Spotlight in Plastic Surgery: January 2021

“Spotlight in Plastic Surgery” continues to provide 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, The New England Journal of Medicine, Nature, Annals of Surgery, 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 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. We plan to continue the addition of a basic science article review, which began as a suggestion of a Plastic and Reconstructive Surgery resident advisor. Should any other readers have specific suggestions of articles to review in recent issues of high-impact journals, please contact us by means of 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 Surgery versus Cast Immobilisation for Adults with a Bicortical Fracture of the Scaphoid Waist (SWIFFT): A Pragmatic, Multicentre, Open-Label, Randomised Superiority Trial. By Dias JJ, Brealey SD, Fairhurst C, et al. Lancet 2020;396:390–401.1 The Scaphoid Waist Internal Fixation for Fractures Trial was a multicenter, randomized, superiority trial comparing early surgical fixation against cast immobilization for less than 2-mm displaced adult scaphoid waist fractures. Primary outcome was measured by means of patient-rated wrist evaluation scores at 52 weeks. The 3-year study analyzed 408 patients and determined no significant difference in mean patient-rated wrist evaluation scores between the two cohorts. Fourteen percent of surgical patients experienced potentially serious operative complications; however, only 2 percent sustained cast-related complications compared to 18 percent of cast-immobilized patients. The study concludes that cast immobilization is as effective as surgical fixation and should be offered as initial treatment for minimally displaced fractures. Ali R. Abtahi, D.O., M.Sc. University of Iowa Hospitals and Clinics Iowa City, Iowa Elucidating the Fundamental Fibrotic Processes Driving Abdominal Adhesion Formation. By Foster DS, Marshall CD, Gulati GS, et al. Nat Commun. 2020;11:4061.2 In this study, Foster and colleagues aimed to better understand the underlying biology of abdominal adhesion formation. Using in vivo models, they demonstrate that adhesions are derived primarily from visceral peritoneum, consistent with the more severe adhesions that result following open abdominal surgical procedures. RNA-seq of mouse/human-derived adhesion fibroblasts identify JUN as a targetable transcriptional regulator by means of JAK-STAT and epithelial-mesenchymal transition pathways. This valuable information can aid plastic surgeons, such as those performing abdominal wall reconstruction or other abdominally based procedures, in providing a target to reduce adhesion formation and its downstream consequences such as pain and intestinal obstruction. Saïd C. Azoury, M.D. University of Pennsylvania Philadelphia, Pa. Deimplementation of the Choosing Wisely Recommendations for Low-Value Breast Cancer Surgery: A Systematic Review. By Wang T, Baskin AS, Dossett LA. JAMA Surg. 2020;155:759–770.3 This study evaluates the extent of deimplementation of the Choosing Wisely recommendations for four low-value breast cancer operations, possible barriers and facilitators, and the implications of decreased use. Rates of axillary lymph node dissection for limited nodal disease and reexcision for close but negative lumpectomy margins have decreased (approximately 50 percent and 40 percent, respectively). Conversely, contralateral prophylactic mastectomy rates continue to rise (up to 30 percent), and sentinel lymph node biopsy in women aged 70 years or older with low-risk breast cancer remains greater than or equal to 80 percent. This review emphasizes the importance of reducing overtreatment of early-stage breast cancer, which results in increased morbidity and costs without improving survival. Íris M. Brito, M.D. Coimbra University Hospital Center Coimbra, Portugal RNA Identification of PRIME Cells Predicting Rheumatoid Arthritis Flares. By Orange DE, Yao V, Sawicka K, et al. N Engl J Med. 2020;383:218–228.4 This study explored the molecular pathophysiology of rheumatoid arthritis through a longitudinal, prospective analysis of patient-collected fingerstick blood specimens before, during, and after rheumatoid arthritis flares. RNA sequencing of the blood specimens and synovial samples from four patients over multiple years was performed and correlated with clinical symptoms. This approach led to the discovery of preinflammatory mesenchymal cells, or PRIME cells, activated by B cells before a clinical flare and then evident in inflamed synovium as inflammatory sublining fibroblasts (pathogenic for rheumatoid arthritis). This knowledge may help with targeted treatments to prevent the disabling pain and hand function limitations. Joshua M. Cohen, M.D. New York University Langone Health New York, N.Y. Objective Measures Needed: Program Directors’ Perspectives on a Pass/Fail USMLE Step 1. By Makhoul AT, Pontell ME, Ganesh Kumar N, Drolet BC. N Engl J Med. 2020;382:2389–2392.5 To assess attitudes on the upcoming change to pass/fail United States Medical Licensing Examination Step I scoring, the authors developed a 19-item survey and administered it to program directors of Accreditation Council for Graduate Medical Education–accredited residencies across 30 specialties; 44.5 percent of program directors responded (n = 2095 respondents; 62 plastic surgery program directors). Of program