer onset, and typically had smaller, less ptotic breasts.2,3 Therefore, although the inframammary fold incision is the technique of choice in Germany for scar concealment in nipple-sparing mastectomy, the lateral approach was favored at the JFCR, yielding a scar that was less apparent in the anterior plane. Furthermore, lower body mass index and childbearing age made abdominal flaps less suitable, whereas profunda artery perforator (PAP) and pedicled latissimus dorsi flaps—often considered second-line options in Germany—were routinely used. And, as innovation often follows necessity, I observed technical refinements that further enhanced these procedures. These included endoscopic, fat-augmented latissimus dorsi flaps and perioperative indocyanine green lymphography for lymphatic vessel identification and preservation in PAP flaps (Fig. 1).4Fig. 1.: Surgical planning of bilateral PAP flap harvest for stacked autologous breast reconstruction in a slim patient at JFCR. Indocyanine green lymphography enabled visualization and preservation of lymphatic vessels, thereby improving safety and postoperative results.Cultural attitudes also differed, as some patients seemed more reluctant than their German counterparts to undergo reconstructive surgery, perceiving it as cosmetic rather than restorative. Apprehension about potentially undergoing multiple operations further contributed to this tendency, especially as secondary interventions such as fat grafting and contralateral breast reduction are not usually covered by Japanese national health insurance, unlike in Germany.5 Consequently, surgeons at JFCR prioritized creating a definitive breast shape during the initial procedure, using bipedicled or stacked flaps to ensure sufficient volume when indicated. It is important to note that these observations do not represent a complete account of all surgical nuances involved, nor do they seek to generalize findings to the population as a whole. Nevertheless, learning from the work of colleagues across the globe can prompt a healthy critical reflection on clinical practices once regarded as self-evident, thereby adding depth to our understanding of plastic surgery. This allows us to act less rigidly and plan more consciously, not just repeating what we have routinely done, but consistently asking why we do it and whether there might be an alternative way—not necessarily one that is better or worse but one more suited to each situation, a defining feature of our discipline. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.
Khosh et al. (Fri,) studied this question.