“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 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 Plastic and Reconstructive Surgery Global Open. Our goal is to enlighten Plastic and Reconstructive Surgery readers with relevant literature of our specialty that they otherwise might not have read. We thank the Plastic and Reconstructive Surgery resident advisors and advisory board members who volunteer to help us identify these articles and provide a brief synopsis of the articles. A new feature to this issue is the addition of a basic science article related to plastic surgery that had been suggested by one of our resident advisors. Should any other readers have specific suggestions of articles to review in recent issues of high-impact journals, please contact us via email at [email protected]. We wish to remain responsive to the needs of our readers in keeping all of us up to date as to key developments relative to plastic surgery.
ARTICLES
Care of Transgender Persons. By Safer JD, Tangpricha V. N Engl J Med. 2019;381:2451–2460.1
In this review article, the authors discuss recommended treatment guidelines for the care of transgender patients, addressing hormonal treatment regimens and surgical options. Half of the medically treated transgender patients seek surgical procedures, with chest reconstruction surgery being the most common procedure and genital reconstruction being the least common. Although hormonal therapy is not a necessary prerequisite for surgery, the deferral of surgical procedures until the patient has completed at least 1 year of hormone treatment is recommended. This review can assist plastic surgeons in providing a broad perspective on the care of transgender patients for successful multidisciplinary collaboration.
Stav Brown, B.S.
Sackler School of Medicine
Tel Aviv, Israel
A Randomized Controlled Trial Evaluating the BREASTChoice Tool for Personalized Decision Support about Breast Reconstruction after Mastectomy. By Politi MC, Lee CN, Philpott-Streiff SE, et al. Ann Surg. 2020;271:230–237.2
In this randomized controlled trial, the authors evaluated BREASTChoice, a decision aid they developed for women considering first-time postmastectomy breast reconstruction. One hundred twenty women were randomized 1:1 to BREASTChoice or enhanced usual care. The BREASTChoice group scored significantly higher on the breast reconstruction knowledge test and felt more confident understanding reconstruction information. The decision aid did not affect consultation time and was found to have high usability. This trial represents an important development in personalized patient education and shared decision-making in breast reconstruction without increasing provider resource burden.
Austin Y. Ha, M.D.
Washington University School of Medicine
St. Louis, Mo.
Patch Repair of Deep Wounds by Mobilized Fascia. By Correa-Gallegos D, Jiang D, Christ S, et al. Nature 2019;576:287–292.3
In this study, the authors demonstrate the importance of facial fibroblasts in wound healing of deeper wounds. The authors propose that, similar to how dermal fibroblasts lay matrices to heal superficial wounds, in deeper wounds there is an additional component of fascial fibroblast migration that contributes to successful healing. They demonstrated that ablation of fascial fibroblasts resulted in defective scars and that placement of an impermeable film beneath the skin to prevent fascial fibroblast migration led to chronic open wounds. Thus, fascia serves as an additional source of scar-forming matrix, which is a previously unrecognized component of deeper wound healing.
Lindsay E. Janes, M.D.
Northwestern University
Chicago, Ill.
International Evaluation of an AI System for Breast Cancer Screening. By McKinney SM, Sieniek M, Godbole V, et al. Nature 2020;577:89–94.4
In this study, the authors report the development of an artificial intelligence system that outperforms expert radiologists in accurately interpreting screening mammograms. The system was first trained using mammograms for 25,856 women in the United Kingdom and 3097 women in the United States. The system was then used to identify the presence of breast cancer in mammograms of women who were known to have had either biopsy-proven breast cancer or normal follow-up imaging results at least 365 days later. The system outperformed six expert human readers and demonstrated an absolute reduction in both false-positives and false-negatives.
Lindsay E. Janes, M.D.
Northwestern University
Chicago, Ill.
Diabetic Peripheral Neuropathy: Advances in Diagnosis and Strategies for Screening and Early Intervention. By Selvarajah D, Kar D, Khunti K, et al. Lancet Diabetes Endocrinol. 2019;12:938–948.5
Diabetic peripheral neuropathy often poses a difficult challenge in plastic surgery clinics, as it is a leading factor in the development of diabetic foot ulcers, chronic pain, and amputation. The authors review the current point-of-care testing to provide early detection and prevention of amputations secondary to diabetic ulcers, which are believed to be associated with poor 5-year survival compared with prostate and breast cancer. The review supports bedside assessments of mixed large and small pain fibers using DPNCheck (NeuroMetrix, Woburn, Mass.) and Sudoscan (Impeto Medical, Paris, France) devices because of their sensitivities (84.3 to 90.5 percent) and specificities (68.3 to 86.1 percent) in early detection. This should be combined with multi–risk factor–lowering intervention (i.e., targeting glycemic control, hypertension, dyslipidemia, and lifestyle modification) to reduce overall risk and progression of autonomic neuropathy (OR, 0.32).
