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• W2980277254 abstract "“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, Annals of Surgery, Journal of the American Medical Association, 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 may not be read. We thank the Plastic and Reconstructive Surgery resident advisors and Plastic and Reconstructive Surgery advisory board members who volunteer to help us identify these articles and provide a brief synopsis of the articles. Should any of our readers have specific suggestions of articles to review in September, October, or November issues of high-impact journals, please contact us by means of e-mail 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 Septoplasty with or without Concurrent Turbinate Surgery versus Non-surgical Management for Nasal Obstruction in Adults with a Deviated Septum: A Pragmatic, Randomised Controlled Trial. By van Egmond MMHT, Rovers MM, Hannink G, Hendriks CTM, van Heerbeek N. Lancet 2019;394:314–321.1 This randomized controlled trial by van Egmond et al. is the first to examine the efficacy of septoplasty for treating nasal obstruction. In this multicenter study, 102 patients received septoplasty with possible concurrent turbinate surgery, and 101 received nonsurgical management. Although all outcome measures demonstrated benefit favoring surgery, the Glasgow Health Status Inventory, a patient-reported outcomes measure, demonstrated a significant benefit of 8.3 points on the 0 to 100 scale. As nasal function can be difficult to assess and insurance coverage for septoplasty has become more tenuous, this study can aid plastic surgeons as an important data point demonstrating its surgical efficacy. David Chi, M.D., Ph.D. Washington University Medical Center St. Louis, Mo. Expanding Traditional Tendon-Based Techniques with Nerve Transfers for the Restoration of Upper Limb Function in Tetraplegia: A Prospective Case Series. By van Zyl N, Hill B, Cooper C, Hahn J, Galea MP. Lancet 2019;394:565–575.2 The authors share the largest prospective study of nerve transfers on 16 patients (27 limbs) in upper extremities with tetraplegia and examine functional outcomes compared to tendon transfers at 12 and 24 months. Medical Research Council grade for muscle strength showed a median elbow extension of 3 and 4 for digital extensors. Significant improvement from baseline was seen in active research arm test, grasp release test, and spinal cord independence measure. These results were comparable to those of tendon transfers, and patient satisfaction with nerve transfer was overall good. This study shows that nerve transfer in tetraplegia is safe and can improve function. Geoffrey E. Hespe, M.D. University of Michigan School of Medicine Ann Arbor, Mich. Association of Duration and Type of Surgical Prophylaxis with Antimicrobial-Associated Adverse Events. By Branch-Elliman W, O’Brien W, Strymish J, Itani K, Wyatt C, Gupta K. JAMA Surg. 2019;154:590–598.3 Here, the authors examined how the type and duration of antibiotic prophylaxis were associated with the risk of complications including surgical-site infection, acute kidney injury, and Clostridium difficile infection. They performed a retrospective study of 79,058 patients undergoing orthopedic, vascular, cardiac, and colorectal procedures in the VA Health System. After stratification for type of surgery and comorbidities, they found that increased duration of antibiotic prophylaxis was associated with an increased risk for acute kidney injury and Clostridium difficile infection without affecting the risk of surgical-site infection. They caution that antibiotic overexposure should be prevented and conclude that “every day—and every dose—matters.” Efstathios Karamanos, M.D. University of Texas Health San Antonio Long School of Medicine San Antonio, Texas Patient-Reported and Functional Outcomes after Revision Amputation and Replantation of Digit Amputations: The FRANCHISE Multicenter International Retrospective Cohort Study. By Chung KC, Yoon AP, Malay S, et al. JAMA Surg. 2019;154:637–646.4 In this study, the authors aimed to understand the indications for replantation of amputated digits. Chung et al. retrospectively reviewed patients who presented with amputated digits and compared patient-reported outcomes and Disabilities of the Arm, Shoulder and Hand questionnaire scores between patients who received a replantation and a revision amputation. Patients with three or more amputated digits (including thumb) who underwent replantation had significantly better outcomes (22 versus 42, p = 0.03 for Disabilities of the Arm, Shoulder and Hand questionnaire score; 61 versus 36, p = 0.01 for patient-reported outcomes). For one-digit amputation, replantation resulted in better two-point discrimination (6 mm versus 8 mm; p = 0.05). This article provides physicians with valuable information, may help in the development of guidelines for treating patient with amputated digits, and may facilitate decision-making and patient counseling in this challenging clinical scenario. Keli Kolegraff, M.D., Ph.D. Johns Hopkins University School of Medicine Baltimore, Md. Clinical and Genomic Risk to Guide the Use of Adjuvant Therapy for Breast Cancer. By Sparano J, Gray R, Ravdin P, et al. N Engl J Med. 2019;380:2395–2405.5 The TAILORx trial previously demonstrated the utility of a 21-gene assay for breast cancer recurrence risk. Hormone receptor-positive, HER2-negative, node-negative breast cancer in some patients, can be treated with endocrine therapy alone without adjuvant chemotherapy depending on the gene-assay score. Here, reanalysis of TAILORx determined whether clinical factors