Spotlight in Plastic Surgery: July 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. We continue to 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 clinical and basic science literature relevant to our specialty that they otherwise may not read. We continue to 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. Should any other readers have specific suggestions of articles to review in recent issues of high-impact journals, please contact us by 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 Examining the Efficacy of Treatments for Arm Lymphedema in Breast Cancer Survivors: An Overview of Systematic Reviews with Meta-Analyses. By Rafn BS, Bodilsen A, von Heymann A, et al. Lancet 2023;67:102397.1 In this study, the authors conducted an overview of systematic reviews with meta-analysis of randomized controlled trials for medication, exercise, laser therapy, Kinesio taping, acupuncture, and complex decongestive physiotherapy for treatment for breast cancer-related lymphedema. The analysis of 40 randomized controlled trials with 1970 participants revealed a small effect across all interventions compared with any control (g = 0.20; P = 0.047) corresponding to volume reductions of 119.7 mL and 88 mL in the interventions and control groups respectively, and a small effect of exercise (g = 0.26; P = 0.022). They conclude that there is no evidence of superiority of any treatment on volume reduction or any solid research refuting these treatments. Eliana Camacho, MD Hospital de Clinicas Montevideo, Uruguay Sensory Outcomes after Neurotization in Nipple-Sparing Mastectomy and Implant-Based Breast Reconstruction. By Peled AW, von Eyben R, Peled ZM. Plast Reconstr Surg Glob Open 2023;11:e5437.2 In this prospective case series, the authors performed nipple-areola complex neurotization to subareolar nerve targets followed by prepectoral direct-to-implant reconstruction in 47 women (79 breasts). Preoperative and postoperative neurosensory testing using 1-point moving and 1-point static pressure thresholds were performed to each quadrant and nipple-areola complex at several time points. At 6 months postoperatively, more than 80% of patients had good to excellent 1-point moving and 1-point static sensation scores across all areas tested, with a mean follow-up of 9.2 months. In addition, no patients reported postmastectomy pain or dysesthesia. This technique is promising for further study to better understand breast reinnervation and postmastectomy pain syndrome. Ryan Dickey, MD MD Anderson Cancer Center Houston, TX An Updated Systematic Review and Meta-Analysis of the Impact of Graduated Compression Stockings in Addition to Pharmacological Thromboprophylaxis for Prevention of Venous Thromboembolism in Surgical Inpatients. By Turner BRH, Machin M, Salih M, et al. Ann Surg. 2024;279:29–36.3 This systematic review and meta-analysis compared rate of venous thromboembolism in surgical patients receiving pharmacologic prophylaxis and graduated compression stockings (GCS) versus pharmacologic thromboprophylaxis alone. Thirty-one articles, including 14,108 patients and published between 2005 and 2022, were included; 2205 patients received GCS and pharmacologic prophylaxis and 11,903 received pharmacologic prophylaxis alone. Rates of deep venous thrombosis (risk ratio, 0.85) and pulmonary embolism (risk ratio, 0.54) were reduced with GCS when compared with pharmacologic prophylaxis alone; however, results were not statistically significant. The use of GCS in clinical guidelines should be thoughtfully considered as they are not supported by the current literature. Amanda Fazzalari, MD Massachusetts General Hospital Brigham & Women's Hospital Boston, MA TrkA-Mediated Sensory Innervation of Injured Mouse Tendon Supports Tendon Sheath Progenitor Cell Expansion and Tendon Repair. By Cherief M, Xu J, Li Z, et al. Sci Transl Med. 2023;15:eade4619.4 This study investigates the relationship between peripheral sensory nerves and tendon healing; specifically, the nerve growth factor tropomyosin receptor kinase A (TrkA) signaling pathway. Removing nerve growth factor in both mesenchymal and macrophage cells resulted in a decreased neurovascular response and decreased tenocyte proliferation after injury. Using a knockout mouse strain of TrkA showed impaired tendon healing and a reduction in transforming growth factor-beta signaling. Finally, human tendon injury had a similar relationship between innervation and transforming growth factor-beta signaling, and use of TrkA small molecule agonist can improve tendon healing. This demonstrates the importance of peripheral nerve-tendon interactions in tendon healing and proposes potential treatment targets. Geoffrey E. Hespe, MD University of Michigan Ann Arbor, MI Skin Antisepsis before Surgical Fixation of Extremity Fractures. By Sprague S, Slobogean G, Wells JL, et al.; PREP-IT Investigators. N Engl J Med. 2024;390:409–420.5 This multicenter, cluster-randomized, crossover trial sought to compare the effectiveness of iodine povacrylex and chlorhexidine gluconate at preventing surgical-site infection (SSI) following operative repair of extremity fractures. The authors found that iodine was superior to chlorhexidine at preventing SSI in closed extremity fractures (2.4% versus 3.3%; OR, 0.74; 95% CI, 0.55 to 1.00; P = 0.049). For open fractures, there was no