Mohsan Malik, M.B.B.S.
Queens Hospital
London, United Kingdom
Head and Neck Cancer. By Chow LQM. N Engl J Med. 2020;382:60–72.6
In this review of advances in the management of head and neck squamous cell carcinomas, the author points to improvements in immunotherapeutic agents, radiotherapy, minimally invasive surgical techniques, and multimodality as having reduced patient morbidity while improving prognosis. This is especially true for human papillomavirus–associated cancers, which exhibit better response to medical therapies. The role of surgical resection for cancers of the oral cavity and other small, accessible tumors remains unchanged. Plastic surgeons who assist in their reconstruction can expect to operate on patients with enhanced function in the future, and to do so through less invasive approaches.
Sameer Massand, M.D.
Penn State Hershey Medical Center
Hershey, Pa.
Artificial Intelligence and Surgical Decision-Making. By Loftus TJ, Tighe PJ, Filiberto AC, et al. JAMA Surg. 2020;155:148–158.7
Surgical decision-making relies on hypothetical-deductive reasoning, individual judgment, and heuristics, methods prone to bias and error. Traditional analytical tools such as the National Surgical Quality Improvement Program risk calculator aim to improve clinical prediction but depend on inefficient manual data management and fail to reflect clinical complexity, often yielding inaccurate results. This review’s authors propose integrating artificial intelligence into physicians’ assessments, harnessing the power of electronic health records to optimize clinical management and resource use. Plastic surgeons will soon have access to technology that enhances nuanced risk stratification, patient counseling, and shared decision-making throughout the perioperative continuum of care.
Elie P. Ramly, M.D.
New York University Langone Health
New York, N.Y.
Breast Conservation after Neoadjuvant Chemotherapy for Triple-Negative Breast Cancer: Surgical Results from the BrighTNess Randomized Clinical Trial. By Golshan M, Loibl S, Wong SM, et al. JAMA Surg. 2020;155:e195410.8
This secondary analysis of a multicentric randomized clinical trial (BrighTNess) revealed that neoadjuvant systemic therapy facilitated breast conservation therapy in 53.2 percent of 604 women with stages II to III triple-negative breast cancer who would have otherwise required mastectomy. The overall percentage of breast conservation therapy eligibility increased from 76.5 percent at diagnosis to 83.8 percent. This information can guide plastic surgeons in counseling women presenting with triple-negative breast cancer that are not candidates for breast conservation therapy. Women treated in Europe and Asia were more likely to opt for breast conservation therapy compared to North Americans (OR, 2.66; 95 percent CI, 1.84 to 3.84).
Shivangi Saha, M.D.
All India Institute of Medical Sciences
New Delhi, India
Effect of Prescription Size on Opioid Use and Patient Satisfaction after Minor Hand Surgery. By Gaddis A, Dowlati E, Apel PJ, et al. Ann Surg. 2019;270:976–982.9
The authors of this study performed the first randomized controlled trial prospectively evaluating the effect of initial prescription size on opiate consumption behavior and patient satisfaction in acute postsurgical patients. One hundred seventy-four patients undergoing outpatient minor hand surgery were randomized to receive either 10 or 30 pills. The authors found that higher prescription size was associated with higher consumption and higher number of leftover pills. There was no difference in pain control efficacy or refill requests. Given the current opioid epidemic, initial postoperative opioid prescription size should be considered a modifiable factor with possible community-wide ramifications.
Arman T. Serebrakian, M.D., M.S.
Harvard Medical School
Boston, Mass.
Sebaceous Carcinoma: Evidence-Based Clinical Practice Guidelines. By Owen JL, Kibbi N, Worley B. Lancet Oncol. 2019;20:e699–e714.10
In this article, an expert panel including a plastic surgeon reviewed 156 studies on sporadic extraocular and periocular sebaceous carcinoma to ascertain the best practices for diagnosis, risk assessment, and management in individuals without a genetic predisposition. The authors conclude that deep biopsy with histochemical staining is often required for diagnosis. First-line treatment for local disease includes surgical removal with assessment of margins or wide local excision. Lymph node involvement if confirmed by biopsy requires radiotherapy or complete lymph node dissection. For systemic disease, targeted therapies and immunotherapies are being developed.
