We are enthusiastic to continue our new initiative, “Spotlight in Plastic Surgery,” which provides a quarterly overview of articles from non–plastic surgery high-impact journals in additional to Plastic and Reconstructive Surgery Global Open. We hope that readers will be interested in reading a brief synopsis of articles that may shape their practice in one way or another. We continue to use the assistance of residents involved with the Journal either as resident ambassadors to Plastic and Reconstructive Surgery or as members of the Plastic and Reconstructive Surgery Resident Advisory Board to identify key articles published between February of 2018 and May of 2018. Our hope is that this section of Plastic and Reconstructive Surgery will stimulate discussion and article suggestions by our readers in the overall goal of increasing medical knowledge and improving patient care. Please contact us by means of e-mail at PRS@PlasticSurgery.org with article recommendations and comments that may improve this objective.
Mesh versus Suture Repair of Umbilical Hernia in Adults: A Randomised, Double-Blind, Controlled, Multicentre Trial.
By Kaufmann R, Halm JA, Eker HH, et al. Published in Lancet, March 2018.1
This study compared mesh versus suture repair of umbilical hernias measuring 1 to 4 cm in 300 patients. The primary outcome, umbilical hernia recurrence, was lower in the mesh repair group than in the suture repair group with 30-month follow-up [six of 146 patients (4 percent) versus 17 of 138 patients (12 percent)]. Umbilical hernias occur in 2 percent of the general population and may occur concurrently in patients seeking abdominal contouring procedures or breast reconstruction with abdominal donor sites. This study can be used by plastic surgeons treating umbilical hernias during these types of procedures to decrease recurrence risk.
Anna K. Steve, M.D.
University of Calgary
Calgary, Alberta, Canada
Encorafenib Plus Binimetinib versus Vemurafenib or Encorafenib in Patients with BRAF-Mutant Melanoma (COLUMBUS): A Multicentre, Open-Label, Randomised Phase 3 Trial.
By Dummer R, Ascierto PA, Gogas HJ, et al. Published in Lancet Oncology, May 2018.2
BRAF mutation, which results in MAPK pathway activation and enhanced cellular survival, is present in 30 to 50 percent of melanoma cases. BRAF or MEK inhibitors represent therapeutic strategies aimed at stunting cellular proliferation. This multicenter, randomized study describes part 1 of the COLUMBUS trial, a phase III study of encorafenib plus binimetinib versus vemurafenib or encorafenib monotherapy in patients with advanced (American Joint Committee on Cancer stage IIIB, IIIC, or IV) BRAF-mutant unresectable or metastatic melanoma. Five hundred seventy-seven patients were included across 162 hospitals in 28 countries. The results demonstrate encorafenib (BRAF inhibitor) in dual therapy with binimetinib (MEK inhibitor) to be better tolerated and to confer a progression-free survival (14.9 months) advantage in patients with BRAF-mutant metastatic melanoma.
Donald Mowlds, M.D., M.B.A.
University of California, Irvine
Restrictive versus Liberal Fluid Therapy for Major Abdominal Surgery.
By Myles PS, Bellomo R, Corcoran T, et al. Published in New England Journal of Medicine, May 2018.3
In this prospective, randomized, assessor-blind trial, investigators assigned 3000 patients with increased risk of complications while undergoing major abdominal surgery to receive either a restrictive or a liberal intravenous fluid regimen during and up to 24 hours after surgery. They found that a restrictive fluid regimen was not associated with a higher rate of disability-free survival than a liberal fluid regimen 1 year after surgery. However, the restrictive regimen was associated with a higher rate of acute kidney injury. This study may help directly guide fluid management of abdominal wall reconstruction. Its broader implications may be applied to massive weight loss surgery and microsurgery.
Or Friedman, M.D.
Tel Aviv Medical Center
Tel Aviv, Israel
Out of the Straitjacket.
