Spotlight in Plastic Surgery: October 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 clinical and basic science 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. Should any 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 on key developments relative to plastic surgery. ARTICLES Neuropathic Pain after Burn Injury: A Severe and Common Problem in Recovery. By Stanton E, McMullen K, Won P, et al. Ann Surg. 2024;279:874–879.1 The authors of this study utilized the Burn Model System national database to determine the incidence of neuropathic pain (NP) following burn injuries and to characterize demographic and clinical factors associated with the development of NP. A total of 915 adults met inclusion criteria. Patient-Reported Outcomes Measurement Information System 29 scores were significantly higher for patients with NP with regard to pain, psychological function, itch, and sleep disturbances. At 6-month follow-up, male sex (OR, 1.9), percentage of total body surface area (OR, 1.03), and pain severity (OR, 5.4) were predictors of NP. This study highlights the importance of monitoring these vulnerable populations for NP after discharge from the inpatient setting. Darren B. Abbas, MD Mayo Clinic Rochester, MN Assessing the Relationship between Obesity and Trigger Point-Specific Outcomes after Headache Surgery. By Ormseth BH, Kavanagh KJ, Saffari TM, Palettas M, Janis JE. Plast Reconstr Surg Glob Open 2024;12:e5629.2 Trigger point deactivation surgery offers significant relief for migraines, yet some patients remain unresponsive. Previous research links obesity with increased migraine risk and reduced response to medical therapies. This study explored whether obesity negatively affects surgical outcomes. In an analysis of 62 patients, 31 of whom were obese (body mass index ≥ 30) and 31 of whom were nonobese, results showed comparable response rates. Multivariable analysis revealed no significant impact of obesity on achieving over 90% symptom reduction. Both groups demonstrated high improvement (≥50% reduction) and symptom elimination rates. The authors’ findings suggest that obesity does not influence the efficacy of surgery for migraine headaches. Mario Alessandri-Bonetti, MD IRCCS European Institute of Oncology University of Milan Milan, Italy Postoperative Radiotherapy Omission in Selected Patients with Early Breast Cancer following Preoperative Breast MRI (PROSPECT): Primary Results of a Prospective Two-Arm Study. Mann GB, Skandarajah A, Zdenkowski N, et al. Lancet 2024;403:261–270.3 The authors report a prospective, multicentered, nonrandomized control trial of preoperative magnetic resonance imaging and postoperative tumor pathology findings. The subjects were women 50 years or older with cT1N0 non–triple-negative breast cancer and those with unifocal cancer undergoing breast-conserving surgery. If the pathology study showed pT1N0 or N1mi, then radiotherapy was omitted. The other group received standard treatment. Of the 443 patients included, magnetic resonance imaging was effective in detecting malignant lesions aside from the primary cancer in 11% of subjects. The incidence rate ratio was found to be 1.0% at 5 years in the test group, compared with 1.7% in the standard group, and quality-adjusted life-years were increased by 0.019. The authors conclude that the PROSPECT regimen can be safely applied in selected cases. Alaa AlSahli, MBBS King Saud bin Abdulaziz University for Health Sciences–National Guards Riyadh, Saudi Arabia Glucagon-Like Peptide-1 Receptor Agonist Use and Residual Gastric Content before Anesthesia. By Sen S, Potnuru PP, Hernandez N, et al. JAMA Surg. 2024;159:660–667.4 In this study, the authors analyzed the association between the use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and increased residual gastric content, which poses a risk for aspiration under anesthesia. The study enrolled patients adhering to fasting guidelines at a university-affiliated hospital. Results indicated a significantly higher prevalence of residual gastric content among GLP-1 RA users compared with nonusers. Patients undergoing plastic surgery may use these agents concomitantly for aesthetic reasons. Understanding the implications of GLP-1 RA use on anesthesia is crucial for plastic surgeons managing perioperative risks, particularly for patients using these agents for weight management. Sthefano Araya, MD Fox Chase Cancer Center Philadelphia, PA Corporate Medicine 2.0—Special Purpose Acquisition Companies in the United States. By Uppal N, Song Z. N Engl J Med. 2024;390:1842–1845. Published online ahead of print April 10, 2024.5 Private health care companies are increasingly turning to special purpose acquisition companies (SPACs) instead of the traditional initial public offering process to enter the public market. A SPAC is typically a public company formed solely for the purpose of acquiring another business. Without business of its own, the SPAC raises public capital to identify and merge with a company. In the case of a private health care company, a merger with a SPAC allows the company to trade on the public market without going through an initial public offering, which is expensive and fraught with regulatory requirements. Camila Franco-Mesa, MD University of Texas Medical Branch Galveston, TX Omitting Axillary Dissection in Breast Cancer with Sentinel-Node Metastases. By de Boniface J, Filtenborg Tvedskov T, Rydén L, et al. N Engl J Med. 2024;390:1163–1175.6 In this study, the authors describe a randomized noninferiority trial assessing the safety of omitting axillary lymph node dissection in clinically node-negative breast cancer patients with sentinel-node macrometastases. The 5-year recurrence-free survival rate was 89.7% in the group who underwent sentinel-node biopsy