Spotlight in Plastic Surgery: April 2022

“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, 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 be 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 via 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 Effect of Platelet-Rich Plasma Injections vs Placebo on Ankle Symptoms and Function in Patients with Ankle Osteoarthritis. By Paget L, Reurink G, Jan de Vos R, et al. JAMA 2021;326:1595–1605.1 Platelet-rich plasma with an available system, but nonoptimal formulation, was used for ankle osteoarthritis and compared with placebo (saline injection). It did not significantly improve outcomes on pain relief, function, or alignment over a 26-week period. Investigators conducted a double-blind, multicenter study that randomized 100 patients with a pain severity score of at least 40 with ankle osteoarthritis during daily activities and radiographic imaging indicating at least two tibiotalar osteoarthritis on the van Dijik classification to receive platelet-rich plasma (n = 48) or placebo (n = 52) via intra-articular injections. This study continues the debate of how plastic surgeons use the benefit of this practice over the concentration of platelet-rich plasma. Jorge A. Barreras-Espinoza, M.D. Hermosillo General Hospital Hermosillo, Sonora, Mexico Covid-19 Breakthrough Infections in Vaccinated Health Care Workers. By Bergwerk M, Gonen T, Lustig Y, et al. N Engl J Med. 2021;385:1474–1484.2 Coronavirus disease of 2019 remains a threat to our health care system’s integrity, as its staff is at permanent risk of infection. In this study, Bergwerk et al. investigate breakthrough infections in 1497 fully vaccinated health care workers in Israel. Although, most cases were mild or asymptomatic, almost 20 percent had long COVID (i.e., symptoms for longer than 6 weeks). Furthermore, 74 percent of cases had a high virus load, but no secondary infections occurred. This highlights the importance of testing and vaccinations in staff for personal and patient protection. Thereby, plastic and reconstructive surgery services can continue to care for patients in need during this pandemic. Konstantin D. Bergmeister, M.D., Ph.D. Karl Landsteiner University of Health Sciences St. Poelten, Austria Opioid-Sparing Strategies in Alloplastic Breast Reconstruction: A Systematic Review. By Crystal D, Ibrahim A, Blankensteijn L, et al. Plast Reconstr Surg Glob Open 2021;9:e3932.3 The authors reviewed articles that focused on opioid-sparing strategies for pain management in alloplastic breast reconstruction. Fourteen articles (five randomized trials and nine cohort studies) reviewing six different strategies met their inclusion criteria. The most frequently used strategy was targeted paravertebral blocks. Despite the heterogenicity in study characteristics, bias, and reporting outcomes, the authors conclude that enhanced recovery after surgery pathways, targeted paravertebral blocks, and use of liposomal bupivacaine are beneficial in reducing opioid use and therefore should be considered as fundamental components of enhanced recovery after surgery protocols. However, further studies are required to establish the efficacy of other modalities. Stav Brown, M.D. Memorial Sloan Kettering Cancer Center New York, N.Y. Racial and Ethnic Bias Impact Perceptions of Surgeon Communication. By Tran T, Raoof M, Melstrom L, et al. Ann Surg. 2021;274:597–604.4 In this study, the authors aimed to evaluate the influence of patient and surgeon race and ethnicity on perceptions of surgeon care. Tran et al. analyzed 4732 Press-Ganey surveys from 2019 to 2020. Black, Hispanic, and Asian patients were more likely to report unfavorable experiences. In addition, Spanish-speaking patients were most likely to perceive that surgeons showed less respect for concerns (13.9 percent versus 9.3 percent, p = 0.004) and spent inadequate time explaining health concerns (12.6 percent versus 9.2 percent, p < 0.001). Asian and “other/prefer not to answer” patients were disproportionately unsatisfied with surgeon explanations, listening, respect, and time spent. This supports the need for further understanding of surgeon cultural awareness on underrepresented patient satisfaction. Samyd S. Bustos, M.D. Mayo Clinic Rochester, Minn. Development and Validation of Image-Based Deep Learning Models to Predict Surgical Complexity and Complications in Abdominal Wall Reconstruction. By Elhage SA, Deerenberg EB, Ayuso SA, et al. JAMA Surg. 2021;156:933–940.5 The authors applied image-based deep learning to predict complexity, defined as the need for component separation, and pulmonary and wound complications after abdominal wall reconstruction. They concluded that image-based deep-learning models using routine, preoperative computed tomography images were successful in predicting surgical complexity and more accurate than expert surgeon judgment. An additional deep-learning model accurately predicted the development of surgical site infection. Using artificial intelligence in plastic surgery to identify patients who will require complex operations or those at high risk of surgical site or systemic