Dharini Tumkur, M.B.B.S.
Safdarjung Hospital
New Delhi, India
Operative Time as the Predominant Risk Factor for Transfusion Requirements in Nonsyndromic Craniosynostosis Repair. By Chocron Y, Azzi AJ, Galli R, et al. Plast Reconstr Surg Glob Open 2020;8:e2592.11
This article reports on a retrospective study of 100 patients with nonsyndromic craniosynostosis who underwent either significant open cranial vault remodeling or minimal cranial vault remodeling. The authors found that both operative time and open procedures were associated with a significantly increased incidence of transfusion and conclude that “increasing operative time was the predominant risk factor for intraoperative transfusion requirements.” However, patients older than 6 months required more extensive, open cranial vault surgery. Therefore, simply stating that operative time is the source of morbidity overlooks that patients requiring longer operations may not have been eligible for minimally invasive cranial vault surgery.
Arun K. Gosain, M.D.
Lurie Children’s Hospital
Chicago, Ill.
Analysis of Trends in the Selection and Production of U.S. Academic Plastic Surgery Faculty. By Daneshgaran G, Cooper MN, Ni P, Zhao S, Weichman KE, Wong AK. Plast Reconstr Surg Glob Open 2020;8:e2607.12
This special topic article aimed to examine the unique attributes of U.S. academic plastic surgeons. They examined 79 programs with 712 surgeons and separated them into the top quartile group and the other group. Top quartile programs were more likely to hire faculty who trained at a top quartile program or medical school. They also were more likely to hire faculty who trained at their own institution. Top programs had more faculty members and a higher number of graduates who entered into academics. Limitations include lack of analysis on independent programs and potential lack of up-to-date data from program websites.
Brett T. Phillips, M.D., M.B.A.
Duke University Hospital
Durham, N.C.
REFERENCES
1. Safer JD, Tangpricha V. Care of transgender persons. N Engl J Med. 2019;381:2451–2460.
2. Politi MC, Lee CN, Philpott-Streiff SE, et al. A randomized controlled trial evaluating the BREASTChoice tool for personalized decision support about breast reconstruction after mastectomy. Ann Surg. 2020;271:230–237.
3. Correa-Gallegos D, Jiang D, Christ S, et al. Patch repair of deep wounds by mobilized fascia. Nature 2019;576:287–292.
4. McKinney SM, Sieniek M, Godbole V, et al. International evaluation of an AI system for breast cancer screening. Nature 2020;577:89–94.
5. Selvarajah D, Kar D, Khunti K, et al. Diabetic peripheral neuropathy: Advances in diagnosis and strategies for screening and early intervention. Lancet Diabetes Endocrinol. 2019;7:938–948.
6. Chow LQM. Head and neck cancer. N Engl J Med. 2020;382:60–72.
7. Loftus TJ, Tighe PJ, Filiberto AC, et al. Artificial intelligence and surgical decision-making. JAMA Surg. 2020;155:148–158.
8. Golshan M, Loibl S, Wong SM, et al. Breast conservation after neoadjuvant chemotherapy for triple-negative breast cancer: Surgical results from the BrighTNess randomized clinical trial. JAMA Surg. 2020;155:e195410.
9. Gaddis A, Dowlati E, Apel PJ, et al. Effect of prescription size on opioid use and patient satisfaction after minor hand surgery: A randomized clinical trial. Ann Surg. 2019;270:976–982.
10. Owen JL, Kibbi N, Worley B. Sebaceous carcinoma: Evidence-based clinical practice guidelines. Lancet Oncol. 2019;20:e699–e714.
11. Chocron Y, Azzi AJ, Galli R, et al. Operative time as the predominant risk factor for transfusion requirements in nonsyndromic craniosynostosis repair. Plast Reconstr Surg Glob Open 2020;8:e2592.
12. Daneshgaran G, Cooper MN, Ni P, Zhao S, Weichman KE, Wong AK. Analysis of trends in the selection and production of U.S. academic plastic surgery faculty. Plast Reconstr Surg Glob Open 2020;8:e2607.
