Spotlight in Plastic Surgery: April 2020

“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 The Lancet, New England Journal of Medicine, Annals of Surgery, Journal of the American Medical Association, 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 may not be 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 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 Five-Year Survival with Combined Nivolumab and Ipilimumab in Advanced Melanoma. By Larkin J, Chiarion-Sileni V, Gonzalez R, et al. N Engl J Med. 2019;381:1535–1546.1 Immunotherapy appears to be a knight in shining armor for patients with advanced cutaneous malignant melanoma. In this multicenter, international, placebo-controlled, randomized trial, 5-year follow-up data are presented. The use of nivolumab, ipilimumab, or a nivolumab-ipilimumab combination regimen was compared in PDL-1 and BRAF-stratified patients with stage III or IV disease. Median survival was greatest in the combination arm, with a mean survival of 60 months compared with 36.9 months in the nivolumab group and 19.9 months in the ipilimumab group. The previously bleak stage III or IV melanoma prognosis is changing, and plastic surgeons provide key diagnostic techniques. Alicia R. Billington, M.D., Ph.D. University of South Florida Health Tampa, Fla. 2019 International Clinical Practice Guidelines for the Treatment and Prophylaxis of Venous Thromboembolism in Patients with Cancer. By Farge D, Frere C, Connors JM, et al. Lancet Oncol. 2019;20:e566–e581. Epublished ahead of print September 3, 2019.2 This 2019 International Initiative on Thrombosis and Cancer update was first developed in 2013. The update includes a review of new evidence on anticoagulants for the treatment and prophylaxis of patients with cancer, new data for risk stratification of venous thromboembolism for decision making on primary prophylaxis strategies, and the use of direct oral anticoagulants in venous thromboembolism. It also addresses treatment of venous thromboembolism in special clinical situations. Plastic surgeons must be aware of these guidelines, because they frequently operate on patients with different types of malignancies and it is essential to understand the risks of venous thromboembolism and its appropriate management. Aakanksha Goel, M.B.B.S., M.S. Lok Nayak Hospital and Associated Maulana Azad Medical College New Delhi, India Parenting during Graduate Medical Training: Practical Policy Solutions to Promote Change. By Weinstein DF, Mangurian C, Jagsi R. N Engl J Med. 2019;381:995–997.3 This article discusses the challenges associated with becoming a parent in residency and potential solutions. Issues associated with parental leave include covering clinical responsibilities, meeting education targets, fulfilling board requirements, and ensuring equity of work for other residents. Guidelines recommended to improve the status quo include increasing leave to 12 weeks, switching to a competency-based training system, and tracking parental data. Childcare assistance, modified training programs, and redundancy in coverage were also discussed as solutions to decrease stress and burnout. Vimal J. Gokani, M.D. Charing Cross Hospital, London, United Kingdom Type and Timing of Menopausal Hormone Therapy and Breast Cancer Risk: Individual Participant Meta-Analysis of the Worldwide Epidemiological Evidence. By Collaborative Group on Hormonal Factors in Breast Cancer. Lancet 2019;394:1159–1168.4 In this meta-analysis evaluating the risk of breast cancer with menopausal hormone therapy, the author group looked at all epidemiological data published from 1992 to 2018 on the topic. They calculated patients’ relative risk with menopausal hormone use, as well as the increased risk with increasing duration of use. The group found that all menopausal hormone types except vaginal estrogens increased breast cancer risk, particularly after 5 years of use and with estrogen receptor–positive cancers. This information is valuable to plastic surgeons, particularly those performing breast reconstruction, to help in understanding risk factors for cancer when counseling patients. Casey T. Kraft, M.D. The Ohio State University Wexner Medical Center Columbus, Ohio Is Bigger Better? The Effect of Hospital Consolidation on Index Hospitalization Costs and Outcomes among Privately Insured Recipients of Immediate Breast Reconstruction. By Cerullo M, Sheckter CC, Canner JK, Rogers SO, Offodile AC 2nd. Ann Surg. 2019;270:681–691.5 This study analyzed privately insured female patients undergoing immediate breast reconstruction after mastectomy in the Nationwide Inpatient Sample. Using a retrospective cross-sectional design, the study aimed to evaluate the relationship between hospital market competition and inpatient cost, procedural markup, inpatient complications, and length of stay. A total of 42,411 patients were divided into two groups: free flap reconstruction and non–free flap reconstruction. The Herfindahl–Hirschman index was used to describe hospital market competition. Decreasing market competition or decreasing the total number of hospitals and their respective shares of the markets was associated with lower inpatient costs and equivocal clinical outcomes. M. Rachadian Ramadan, M.D., B.Med.Sc. Universitas Indonesia Jakarta, Indonesia Long-Term Follow-Up of Autologous Fat Transfer vs Conventional Breast Reconstruction and Association with Cancer Relapse in Patients with Breast Cancer. By Krastev T, van Turnhout A, Vriens E, et al. JAMA Surg. 2018;154:56–63.6 In this matched cohort study, the authors compared the rates of locoregional recurrence in patients with breast cancer treated with autologous fat transfer versus conventional breast reconstruction. They found no