Spotlight in Plastic Surgery: October 2023

“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 Lancet, The New England Journal of Medicine, Transplant Immunology, 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 Plastic and Reconstructive Surgery advisory board members who volunteer to help us identify these articles and provide a brief synopsis. Should any other readers have specific suggestions for articles to review in recent issues of high-impact journals, please contact us by 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 Assessing Breast and Ovarian Cancer Risk before Gender-Affirming Surgery. By Cortina CS. JAMA Surg. 2023;158:339–340.1 Cortina’s editorial emphasizes the need for individualized breast cancer risk assessment and consideration of germline genetic testing before gender-affirming surgery in individuals assigned female at birth. The author points out that risk-reducing mastectomies reduce breast cancer development (<1% risk at 10 years) but lack evidence for decreasing breast cancer–specific mortality, except in BRCA1 carriers. The presence of pathogenic germline variants might influence an individual’s choice and a surgeons’ operative approach. This highlights the need for surgeons who perform gender-affirming operations to thoroughly assess patients for possible hereditary breast or ovarian cancer syndromes and refer them for genetic counseling where indicated. Stephanie M. Bollard, MBBCh Mater Misericordiae University Hospital Dublin, Ireland Serine and One-Carbon Metabolism Sustain Nonmelanoma Skin Cancer Progression. By Cappello A, Zuccotti A, Mancini M, et al. Cell Death Discov. 2023;9:102.2 This study investigated the role of serine and one-carbon metabolism in nonmelanoma skin cancer (NMSC). The researchers observed differential up-regulation of mitochondrial enzymes SHMT2 and MTHFD2 in basal cell and squamous cell carcinomas compared with normal skin. They demonstrated that silencing their expression in A431 cells reduced cell proliferation, supporting their significance in NMSC pathogenesis. Understanding the metabolic mechanisms underlying NMSC development is crucial for developing effective treatment strategies targeting these vulnerabilities. These findings offer valuable insights into the role of serine and one-carbon metabolism in NMSC and have the potential to identify promising targets for therapeutic intervention. Chad Chang, MBChB, MRes China Medical University Hospital Taichung, Taiwan Secukinumab in Moderate-to-Severe Hidradenitis Suppurativa (SUNSHINE and SUNRISE): Week 16 and Week 52 Results of Two Identical, Multicentre, Randomised, Placebo-Controlled, Double-Blind Phase 3 Trials. By Kimball AB, Jemec GBE, Alavi A, et al. Lancet 2023;401:747–761.3 This study compared two phase III randomized trials, SUNSHINE and SUNRISE, which evaluated the efficacy of the monoclonal antibody secukinumab. Enrolled patients had moderate to severe hidradenitis suppurativa, and clinical response was measured as a 50% decrease in abscesses and inflammatory nodules without increase in abscesses or fistulas. Secukinumab was administered every 2 weeks or 4 weeks and compared with placebo. Secukinumab given every 2 weeks demonstrated a significant clinical response, sustained up to 52 weeks. Secukinumab represents another therapeutic option in the multimodal treatment of a condition commonly treated by plastic surgeons as part of a multidisciplinary team. Jesse Chou, MD University of Virginia Health Charlottesville, VA Pregnancy and Residency—Overdue for Equity. By Koven S, Haberer JE, Kwolek DG. N Engl J Med. 2023;388:966–967.4 Women in medicine face challenges when considering motherhood during training. Since the 1980s, advances have been implemented, yet current residents continue to struggle and frequently have to choose between pursuing a pregnancy with a grueling schedule, deferring pregnancy, or taking time off and accepting a stalled career trajectory. Historically, men dominated the practice of medicine, and systems were not designed to support child-bearing trainees. Reviewing duty-hour restrictions, night-float coverage, workplace lactation room availabilities, and leave or interrupted full training and merit-based assessment policies have the potential to benefit all residents, including plastic surgery residents, but their implementation has to be reinforced. Rawan ElAbd, MD, MSc McGill University Health Center Quebec, Quebec, Canada Anthracycline-Containing and