including tumor size/grade add prognostic benefit to the 21-gene recurrence score. Analysis of 9427 women demonstrated that clinical risk stratification provided valuable information to help identify women who could benefit from additional therapy. Plastic surgeons should be aware of such developments in the treatment of their breast cancer patients. Kerry-Ann Mitchell, M.D., Ph.D. Johns Hopkins University School of Medicine Baltimore, Md. Fluorescence Imaging of Nerves During Surgery. By Walsh EM, Cole D, Tipirneni KE, et al. Ann Surg. 2019;270:69–76.6 Fluorescence-guided imaging is already in preclinical and translational use to visualize nerves in surgery. It generally has been shown to help prevent iatrogenic nerve injury and shorten operation time. Recent rapid adoption of this technique across various surgical specialties indicates the technology’s maturity for this application. For example, indocyanine green, which is already widely used in reconstructive surgery to visualize free flap perforators, has recently been used for visualizing the facial nerve with promising results. Various fluorescent agents are being researched for their clinical use. Given its potential, it warrants wider acceptance for more clinical trials in plastic surgery. Ines D. Prasidha, B.Med.Sci., M.B.B.S.(Hons.) Nepean Hospital Sydney, New South Wales, Australia Five-Year Follow-Up after Face Transplantation. By Tasigiorgos S, Kollar B, Turk M, et al. N Engl J Med. 2019;380:2579–2581.7 Facial vascularized composite allotransplantation is an intriguing reconstruction modality to improve form and function for patients with severe facial disfigurement. Here, Tasigiorgos and colleagues report 5-year follow-up of six patients who underwent face transplantation. There was no allograft loss, cancer development, or deaths in this cohort. Patients had improved motor function and sensory return. These findings suggest that despite challenges associated with immunosuppression, ethical considerations, and uncertainty of long-term outcomes, facial allograft transplantation can improve the quality of life for patients with no satisfactory alternatives. Further research in transplant immunology is imperative to advance this treatment option. Rami Sherif, M.D. University of Michigan School of Medicine Ann Arbor, Mich. Targeted Muscle Reinnervation Treats Neuroma and Phantom Pain in Major Limb Amputees: A Randomized Clinical Trial. By Doumanian GA, Potter BK, Mioton LM, et al. Ann Surg. 2019;270:238–246.8 The standard of care for surgical treatment of postamputation pain is currently neuroma excision. However, the efficacy of this treatment for residual limb or phantom limb pain is debatable. Targeted muscle reinnervation, a procedure in which a nerve or nerves are transferred to assist in establishing prosthesis control, was recently found to improve postamputation pain. This prospective, controlled trial included 28 amputees with postamputation pain who were randomized to standard neuroma excision or targeted muscle reinnervation. At 1 year, targeted muscle reinnervation improved phantom limb pain in comparison to conventional neurectomy. This study suggests an emerging role for plastic surgeons in performing targeted muscle reinnervation in patients with limb amputations to improve chronic pain. Andrew T. Timberlake, M.D., Ph.D. New York University Langone Medical Center New York, N.Y. Computerized Approach to Facial Transplantation: Evolution and Application in 3 Consecutive Face Transplants. By Ramly EP, Kantar RS, Diaz-Siso JR, et al. Plast Reconstr Surg Glob Open 2019;7:e2379.9 The authors evaluate the utility of a computerized surgical planning protocol to improve execution and outcome of facial transplantation. Their computerized surgical planning protocol consists of computer-aided design and manufacturing, intraoperative navigation, and intraoperative computerized tomography. They report on the use of this protocol in three consecutive facial transplantations performed by the senior author. Computed tomography–derived cephalometric measurements demonstrated only minor cephalometric variations between preoperative and immediate postoperative imaging. The authors also found improvement in operative times and less need for subsequent orthognathic surgery from cases 1 to 3, although they acknowledge that these differences may be attributable in part to the learning curve involved in facial transplantation. Arun K. Gosain, M.D. Lurie Children’s Hospital Chicago, Ill. Maximizing Plastic Surgery Education Impact: Lessons from Resident Learning Styles and Experiential Learning Theory. By Saldanha FY, Levites HA, Staff SJ, et al. Plast Reconstr Surg Glob Open 2019;7:e2252.10 This study sought to better understand learning styles of plastic surgery residents. A 12-item Kolb Learning Style Index survey was sent to 45 residents dividing learning styles into four categories: converging, accommodating, assimilating, and diverging. Converging and accommodating styles were the most common. When grasping new information, residents valued thinking and experiencing information similarly (abstract conceptualization versus concrete experience). When transforming that information into learning, more residents valued active experimentation over reflective observation (64 percent versus 36 percent; p = 0.05). Results appeared consistent across multiple other surgical specialties besides neurosurgery. Limitations include small resident sample size and limited data for surgical specialty comparison. Brett T. Phillips, M.D., M.B.A. Duke University Hospital Durham, N.C." @default.
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