significant differences between the groups and subgroups based on the type of oncological surgery, tumor invasiveness, or pathological stage after 5-year follow-up. In addition, no increased risks of distant recurrences or breast cancer–specific mortality were seen in the fat transfer group. Concordant with other published studies, there is no clear clinical evidence to suggest that autologous fat transfer leads to increased rates of cancer relapse in breast cancer patients. Esteban Elena Scarafoni, M.D. Hospital de Quemados Buenos Aires, Argentina Heterogeneity in Old Fibroblasts Is Linked to Variability in Reprogramming and Wound Healing. By Mahmoudi S, Mancini E, Xu L, et al. Nature 2019;574:553–558.7 Fibroblasts play a central role in wound healing, particularly by secreting factors that reprogram cells to induced pluripotent stem cells. In this study, the authors demonstrate that fibroblasts derived from old mice secrete inflammatory cytokines with lesser ability to induce stem cell pluripotency than fibroblasts derived from young mice. Experiments demonstrated that these differences were attributable in part to extrinsic factors secreted by activated fibroblasts. These findings hold promise in developing novel therapeutics to improve induction of pluripotent stem cells and thus wound healing in elderly patients. Andrew T. Timberlake, M.D., Ph.D. New York University Langone Medical Center New York, N.Y. Association between Heart Failure and Postoperative Mortality among Patients Undergoing Ambulatory Noncardiac Surgery. By Lerman BJ, Popat RA, Assimes TL, et al. JAMA Surg. 2019;154:907–914.8 This retrospective cohort study utilizing the Veterans Affairs Surgical Quality Project database (2009 to 2016) evaluated the association between heart failure and 30-day postoperative complications and 90-day mortality rate in adult patients undergoing ambulatory noncardiac surgeries. Thirty-day postoperative complication rate was increased in patients with heart failure (adjusted OR, 1.10). Heart failure patients were at higher risk of 90-day mortality (adjusted OR, 1.95), which increased with decreasing systolic function; this was profound with symptomatic heart failure (adjusted OR, 2.76) but was also observed with asymptomatic heart failure (adjusted OR, 1.85). These data may guide discussions with heart failure patients undergoing ambulatory surgery, who may be at increased risk of postoperative morbidity and mortality. Krishna S. Vyas, M.D., Ph.D., M.H.S. Mayo Clinic Rochester, Minn. Long-Term Patient-Reported Outcomes following Postmastectomy Breast Reconstruction: An 8-Year Examination of 3268 Patients. By Nelson JA, Allen RJ Jr, Polanco T, et al. Ann Surg. 2019;270:473–483.9 This study aimed to better understand long-term patient-reported outcome following postmastectomy reconstruction using the BREAST-Q, and to compare patients undergoing implant-based breast reconstruction or autologous breast reconstruction. Overall, 3268 patients were included, with 336 in the autologous breast reconstruction group and 2932 in the implant-based group. Satisfaction in both groups was adversely affected by postoperative radiation and mental illness. Autologous breast reconstruction patients had significantly better postoperative satisfaction at all timepoints compared with patients undergoing implant-based breast reconstruction. However, implant-based breast reconstruction patients had very stable satisfaction over time, which contradicts the common belief that implant-based reconstruction has better aesthetics immediately after surgery but worsens overtime. Annie M. Wang, M.D., M.Sc. University of Toronto Toronto, Ontario, Canada International Expert Panel Consensus on Fat Grafting of the Breast. By Nava MB, Blondeel P, Botti G, et al. Plast Reconstr Surg Glob Open 2019;7:e2426.10 To explore the current practice for optimal fat grafting of the breast and its oncological safety, the authors organized a survey and an international consensus conference that was held at the Aesthetic Breast Meeting, in Milan, Italy, on December 15, 2018. After a literature review was conducted, 10 key statements that the authors felt addressed the most debated topics on fat grafting were developed for the survey. Levels of evidence for the key statements ranged from III to IV. There was 100 percent consensus that while oncologic concerns have risen, fat grafting is a safe procedure when considering the impact on breast cancer detection and surveillance if a proper technique is used and the surveillance is granted by dedicated breast imaging specialists. Arun K. Gosain, M.D. Lurie Children’s Hospital Chicago, Ill. Successful Immediate Staged Breast Reconstruction with Intermediary Autologous Lipotransfer in Irradiated Patients. By Crawford, KM, Lawlor, D, Alvis, E, et al. Plast Reconstr Surg Glob Open 2019: 7:e2398.11 This single-surgeon retrospective study examined fat grafting before second-stage, implant-based breast reconstruction in irradiated patients. The authors compared nonirradiated patients to irradiated patients who received lipotransfer as a separate operation before implant exchange. They examined 131 patients, of whom only 18 were irradiated (14 percent). They found no statistical difference in overall surgical complications between the nonirradiated and irradiated groups (8.84 percent versus 16.67 percent, p = 0.387). They also examined patients who were their own internal controls (bilateral, one side irradiated) and found no difference. Limitations include lack of an appropriate control group, small sample size, and limited additional postoperative surgical data. Brett T. Phillips, M.D., M.B.A. Duke University Hospital Durham, N.C.

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