Spotlight in Plastic Surgery: October 2022 : Plastic and Reconstructive Surgery (2024)

“Spotlight in Plastic Surgery” provides a quarterly overview of articles from non–plastic surgery high-impact journals and Plastic and Reconstructive Surgery Global Open. This month we will review key articles of relevance to plastic surgeons from The Lancet, New England Journal of Medicine, Nature, Annals of Surgery, and JAMA Surgery, in addition to those form Plastic and Reconstructive Surgery Global Open. Our goal is to enlighten Journal readers with clinical and basic science literature relevant to our specialty that they otherwise may not read. We continue to thank the Journal’s resident advisors and advisory board members who volunteer to help us identify these articles and provide a brief synopsis. Should any other readers have specific suggestions of articles to review in recent issues of high-impact journals, please contact us via email at [emailprotected]. We wish to remain responsive to the needs of our readers in keeping all of us up to date on key developments relative to plastic surgery.

ARTICLES

Two Phase 3 Trials of Baricitinib for Alopecia Areata. By King B, Ohyama M, Kwon O, et al.; BRAVE-AA Investigators. N Engl J Med. 2022;386:1687-1699.¹

This study describes two phase 3 double-blind, randomized trials, BRAVE-AA1 and BRAVE-AA2, assessing the efficacy of baricitinib, an oral JAK1 and JAK2 inhibitor, in the treatment of severe alopecia areata. A total of 654 and 546 patients in the BRAVE-AA1 and BRAVE-AA2 trials, respectively, were assigned to receive once-daily baricitinib (4 mg, 2 mg, or placebo) for 36 weeks. Baricitinib was superior to placebo with respect to hair regrowth (p < 0.001) in each trial. Although further evidence is necessary before baricitinib can be used in daily practice, knowledge about a new medical treatment may be helpful to plastic surgeons in counseling patients seeking hair restoration.

Mario Alessandri-Bonetti, M.D., I.R.C.C.S. Istituto GaleazziUniversita Degli Studi di Milano, Milan, Italy

Negative Pressure Wound Therapy Prevents Hernia Recurrence in Simultaneous Ventral Hernia Repair and Panniculectomy. By Deldar R, Abu El Hawa AA, Bovill JD, et al. Plast Reconstr Surg Glob Open 2022;10:e4171.²

The authors conducted a retrospective review of 114 patients who underwent ventral hernia repair with panniculectomy. The patients were divided into two groups: those who received standard sterile dressings and those who received negative-pressure wound therapy. Surgical site occurrences were similar between groups. However, hernia recurrence was higher in the standard sterile dressings group. The authors conclude that incisional negative-pressure wound therapy is beneficial in decreasing the hernia recurrence rate in this patient population. However, larger prospective studies are needed to validate these findings. This study highlights the benefit of negative-pressure wound therapy in improving postoperative outcomes in patients who undergo abdominal wall reconstruction.

Murad Karadsheh, M.D., Houston Methodist Hospital, Houston, Texas

The iBreastExam versus Clinical Breast Examination for Breast Evaluation in High Risk and Symptomatic Nigerian Women: A Prospective Study. By Mango VL, Olasehinde O, Omisore AD, et al. Lancet Glob Health 2022;10:e555–e563.³

Low-resource settings have a need for a portable low-cost technology for breast cancer screening. This prospective study enrolled 424 Nigerian women who underwent four examinations: clinical breast examination, iBreastExam (a novel handheld device using sensors to palpate breasts), and ultrasound and mammography as standard tests. For any breast finding, the iBreastExam was found to be more sensitive and less specific than the clinical breast examination. For suspicious findings, both tests had high negative predictive values. This is the first study of this device in Africa, which highlights its potential applicability as a screening tool in low-resource settings.

Aneesh Karir, M.D., University of Manitoba, Winnipeg, Manitoba, Canada

Perioperative Topical Antisepsis and Surgical Site Infection in Patients Undergoing Upper Aerodigestive Tract Reconstruction. By Beydoun AS, Koss K, Nielsen T, et al. JAMA Otolaryngol Neck Surg. 2022;148:547–554.⁴

In a prospective study of more than 500 patients undergoing upper aerodigestive tract surgery with complex flap reconstruction, the authors found that patients could have their risk of surgical site infection reduced by 51 percent with the use of a preoperative topical antisepsis mucosal preparation. The response to piperacillin and tazobactam was a 58 percent decrease in the infection rate. Previous studies have all found a significant reduction in mucosal microbial bioburden with the use of topical antisepsis. The authors mention the need for more randomized controlled trials to evaluate individual topical and systemic prophylactic interventions. The breadth of plastic surgery makes it challenging to choose an appropriate antibiotic for distinctive procedures.

Siddharth Mendiratta, M.Ch. Datta Meghe Institute of Medical Sciences Wardha, India

Tranexamic Acid in Patients Undergoing Noncardiac Surgery. By Devereaux PJ, Marcucci M, Painter TW, et al.; POISE-3 Investigators. N Engl J Med. 2022;386:1986–1997.⁵

The international, randomized, controlled trial POISE-3 assessed whether tranexamic acid, an antifibrinolytic drug, safely decreased bleeding in noncardiac surgery. A total of 9535 patients were randomly assigned 1:1 to receive tranexamic acid (1-g intravenous bolus) or placebo at the start and end of surgery. The incidence of a bleeding event (specifically, a life-threatening bleed, major bleed, or bleeding into a critical organ at 30 days) was significantly lower with tranexamic acid (9.1 percent, 433 patients) than with placebo (11.7 percent, 561 patients). Hence, this study provides level 1 evidence to support the increasing use of tranexamic acid in plastic surgery procedures.