By Weinstein M. Published in the New England Journal of Medicine, March 2018.4
This is an intimate, personal, and moving tour de force fired straight from the heart from one surgeon—better yet, one man—who succeeded when it came to trauma surgery, and thrived when it came to family, but still found himself weighed down by burnout, mental illness, and the intrusive thought patterns we all probably feel, but do not share. Ultimately, Dr. Weinstein got the help he needed from his family, his friends, and his doctors. This editorial, although not “level I” evidence, may be more meaningful anyway—because if medicine is just a study in humanity, then doctors are human too, and need the same help and compassion as do we all.
Ketan Sharma, M.D., M.P.H.
Washington University in St. Louis
St. Louis, Mo.
Penis Transplantation: First US Experience.
By Cetrulo CL Jr, Li K, Salinas HM, et al. Published in the Annals of Surgery, May 2018.5
Cetrulo et al. describe the first successful penis transplantation in the United States, with 7-month follow-up. Despite reoperations for hematoma and eschar débridement, the patient has spontaneous penile tumescence and partial sensory recovery of the shaft. Although successful vascularized composite allotransplantation has been limited to a handful of patients and case series worldwide, radically improved quality of life and self-image are possible. Significant attention and funding directed toward these programs for expanded treatment options are expected. Plastic surgeons must be aware of these novel operations and explore our potential role in the multidisciplinary treatment of these patients.
Marten N. Basta, M.D.
Brown University and Rhode Island Hospital
Association between Hospital Financial Distress and Immediate Breast Reconstruction Surgery after Mastectomy among Women with Ductal Carcinoma In Situ.
By Richards CA, Rundle AG, Wright JD, Hershman DL. Published in JAMA Surgery, April 2018.6
Richards et al. examined 5760 women with ductal carcinoma in situ undergoing mastectomy and analyzed whether hospital financial distress was a predictor of immediate breast reconstruction. Significantly fewer patients underwent immediate reconstruction in hospitals with high/medium financial distress versus low/none. Women were more likely to undergo immediate reconstruction if they were at teaching, cancer, or private hospitals and if they were white, aged 18 to 40 years, and had private insurance. High financial distress was associated with patient age, race, insurance status, and hospital type. This may have implications on broadening breast reconstruction services we provide and changing reimbursement for immediate breast reconstruction.
M. Shuja Shafqat, M.D.
Fox Chase Cancer Center
Behavioral Counseling for Skin Cancer Prevention: Evidence Report and Systematic Review for the US Preventive Services Task Force.
By Henrikson NB, Morrison CC, Blasi PR, et al. Published in the JAMA, March 2018.7
In this systematic review, Henrikson et al. examine evidence related to behavioral counseling for skin cancer prevention to inform and update the U.S. Preventive Services Task Force recommendations. Overall, they found that protective behaviors increased after intervention, although this was not consistently associated with a reduction in sunburn or skin cancer. Plastic surgeons frequently assess and treat patients’ skin for both aesthetic and reconstructive purposes. It is therefore important to be updated on current U.S. Preventive Services Task Force recommendations, with current evidence supporting patient counseling to minimize ultraviolet radiation exposure to reduce skin cancer risk with insufficient evidence to support skin self-examination.
Jordan D. Frey, M.D.
New York University Langone Health
New York, N.Y.
Health Care Spending in the United States and Other High-Income Countries.
By Papanicolas I, Woskie LR, Jha AK. Published in JAMA, March 2018.8
Health care reform discussions in the United States often focus on the high relative spending in the United States compared with other developed countries. However, rigorous studies identifying the key drivers that contribute to this cost differential are nonexistent. This landmark study compared potential drivers of health care spending of the 10 highest income countries. The study identified two specific variables as key drivers: prices of labor and goods (specifically pharmaceuticals) and administrative costs. This is important for plastic surgeons (and all specialties) to understand as we advocate for key initiatives and tailor our practices to cut down on U.S. health care costs.
Akash A. Chandawarkar, M.D.
The Johns Hopkins School of Medicine
Assessment of Functional Rhinoplasty with Spreader Grafting Using Acoustic Rhinomanometry and Validated Outcome Measurements.