directors surveyed, 77.2 percent expect increased difficulty assessing applicants; 80.7 percent expect Step 2 Clinical Knowledge—which will retain a numerical score—to carry more weight in reviewing applicants; and 56.8 percent felt students’ medical schools will factor more into decision-making. This impacts plastic surgeons as we navigate the changes to United States Medical Licensing Examination scoring, both in evaluating prospective residents and in mentoring applicants. Adam M. Goodreau, M.D. Virginia Commonwealth University Health System Richmond, Va. Quality-of-Life Outcomes in Surgical vs Nonsurgical Treatment of Breast Cancer-Related Lymphedema: A Systematic Review. By Fish ML, Grover R, Schwarz GS. JAMA Surg. 2020;155:513–519.6 In this study, the authors performed a systematic review aimed to summarize evidence of health-related quality-of-life outcomes of surgical versus nonsurgical treatment in patients with breast cancer–related lymphedema. The authors identified 16 prospective articles, two studies on vascularized lymph node transfer as the surgical modality and 14 articles on complex decongestive therapy. Health-related quality-of-life data showed favorable outcomes at 12-month postoperative follow-up in patients who underwent vascularized lymph node transfer, whereas the data were more diverse with variable association in patients who underwent complex decongestive therapy. This information is valuable in counseling patients on short-term outcomes of vascularized lymph node transfer. George N. Kamel, M.D. Joe DiMaggio Children’s Hospital Hollywood, Fla. Doxycycline Reduces Scar Thickness and Improves Collagen Architecture. By Moore AL, desJardins-Park HE, Duoto BA, et al. Ann Surg. 2020;272:183–193.7 This study investigated the effects of local doxycycline administration on skin scarring. Using an animal wound model, the investigators found that local administration of doxycycline was associated with significantly reduced scar thickness without compromising tensile strength of the wound. They also found that fibroblasts specifically responsible for scar extracellular matrix deposition were significantly reduced with doxycycline treatment. As skin scarring is a significant concern to patients and plastic surgeons alike, this study suggests that doxycycline could represent a promising vulnerary agent. Further research using human patients could elucidate whether local doxycycline could be used as an antiscarring treatment. Michael S. Keyes, M.D. University of Louisville Louisville, Ky. Consensus Statement on Robotic Mastectomy: Expert Panel from International Endoscopic and Robotic Breast Surgery Symposium (IERBS) 2019. By Lai HW, Toesca A, Sarfati B, et al. Ann Surg. 2020;271:1005–1012.8 The study aims to provide standardized guidelines on robotic mastectomy based on consensus statements by a panel of experts. Fifty-two statements were created in six domains: indications, contraindications, technical considerations, patient counseling, outcome measures and indicators, and training and learning curve assessment. In all, the greatest strength of the robotic nipple-sparing mastectomy is the inconspicuous scar location and that no (0 percent) nipple-areola complex necrosis is reported in any study. Conversely, there are variations in terms of techniques used. In addition, there is a described steep learning curve. These 52 statements should serve as a guide to help the surgeon starting to perform these procedures. Tyler Safran, M.D. McGill University Montreal, Quebec, Canada Transitioning Multidisciplinary Craniofacial Care to Telehealth during the COVID-19 Pandemic: A Single Center Experience and View towards the Future. By Badiee R, Willsher H, Rorison E, et al. Plast Reconstr Surg Glob Open 2020;8:e3143.9 This article evaluates the transition to a hybrid model of telehealth in response to the coronavirus of 2019 pandemic at a large U.S. academic medical center multidisciplinary craniofacial clinic. Postvisit surveys demonstrated high rates of satisfaction, with time saving cited as a particular benefit. Their team plans to extend telehealth in a hybrid model after the pandemic. However, one must also ask whether appropriate evaluation can be performed using telehealth, as the annual team visit often entails comprehensive dental, orthodontic, and speech assessment. Over time, objective outcome parameters must be established to better delineate which annual team visits can be adequately managed using telehealth. Arun K. Gosain, M.D. Lurie Children’s Hospital Chicago, Ill. Precaution Costs: The Presumption of Breast Cancer Seeding and Its Impact on Surgical Expenditure. By Caudill AR, Newman A, Davison SP. Plast Reconstr Surg Glob Open 2020;8:e2903.10 This article evaluates increased health care costs with treating breast cancer patients and the effectiveness of empiric instrument and setup changes between oncologic and reconstructive portions of the case. This change is costly and is based on concerns for cancer cell and bacterial contamination. There are few data to support the potential $125 million cost of empiric setup changes as it relates to cancer recurrence and infection. This is an interesting examination of surgical dogma but will not likely gain traction without more substantial clinical data. Brett T. Phillips, M.D., M.B.A. Duke University Hospital Durham, N.C.

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