complications by predicting surgical outcomes will significantly advance the field. Jose A. Facio, M.D. Hospital Universitario Monterrey, Nuevo León, Mexico Reducing Surgical Site Infections in Low-Income and Middle-Income Countries (FALCON): A Pragmatic, Multicentre, Stratified, Randomised Controlled Trial. By NIHR Global Research Health Unit on Global Surgery. Lancet 2021;398:1687–1699.6 This multicenter controlled trial randomized 5788 clean-contaminated, contaminated, or dirty abdominal surgery patients from 54 hospitals in seven low-income and middle-income countries to one of four groups: (1) 2% chlorhexidine and noncoated suture, (2) 2% chlorhexidine and triclosan-coated suture, (3) 10% aqueous povidone-iodine and noncoated suture, or (4) 10% aqueous povidone-iodine and triclosan-coated suture. The primary outcome was surgical site infection. There was no difference in the incidence of surgical site infection using alcoholic chlorhexidine or triclosan-coated sutures versus povidone-iodine and noncoated suture. Given these interventions are more expensive than alternatives, routine use in low-resource settings is not recommended. Lucas Gallo, M.D., M.Sc. McMaster University Hamilton, Ontario, Canada Efficient DIEP Flap: Bilateral Breast Reconstruction in Less Than Four Hours. By Haddock NT, Teotia SS. Plast Reconstr Surg Glob Open 2021;9:e3801.7 In this article, the authors analyze and highlight their operative flow and results in bilateral breast reconstruction using deep inferior epigastric perforator flaps (100 flaps, 50 procedures). They demonstrate that adopting a team-based approach involving like-minded, well-trained, and coordinated multiple surgeons can lead to efficient deep inferior epigastric perforator flap bilateral breast reconstruction. Their average surgical time was 3 hours 58 minutes, with the fastest recorded time being 2 hours 14 minutes. The authors report no immediate postoperative complications, and an anastomotic revision rate of 6 percent. They also highlight that the majority of their cases involved multiple surgeons. Rami S. Kantar, M.D., M.P.H. Maryland Shock Trauma Center Baltimore, Md. Integrating Research into Community Practice: Toward Increased Diversity in Clinical Trials. By Woodcock J, Araojo R, Thompson T, Puckrein GA. N Engl J Med. 2021;385:1351–1353.8 This article identifies ways to incorporate community-based physicians into clinical trials. This includes clinicians from a referral network, ongoing training in best practices for discussing clinical trials with patients, up-to-date information about trial opportunities for patients, support for patient education, decision-making, navigation translated into the languages spoken by patients within communities and tailored to cultures, and assistance with care coordination. Most plastic surgeons are community-based physicians. Those involved in clinical trials represent the minority of the plastic surgery population. This study recognizes a deficit applicable to the plastic surgery community and provides an opportunity to incorporate community practice clinicians. Kevin M. Klifto, D.O., Pharm.D. University of Missouri Columbia, Mo. The Association Between Preoperative Opioid Exposure and Prolonged Postoperative Use. By Katzman C, Harker EC, Ahmed R, et al. Ann Surg. 2021;274:e410–e416.9 This study aimed to determine the effect of nonchronic, periodic preoperative opioid use on persistent postoperative opioid use in surgical patients. The authors utilized a national private insurance claims database to identify patterns of opioid fills, and conducted a multivariable logistic regression model with other covariates to determine association with postoperative opioid use. They found that patients with periodic preoperative opioid use, even when minimal or intermittent, were significantly more likely to have prolonged use when compared with opioid-naïve patients. This suggests the importance of screening for at-risk patients to optimize perioperative pain control, including the use of multimodal analgesia. Anna Luan, M.D., M.S. Stanford University Medical Center Palo Alto, Calif. Assessing Procedural Pain in Infants: A Feasibility Study Evaluating a Point-of-Care Mobile Solution Based on Automated Facial Analysis. By Hoti K, Chivers PT, Hughes JD. Lancet Digit Health 2021;3:e623–e634.10 This feasibility study aimed to assess the utility of the PainChek Infant, a point-of-care mobile application that utilizes automated facial analysis to detect pain in infants. This was compared against two scales: the Neonatal Facial Coding System and observer-administered visual analogue scale pain scales. Videos of 40 infants undergoing immunization were randomly selected and subjected to 4303 assessments in two separate sessions. PainChek showed good to excellent interrater reliability and high levels of internal consistency in procedural pain detection. Plastic surgeons can leverage their intricate knowledge of facial anatomy for better understanding of procedural pain in infants. George O. Onyejekwe, M.D., M.Sc. National Orthopaedic Hospital Lagos, Nigeria

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