BACKGROUND Objective assessment of aesthetic outcomes following post-mastectomy breast reconstruction remains challenging. The Aesthetic Grading Tool (AGT) was developed as a standardized tool to evaluate aesthetic outcomes independent of patient-reported satisfaction. This study aimed to identify factors associated with aesthetic outcomes using the AGT. METHODS 35 de-identified photographs of patients who underwent bilateral autologous reconstruction were included in the AGT. Respondents including attending physicians, advanced practice providers, nurses, trainees, and patients rated aesthetic outcomes on a 5-point Likert scale. Associations between aesthetic scores and clinical variables, including receipt of radiation, 90-day readmission, and mastectomy type, were assessed. Differences in scores by respondent training level were also analyzed. RESULTS 91 respondents completed the AGT. Of the 35 patients whose photographs are included in the AGT, 26% received radiation, and 91% underwent a skin-sparing mastectomy. Receipt of preoperative radiation was associated with lower scores (beta = -0.68, 95% CI: -1.3 -0.04, p=0.039). Patients with 90-day readmission (1.98 vs 3.15, p=0.11) and those who underwent conventional as opposed to skin-sparing or nipple-sparing mastectomy (2.25 vs 3.09 vs 3.21, p=0.5) trended towards lower AGT scores. Attending physicians consistently assigned higher scores across all variables, whereas patient respondents provided among the lowest scores. CONCLUSION Receipt of radiation is associated with worse aesthetic outcomes following bilateral autologous reconstruction. Patients with 90-day readmission and conventional mastectomy trend towards worse aesthetic outcomes. Providers should counsel patients who are undergoing bilateral DIEP flap reconstruction on expected aesthetic outcomes based on their treatment course.

This position paper was developed by the World Society for Reconstructive Microsurgery Task Force on Lymphedema to establish consensus-based recommendations for the management of extremity lymphedema. The document addresses key domains of care, including assessment, treatment strategies, surgical interventions, and postoperative management, with the goal of providing practical and adaptable guidance applicable across diverse clinical settings. Effective management of extremity lymphedema requires a structured and standardized approach encompassing comprehensive evaluation, individualized treatment, and long-term follow-up. Initial assessment should include a detailed history and physical examination, supplemented by standardized limb circumference measurements and clinical photography to ensure objective and reproducible documentation. Imaging modalities, such as lymphoscintigraphy and indocyanine green (ICG) fluorescent lymphography, are essential for accurate disease characterization and surgical planning. Preoperative optimization with conservative therapy and compression remains a critical step prior to intervention. Surgical management should be tailored to disease severity and patient-specific factors, incorporating physiologic procedures-including lymphaticovenous anastomosis (LVA), vascularized lymph node transfer (VLNT), and lymphaticovenular anastomosis (LNVA)-as well as excisional techniques such as liposuction and direct excision when indicated. Postoperative care should include regular noninvasive assessments at three-month intervals and annual imaging to monitor outcomes. Long-term follow-up, extending up to five years, is recommended to ensure sustained clinical improvement and to guide ongoing management.