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Spotlight in Plastic Surgery: July 2019

Phillips, Brett T. M.D., M.B.A.; Aliotta, Rachel E. M.D.; Broyles, Justin M. M.D.; Firriolo, Joseph M. M.D.; Goldman, Joshua J. M.D.; Kantar, Rami S. M.D.; Kinuthia, Kevin M. M.B., Ch.B.; Steve, Anna K. M.D.; Weinstein, Andrew L. M.D., M.S.; Gosain, Arun K. M.D.

Plastic and Reconstructive Surgery: July 2019 - Volume 144 - Issue 1 - p 261-263
doi: 10.1097/PRS.0000000000005786
Book and Media Reviews

Received for publication March 4, 2019; accepted March 5, 2019.

Disclosure:The authors have no financial interest to declare in relation to the content of these reviews.

“Spotlight in Plastic Surgery” continues to provide a quarterly overview of articles from non–plastic surgery high-impact journals and PRS Global Open. We continue our goal of enlightening Plastic and Reconstructive Surgery readers with relevant literature of our specialty that otherwise may not be read. Plastic and Reconstructive Surgery resident advisors and Plastic and Reconstructive Surgery advisory board members volunteer to help us identify these articles and provide a brief synopsis of the articles. We would love to hear any suggestions you may have in reference to articles that are relevant to our goal. Please contact us by means of e-mail at with comments and article recommendations. We look forward to hearing from you!

Short-Term Safety Outcomes of Mastectomy and Immediate Implant-Based Breast Reconstruction with and without Mesh (iBRA): A Multicenter, Prospective Cohort Study. By Potter S, Conroy EJ, Cutress RI, et al. Lancet Oncol. January 9, 2019. DOI: 10.1016/S1470-2045(18)30781-2.1

This prospective multicenter study sought to determine the rate of infection, implant loss, readmission, and reoperation in single-stage implant-based reconstruction in the United Kingdom. Reconstructive techniques were compared using various supportive materials (i.e., dermal sling, biological and synthetic meshes, combination, or none). At 3-month follow-up of 2081 heterogeneous patients across 81 centers, there was no significant difference in short-term safety outcomes among the groups. Still, complication rates were higher than current UK National Quality Criteria standards for all endpoints in all groups. The authors should be commended for performing a large multicenter prospective study.

Rachel E. Aliotta, M.D.

Cleveland Clinic Foundation

Cleveland, Ohio

Lymphedema after Breast Cancer Treatment. By Rockson SG. N Engl J Med. November 15, 2018. DOI: 10.1056/NEJMcp1803290.2

Breast cancer–related lymphedema is the most common form of lymphedema in the United States and occurs in up to 40 percent of patients after treatment. Dr. Stanley Rockson provides a critical outline of breast cancer–related lymphedema in this review article where he evaluates the natural history, diagnostic criteria, and treatment options. The article highlights some of the emerging areas within microsurgery where he describes the exciting outcomes seen in prophylactic lymphatic-to-venous anastomosis and vascularized lymph node transfers. Also emphasized is the burgeoning evidence in this innovative field to a target audience who may not be familiar with surgical options for breast cancer–related lymphedema.

Justin M. Broyles, M.D.

University of Texas M. D. Anderson Cancer Center

Houston, Texas

Persons of Nonbinary Gender: Awareness, Visibility, and Health Disparities. By Liszewski W, Peebles JK, Yeung H, Arron S. N Engl J Med. December 20, 2018. DOI: 10.1056/NEJMp1812005.3

In this review, the authors report the health disparities encountered by persons of nonbinary gender and propose initiatives to improve quality of care among this population. Specifically, the authors suggest clear documentation of patient pronouns, gender-literacy training for clinicians, institutional nondiscrimination policies, and optimization of the physical environment (e.g., gender-neutral restrooms). This information is particularly relevant to plastic surgeons, given the increasing number of patients seeking gender-affirming surgery. For gender nonbinary individuals, the authors recommend that surgeons discuss surgical goals with reference to the specific features that patients would like to achieve, rather than focusing on “feminization” or “masculinization.”

Joseph M. Firriolo, M.D.

University of California, Davis

Sacramento, Calif.