By Paul MA, Kamali P, Chen AD, Ibrahim AMS, Wu W, Becherer BE, Medin C, Lin SJ. Published in PRS Global Open, June 2018.9
This is a retrospective review of consecutive patients who underwent open or closed rhinoplasty with the use of spreader grafts for nasal obstruction performed by a single surgeon (n = 38 patients, 78.9 percent closed). Average cross-sectional area increased after open rhinoplasty only. Closed rhinoplasty patients were evaluated with the Nasal Obstruction Symptom Evaluation Scale, demonstrating significant improvements in airway passage. This article provides patient-reported outcome data supporting closed rhinoplasty with spreader grafts to improve airway function; however, there is not a patient-reported outcome comparison between open and closed approaches. Additional limitations include small sample size, single-surgeon experience, and multiple patients with concurrent procedures (e.g., turbinectomy).
Lily R. Mundy, M.D.
Duke University Hospital
Incisional Negative Pressure Wound Therapy for Prevention of Wound Healing Complications Following Reduction Mammaplasty.
By Galiano RD, Hudson D, Shin J, van der Hulst R, Tanaydin V, Djohan R, Duteille F, Cockwill J, Megginson S, Huddleston E. Published in PRS Global Open, January 2018.10
In this prospective, within-patient, randomized, controlled, multicenter clinical trial, breast reduction patients were provided postoperative negative-pressure wound therapy or Steri-Strips (3M, Maplewood, Minn.) covered by nonadherent incisional dressings. The primary endpoint was healing complications within 21 days of surgery. Overall wound healing complications were 56.8 percent versus 61.8 percent in negative-pressure wound therapy and standard care groups. When looking at wound dehiscence, 16.2 percent versus 26.4 percent rates were observed by day 21 in the same groups, respectively. The largest effect difference was documented in patients with a body mass index greater than 25 kg/m2 and resections greater than 500 g. Limitations of this study are industry funding and presence of suboptimal standardization across centers.
Brett T. Phillips, M.D., M.B.A.
Duke University Hospital
1. Kaufmann R, Halm JA, Eker HH, et al. Mesh versus suture repair of umbilical hernia in adults: A randomised, double-blind, controlled, multicentre trial. Lancet 2018;391:860869.
2. Dummer R, Ascierto PA, Gogas HJ, et al. Encorafenib plus binimetinib versus vemurafenib or encorafenib in patients with BRAF-mutant melanoma (COLUMBUS): A multicentre, open-label, randomised phase 3 trial. Lancet Oncol. 2018;19:603615.
3. Myles PS, Bellomo R, Corcoran T, et al. Restrictive versus liberal fluid therapy for major abdominal surgery. N Engl J Med. 2018;378:22632274.
4. Weinstein M. Out of the straitjacket. N Engl J Med. 2018;378:793795.
5. Cetrulo CL Jr, Li K, Salinas HM, et al. Penis transplantation: First US experience. Ann Surg. 2018;267:983988.
6. Richards CA, Rundle AG, Wright JD, Hershman DL. Association between hospital financial distress and immediate breast reconstruction surgery after mastectomy among women with ductal carcinoma in situ. JAMA Surg. 2018;153:344351.
7. Henrikson NB, Morrison CC, Blasi PR, et al. Behavioral counseling for skin cancer prevention: Evidence report and systematic review for the US Preventive Services Task Force. JAMA 2018;319:11431157.
8. Papanicolas I, Woskie LR, Jha AK. Health care spending in the United States and other high-income countries. JAMA 2018;319:10241039.
9. Paul MA, Kamali P, Chen AD, et al. Assessment of functional rhinoplasty with spreader grafting using acoustic rhinomanometry and validated outcome measurements. Plast Reconstr Surg Glob Open 2018;6:e1615.
10. Galiano RD, Hudson D, Shin J, et al. Incisional negative pressure wound therapy for prevention of wound healing complications following reduction mammaplasty. Plast Reconstr Surg Glob Open 2018;6:e1560.