only, compared with 88.7% in the axillary lymph node dissection group, with a hazard ratio for recurrence or death of 0.89, which is significantly below the noninferiority margin of 1.44. These findings suggest that less invasive procedures can accelerate recovery, minimize lymphedema risk, and potentially broaden the spectrum of breast reconstruction techniques available to surgeons, enhancing overall patient outcomes. Giulio Marinello, MD BG Trauma Center Murnau Murnau, Germany The Posthyaluronidase Syndrome: Dosing Strategies for Hyaluronidase in the Dissolving of Facial Filler and Independent Predictors of Poor Outcomes. By Wilde CL, Jiang K, Lee S, Ezra DG. Plast Reconstr Surg Glob Open 2024;12:e5765.7 The authors investigated the use of hyaluronidase in 157 periorbital hyaluronic acid filler treatments in the largest retrospective case series to date. Indications for treatment included swelling, lumpiness, and preblepharoplasty status. No significant differences in outcomes were found among the commonly used hyaluronidase concentrations. A correlation was noted between posthyaluronidase syndrome (negative effect on appearance after hyaluronidase treatment) and both the duration and volume of prior filler used. For plastic surgeons, understanding these predictors is crucial for managing filler complications and advising patients about potential adverse effects following hyaluronidase treatment. Surgeons can leverage these insights to enhance patient satisfaction and reduce complications. Francisco Moura, MBChB Oxford University Hospitals NHS Trust Oxford, United Kingdom Peripheral Neural Interfaces: Skeletal Muscles Are Hyper-Reinnervated According to the Axonal Capacity of the Surgically Rewired Nerves. By Tereshenko V, Dotzauer DC, Schmoll M, et al. Sci Adv. 2024;10:eadj3872.8 This study assessed muscle reinnervation using high– and low–neural capacity donor nerve transfers to the (originally low-capacity innervated) sternomastoid muscle in a rat model. High-capacity (facial nerve) transfers resulted in a 15-fold greater, hyperreinnervation, compared with low-capacity (ulnar nerve) transfers. Furthermore, high-capacity transfers led to significant differences in muscle fiber–type composition and increased density of motor units, thereby suggesting changes in muscle physiology. These findings contribute to understanding the impact of axonal capacity on muscle reinnervation and will aid in advancing man-machine interfaces based on nerve transfers and myoelectric signal processing, allowing precise control of bionic protheses. Elena Millesi, MD Mayo Clinic Rochester, MN Tumor-Infiltrating Lymphocytes in Triple-Negative Breast Cancer. By Leon-Ferre RA, Jonas SF, Salgado R, et al.; International Immuno-Oncology Biomarker Working Group. JAMA 2024;331:1135–1144.9 An international multicenter retrospective analysis across 13 centers studied 1966 patients with early-stage triple-negative breast cancer (TNBC) who were treated with locoregional therapy but no chemotherapy. The aim of the study was to investigate the link between survival rates and the abundance of tumor-infiltrating lymphocytes in breast cancer tissue. Higher levels of tumor-infiltrating lymphocytes correlated with improved invasive disease-free survival, recurrence-free survival, survival free of distant recurrence, and overall survival. Therefore, an abundance of tumor-infiltrating lymphocytes can function as a prognostic marker for patients with early-stage TNBC not undergoing chemotherapy, providing valuable insights for plastic surgeons involved in TNBC treatment planning and prognostication. Adriana C. Panayi, MD, PhD BG Trauma Center Ludwigshafen Heidelberg, Germany Implementing Enhanced Recovery Pathways: A Qualitative Study of Factors That Distinguished Higher Performing Hospitals. By Yuan CT, Wu J, Cardell CP, et al. Ann Surg. 2024;279:789–795.10 Enhanced recovery pathways improve clinical outcomes, reduce hospital length of stay, and improve patient experience. The authors qualitatively studied the relationship between perceived barriers and facilitators of enhanced recovery pathway implementation and quantitative success in meeting core clinical process measures in colorectal surgery by interviewing 168 staff members in 8 hospitals. Robust planning, engagement, and information-sharing infrastructure; positive clinician knowledge and beliefs about pathways; and strong clinician and executive leadership support correlated with successful implementation of enhanced recovery pathways. These strategies should be emulated in plastic surgery pathways to optimize our patient care. Yoshiko Toyoda, MD University of Pennsylvania Philadelphia, PA Methotrexate to Treat Hand Osteoarthritis with Synovitis (METHODS): An Australian, Multisite, Parallel-Group, Double-Blind, Randomised, Placebo-Controlled Trial. By Wang Y, Jones G, Keen HI, et al. Lancet 2023;402:1764-1772.11 In this double-blind, randomized controlled trial, the authors studied the safety and efficacy of using methotrexate to treat patients with hand osteoarthritis with synovitis. They measured pain reduction using a visual analog scale and hand function using the Australian Canadian Osteoarthritis Hand Index over a 6-month period. The authors found that the methotrexate group had a greater reduction in mean pain scale score and a greater reduction in mean pain and stiffness index score than the placebo group. Overall, methotrexate had a moderate but potentially meaningful impact on pain and stiffness in patients with hand osteoarthritis with synovitis. Zachary D. Zapatero, MD University of Pennsylvania Philadelphia, PA DISCLOSURE The authors have no financial interest in any of the products, devices, or drugs mentioned in this article.

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