significant difference in rates of SSI between the two groups. Plastic surgeons should consider using iodine povacrylex rather than chlorhexidine gluconate as their choice of skin antiseptic before operative repair of closed extremity fractures. Emily Long, MD Beth Israel Deaconess Medical Center Boston, MA Robotic versus Conventional or Endoscopic-Assisted Nipple-Sparing Mastectomy and Immediate Prosthesis Breast Reconstruction in the Management of Breast Cancer: A Prospectively Designed Multicenter Trial Comparing Clinical Outcomes, Medical Cost, and Patient-Reported Outcomes (RCENSM-P). By Hung-Wei L, Dar-Ren C, Liang-Chih L, et al. Ann Surg. 2024;279:138–146.6 This multicenter prospective study sought to compare the clinical and patient-related outcomes and medical cost implications of minimal access (ie, robotic [R] nipple-sparing mastectomy [NSM] and endoscopic NSM) and conventional NSM procedures. The study involved 73 conventional NSM, 84 endoscopic NSM, and 76 R-NSM procedures. Patients who had the minimal access procedures experienced better wound healing and less acute pain scores. There was no significant difference in nipple-areola sensation or patient-reported aesthetic outcomes. Expectedly, R-NSM was associated with significantly higher cost. The results of this study can help plastic surgeons in counseling patients undergoing nipple-sparing mastectomy and immediate implant-based breast reconstruction. George O. Onyejekwe, MD Cynosure Aesthetic Plastic Surgery Centre Lagos, Nigeria Radiotherapy to Regional Nodes in Early Breast Cancer: An Individual Patient Data Meta-Analysis of 14 324 Women in 16 Trials. By the Early Breast Cancer Trialists' Collaborative Group (EBCTCG). Lancet 2023;402:1991–2003.7 The objective of this meta-analysis was the analysis of data from 14,324 participants in 16 trials that were initiated between 1961 and 2008. The effects of radiation therapy to the internal mammary chain, supraclavicular fossa, and axillary lymph nodes in women with early breast cancer were evaluated. This study showed that regional lymph node irradiation significantly reduced breast cancer recurrence and mortality and all-cause mortality after the 1980s. The estimated absolute reductions in 15-year breast cancer mortality were 2.7% and 4.5% for those with 1 to 3 and greater than or equal to 4 positive axillary nodes, respectively. These findings could reflect improvements in radiotherapy since the 1980s. René M. Palacios Huatuco, MD Hospital Italiano de Buenos Aires Buenos Aires, Argentina Revision Carpal Tunnel Release following Endoscopic Compared with Open Decompression. By Ferrin PC, Sather BK, Krakauer K, et al. JAMA Netw Open 2024;7:e2352660.8 This retrospective cohort study evaluated the need for revision carpal tunnel release following endoscopic and open carpal tunnel release. The authors used a large national cohort of 103,455 adult patients who underwent outpatient carpal tunnel release at the Veterans Health Administration. Their data showed a cumulative incidence of revision of 1.06% at 5 years and 1.59% at 10 years. Endoscopic carpal tunnel release was associated with an increased risk of revision compared with open carpal tunnel release (0.57% risk difference at 5 years, 0.72% risk difference at 10 years); however, the absolute risk was low regardless of technique. William J. Rifkin, MD New York University Langone Health New York, NY Pharmacokinetics of Locally Applied Antibiotic Prophylaxis for Implant-Based Breast Reconstruction. By Hemmingsen MN, Bennedsen AK, Kullab RB, et al. JAMA Netw Open 2023;6: e2348414.9 In this cohort study of 40 women undergoing implant-based breast reconstruction, the duration of antibiotic concentrations in the implant pocket above the minimum inhibitory concentrations (MICs) for common bacteria was examined. Results showed that vancomycin and cefazolin maintained concentrations above the MIC for Staphylococcus aureus significantly longer (6.9 days and 3.7 days, respectively) than did gentamicin (0.9 day). Gentamicin concentrations dropped below the MIC for Pseudomonas aeruginosa after 1.3 days. The study suggests local antibiotic prophylaxis may protect against S. aureus but could be inadequate against gentamicin-sensitive Gram-negative bacteria. These findings underscore the importance of antibiotic selection based on bacterial susceptibility in implant procedures. Amiteshwar Singh, MCh Medanta—The Medicity Gurugram, India CRISPR-Cas9 In Vivo Gene Editing of KLKB1 for Hereditary Angioedema. By Longhurst HJ, Lindsay K, Petersen RS, et al. N Engl J Med. 2024;390:432–441.10 Hereditary angioedema is a rare genetic disease that leads to severe and unpredictable swelling attacks. The authors conducted a clinical trial of a phase 1 dose-escalation portion of a combined phase 1 and 2 trial of NTLA-2002 in adults with hereditary angioedema. No dose-limiting toxic effects or serious adverse events were observed after the administration of NTLA-2002. The frequency of angioedema attacks decreased by 95% on average among all the patients. The development of this study provides a new perspective on the treatment of hereditary angioedema. Hayson Chenyu Wang, MD Shanghai Ninth People's Hospital Shanghai, People's Republic of China DISCLOSURE The authors have no financial interest in any of the products, devices, or drugs mentioned in this article.