Antibiotic Allergy. By Blumenthal KG, Peter JG, Trubiano JA, Phillips EJ. Lancet. DOI: 10.1016/S0140-6736(18)32218–9.4

This global review provides a comprehensive perspective on the current status of antibiotic allergy, and its effect on patient and population health, with exposition of pathophysiology, epidemiology, and the results of misclassification and mislabeling. The article concludes with an impassioned call to arms in evaluating antibiotic allergy labels in a standardized fashion. Given the acute and far-reaching implications of prescribing non–first-line antibiotics in the setting of presumed antibiotic allergy, plastic and reconstructive surgeons should continue to practice evidence-based antibiotic stewardship and engage in efforts to reclassify mislabeled “antibiotic-allergic” patients.

Joshua J. Goldman, M.D.

University of Nevada, Las Vegas School of Medicine

Las Vegas, Nev.

Outcomes of Lymphedema Microsurgery for Breast Cancer-Related Lymphedema with or without Microvascular Breast Reconstruction. By Engel H, Lin CY, Huang JJ, Cheng MH. Ann Surg. DOI: 10.1097/SLA.0000000000002322.5

In this study of 124 patients, the authors evaluate the impact of lymphedema surgery with or without microsurgical breast reconstruction on breast cancer–related lymphedema. Patients underwent complete decongestive therapy, lymphovenous anastomosis, or vascularized lymph node transfer with or without microsurgical breast reconstruction. Circumferential difference, reduction rate, and cellulitis were the outcomes of interest. Improvements in the circumferential difference (12.8 ± 4.2 percent versus 11.5 ± 5.3 percent ), reduction rate (20.4 ± 5.1 percent versus 14.7 ± 6 percent ), and episodes of cellulitis (1.7 ± 1.1 versus 2.1 ± 2.4 times/year) were not different with or without microsurgical breast reconstruction. In both groups, vascularized lymph node transfer was superior to lymphovenous anastomosis and complete decongestive therapy in improving outcomes.

Rami S. Kantar, M.D.

New York University Langone Health

New York, N.Y.

Association of Opioid Prescribing with Opioid Consumption after Surgery in Michigan. By Howard R, Fry B, Gunaseelan V, et al. JAMA Surg. November 7, 2018. DOI: 10.1001/jamasurg.2018.4234.6

In this retrospective population-based study using the Michigan Surgical Quality Collaborative database to investigate the relationship between opioid prescribing and patient-reported consumption following common surgical procedures, the authors found that among 2392 patients across 33 health systems, the median opioid consumption was only 27 percent of that prescribed. The prescription size was associated with higher consumption, with 5.3 more pills consumed for every 10 additional pills prescribed. The authors recommend recognizing widespread overprescribing and accurately identifying patient consumption after surgery as important first steps in improving postoperative opioid prescribing practices, while noting the potential utility of predictive modeling based on patient characteristics.

Kevin M. Kinuthia, M.B.Ch.B.

University of Nairobi

Nairobi, Kenya

Necrotizing Soft Tissue Infection: Diagnostic Accuracy of Physical Examination, Imaging, and LRINEC Score. A Systematic Review and Meta-Analysis. By Fernando SM, Tran A, Cheng W, et al. Ann Surg. January 2019. DOI: 10.1097/SLA.0000000000002774.7

Delayed diagnosis of necrotizing soft-tissue infections increases mortality. This meta-analysis summarizes the diagnostic sensitivity and specificity of physical examination findings, imaging, and Laboratory Risk Indicator for Necrotizing Fasciitis score in 5982 patients. Sensitivity and specificity of fever were 46.0 percent and 77.0 percent, respectively; 25.2 percent and 95.8 percent for hemorrhagic bullae; 21.0 percent and 97.7 percent for hypotension; 88.5 percent and 93.3 percent for computed tomography; 48.9 percent and 94.0 percent for plain radiography; 68.2 percent and 84.8 percent for Laboratory Risk Indicator for Necrotizing Fasciitis score greater than or equal to 6; and 40.8 percent and 94.9 percent for Laboratory Risk Indicator for Necrotizing Fasciitis score greater than or equal to 8. In conclusion, physical examination findings, imaging, and Laboratory Risk Indicator for Necrotizing Fasciitis score all have low sensitivity and should not be used to rule out necrotizing soft-tissue infections.

Anna K. Steve, M.D.

University of Calgary

Calgary, Alberta, Canada

Evaluation and Management of Penicillin Allergy: A Review. By Shenoy ES, Macy E, Rowe T, Blumenthal KG. JAMA. January 15, 2019. DOI: 10.1001/jama.2018.19283. PMID: 30644987.8

In this review article, the authors highlight study findings that over 95 percent of patients with documented penicillin allergies were penicillin-tolerant on evaluation. Moreover, only a minority of the estimated 32 million Americans labeled as penicillin-allergic undergo confirmatory allergy testing, leading to inappropriate antibiotic use of β-lactam alternatives, which are associated with decreased efficacy against preventing surgical-site infections and an increased risk of Clostridium difficile infection and antimicrobial resistance. The authors therefore recommend routine evaluation of patients with reported penicillin allergies to achieve the safest and most effective antibiotic prescribing practices.