Kerry A. Morrison, M.D. New York University Langone Health New York, N.Y.

Association between Operative Autonomy of Surgical Residents and Patient Outcomes. By Oliver JB, Kunac A, McFarlane JL, Anjaria DJ. JAMA Surg. 2022;157:211–219.⁶

This study aimed to assess whether surgical procedures performed by residents without an attending surgeon scrubbed are associated with differences in patient outcomes. They utilized the U.S. Veteran Affairs database to retrospectively analyze a score-matched 15-year cohort and compared mortality and morbidity rates of resident-performed procedures with those of surgeon-performed and surgeon-assisted procedures. The authors confirm that surgical procedures performed by residents alone were not associated with changes in all-cause mortality or composite morbidity. This information supports the surgical autonomy of residents to prepare for independent practice.

Miguel Ribeiro Matias, M.D. Centro Hospitalar Universitário Lisboa Central Lisboa, Portugal

Acellular Dermal Matrices in Breast Reconstruction: CARE Trial 5-Year Outcomes Data for More Than 9500 Patients. By Ellsworth WA 4th, Hammer J, Luo L, Schumacher A. Plast Reconstr Surg Glob Open. 2022;10:e4258.⁷

This study compared outcomes and complications in acellular dermal matrix implant-based breast reconstruction patients enrolled in the prospective Continued Access Reconstruction/Revision Expansion trial who underwent primary breast reconstruction or revision/reconstruction over a 5-year span. Capsular contracture rates in both primary reconstruction and revisions were lower in the acellular dermal matrix group at year 5 (3.2 percent versus 7.4 percent, 1.4 percent versus 8.9 percent, respectively). Seroma rates were low in both groups (≤2.9 percent). Reoperation rates increased over time in all cohorts; however, the acellular dermal matrix group had less asymmetry and implant malposition. Long-term acellular dermal matrix may be associated with less capsular contracture and fewer implant complications and may maintain low rates of seroma.

Tyler Safran, M.D., M.Sc. McGill University Montreal, Quebec, Canada

Validation of Artificial Intelligence Prediction Models for skin Cancer Diagnosis Using Dermoscopy Images: The 2019 International Skin Imaging Collaboration Grand Challenge. By Combalia M, Codella N, Rotemberg V, et al. Lancet Digital Health 2022;4:e330–e339.⁸

With the surge in telehealth during the COVID-19 pandemic, utilizing diagnostic artificial intelligence to expand medical access to remote and underserved populations continues to gain traction. This study aimed to systematically evaluate errors diagnostic dermatologic algorithms are prone to, particularly on untrained images, with the goal of highlighting current limitations. While the 129 algorithms’ ability to classify trained diagnoses outperformed dermatologists, nontrained images (predominantly scars and benign inflammation) were mislabeled as malignancy up to 47 percent of the time. These findings underscore the limits of dermatological artificial intelligence and pinpoint increased unnecessary biopsies as a potential consequence of implementation in its present form.

Benjamin R. Slavin, M.D. University of Miami Miami, Fla.

Robot-Assisted Nipple-Sparing Mastectomy with Immediate Breast Reconstruction: An Initial Experience of the Korea Robot-Endoscopy Minimal Access Breast Surgery Study Group (KoREa-BSG). By Ryu JM, Kim JY, Choi HJ, et al. Ann Surg. 2022;275:985–991.⁹

A retrospective review was performed of 73 women who underwent robot-assisted nipple-sparing mastectomy with immediate reconstruction. Patients who met nipple-sparing mastectomy criteria without planned radiotherapy were included. Most were premenopausal with early disease. Midaxillary 5-cm incisions were used, including for lymph node biopsy and for deep inferior epigastric perforator flap reconstruction to the thoracodorsals. All patients underwent implant-based reconstruction, except for one deep inferior epigastric perforator flap and one latissimus dorsi flap. Mastectomy took a median time of 189 minutes. The nipple-areola ischemia rate was similar to the rate in open surgery. The technical learning curve was reasonable. With improved cosmetic outcome and noninferior complications, robot-assisted nipple-sparing mastectomy and reconstruction may increasingly replace traditional open surgery.

Yoshiko Toyoda, M.D. University of Pennsylvania Philadelphia, Pa.

Breast Implant-Associated Anaplastic Large Cell Lymphoma: A Prospective Series of 52 Patients. By Tevis SE, Hunt KK, Miranda RN, et al. Ann Surg. 2022;275:e245–e249.¹⁰

Authors report patient presentation, clinical course, treatment, and outcomes in patients with breast implant anaplastic large-cell lymphoma between 2014 and 2019. Patients had undergone either aesthetic breast augmentation (61.5 percent) or reconstruction (36.5 percent), and all had textured surfaces. Delayed seroma presented in 69.2 percent and systemic symptoms in 13.5 percent. Stage 1A disease was diagnosed in most cases. All patients achieved excellent results and complete remission, even after two disease recurrences. The authors conclude that analysis of the breast implant anaplastic large-cell lymphoma PROFILE database will boost understanding of the disease and its clinical course, resulting in progressive awareness in both patients and caregivers, achieving early diagnosis, and enhancing treatment outcomes.

Otto R. Ziegler Rodríguez, M.D. Clínica Ziegler Lima, Peru

REFERENCES