Andrew L. Weinstein, M.D., M.S.

New York Presbyterian Hospital

New York, N.Y.

Is Nicotine Replacement a Safe Alternative to Smoking in Plastic Surgery Patients? By Michaels BM, Craft P, Michaels JA, Csank GA. Plast Reconstr Surg Glob Open. December 17, 2018. DOI: 10.1097/GOX.0000000000002017.9

This is a prospective study of 480 patients over 5 years undergoing outpatient plastic surgery procedures in which patients were tested preoperatively for nicotine and followed for postoperative complications. The groups included never-smokers, past smokers with a negative urine test, current smokers, and past smokers with a positive urine test. There were statistically significant increases in complications with cotinine-positive patients versus negative patients. Also, there were no statistically significant differences between active smokers and past smokers who were using nicotine replacements such as e-cigarettes, nicotine patches, or gum. Self-reporting and small group numbers limit this study.

Brett T. Phillips, M.D., M.B.A.

Duke University Hospital

Durham, N.C.

Influence of Severity on Aesthetic Outcomes of Unilateral Cleft Lip Repair in 1,823 Patients. By Campbell A, Restrepo C, Park E, et al. Plast Reconstr Surg Glob Open. January 22, 2019. DOI: 10.1097/GOX.0000000000002083.10

This is a retrospective study of 1823 consecutive patients who underwent primary unilateral cleft lip/nose repair performed by Operation Smile from 2011 to 2017. Three separate evaluators determined a preoperative Cleft Lip Severity Index and a postoperative Cleft Lip Surgical Outcomes Evaluation based on preoperative and immediate postoperative photographs. Evaluators were laypersons that received training before assessment. The study (1) established normative early aesthetic outcomes following repair for each preoperative severity index, and (2) found that with increasing preoperative severity of the cleft deformity, there is a corresponding decrease in early aesthetic outcome scores.

Arun K. Gosain, M.D.

Lurie Children’s Hospital

Chicago, Ill.

Back to Top | Article Outline


1. Potter S, Conroy EJ, Cutress RI, et al.; iBRA Steering Group; Breast Reconstruction Research Collaborative. Short-term safety outcomes of mastectomy and immediate implant-based breast reconstruction with and without mesh (iBRA): A multicentre, prospective cohort study. Lancet Oncol. 2019;20:254–266.
2. Rockson SG. Lymphedema after breast cancer treatment. N Engl J Med. 2018;379:1937–1944.
3. Liszewski W, Peebles JK, Yeung H, Arron S. Persons of nonbinary gender: Awareness, visibility, and health disparities. N Engl J Med. 2018;379:2391–2393.
4. Blumenthal KG, Peter JG, Trubiano JA, Phillips EJ. Antibiotic allergy. Lancet 2019;393:183–198.
5. Engel H, Lin CY, Huang JJ, Cheng MH. Outcomes of lymphedema microsurgery for breast cancer-related lymphedema with or without microvascular breast reconstruction. Ann Surg. 2018;268:1076–1083.
6. Howard R, Fry B, Gunaseelan V, et al. Association of opioid prescribing with opioid consumption after surgery in Michigan. JAMA Surg. 2019;154:e184234.
7. Fernando SM, Tran A, Cheng W, et al. Necrotizing soft tissue infection: Diagnostic accuracy of physical examination, imaging, and LRINEC score: A systematic review and meta-analysis. Ann Surg. 2019;269:58–65.
8. Shenoy ES, Macy E, Rowe T, Blumenthal KG. Evaluation and management of penicillin allergy: A review. JAMA 2019;321:188–199.
9. Michaels BM, Craft P, Michaels JA, Csank GA. Is nicotine replacement a safe alternative to smoking in plastic surgery patients? Plast Reconstr Surg Glob Open 2018;6:e2017.
10. Campbell A, Restrepo C, Park E, et al. Influence of severity on aesthetic outcomes of unilateral cleft lip repair in 1,823 patients. Plast Reconstr Surg Glob Open 2019;7:e2083.
Copyright © 2019 by the American Society of Plastic Surgeons