Taxane-Containing Chemotherapy for Early-Stage Operable Breast Cancer: A Patient-Level Meta-Analysis of 100 000 Women from 86 Randomised Trials. By the Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Lancet 2023;401:1277–1292.5 This is a meta-analysis of studies comparing the use of anthracyclines plus taxanes versus taxanes alone, in patients with early-stage breast cancer. There were 23 studies with 19,434 women. The addition of anthracyclines reduced the recurrence of the disease by 14% and reduced overall mortality risk from breast cancer at 10 years by 1.6%. These reductions were independent of hormone receptor status, nodal status, and tumor size. In conclusion, the use of chemotherapy with anthracyclines and taxanes in cumulative doses reduces recurrence of the disease and the overall 10-year mortality rate. Jaime Aron Garcia Espinoza, MD Clinica Planas Barcelona, Spain Impact of Axillary Lymph Node Dissection and Sentinel Lymph Node Biopsy on Upper Limb Morbidity in Breast Cancer Patients: A Systematic Review and Meta-Analysis. By Bakri NAC, Kwasnicki RM, Khan N, et al. Ann Surg. 2023;277:572–580.6 This study investigates the impact of axillary lymph node dissection (ALND) and sentinel lymph node biopsy on upper extremity morbidity in patients with breast cancer. Included studies were objective-based, using validated tools for lymphedema, range of motion, and strength. Lymphedema incidence more than 24 months was 5.9% in sentinel lymph node biopsy and 23.6% in ALND. ALND with lymph node irradiation had the highest risk at 31.2%. Other significant risk factors included chemotherapy, high body mass index, diabetes, increased lymph nodes, radical mastectomy, and advanced age. Their findings provide important information for counseling patients about decreasing morbidity with lymphovenous bypass and vascularized lymph node transfers. Lucas M. Harrison, MD University of Texas Southwestern Medical Center Dallas, TX Aspirin or Low-Molecular-Weight Heparin for Thromboprophylaxis after a Fracture. By Major Extremity Trauma Research Consortium (METRC); O’Toole RV, Stein DM, O’Hara NM, et al. N Engl J Med. 2023;388:203–213.7 The PREVENT CLOT randomized controlled trial demonstrated that aspirin (81 mg twice daily) was noninferior to enoxaparin (30 mg twice daily) in preventing death and was associated with a low incidence of deep-vein thrombosis or pulmonary embolism among patients with upper extremity or lower extremity orthopedic trauma. Several physicians provided commentary expressing concern about the generalizability of these favorable findings because of potential selection bias of including young patients and upper extremity trauma. However, these low-risk patients make up much of the orthopedic trauma treated by plastic surgeons. Therefore, the results of this trial remain promising for plastic surgeons treating distal upper extremity fractures. Christopher L. Kalmar, MD, MBA Vanderbilt University Medical Center Nashville, TN Predictive Analytics and Artificial Intelligence in Surgery—Opportunities and Risks. By Colborn K, Brat G, Callcut R. JAMA Surg. 2023;158:337–338.8 Colborn et al. discuss use cases for artificial intelligence in surgery as highlighted by four experts at the 2022 meeting of a consortium of surgeons and health services researchers. Specifically, video-based analytics may be used as training tools to assist the budding surgeon, thereby reducing technical errors, and providing detailed tracking of surgical skills and surgeon behavior. In high-pressure environments, it may be used as a clinical decision-making adjunct. In clinical research, it has been used to obviate manual record review and augment provider notes. For plastic surgeons, artificial intelligence’s potential for enhancing surgical training may hold particular promise. Ishani D. Premaratne, MD University of Southern California Los Angeles, CA Technical Feasibility of Whole-Eye Vascular Composite Allotransplantation: A Systematic Review. By Laspro M, Chaya BF, Brydges HT, et al. Plast Reconstr Surg Glob Open 2023;11:e4946.9 This study systematically reviews the surgical techniques and outcomes of whole-eye transplantation (WET), aiming to assess feasibility, identify barriers, and address ethical concerns. The findings indicate that whole-eye allograft survival is feasible using current microsurgical techniques in rodent and porcine models. WET holds potential as a future option for patients undergoing concurrent facial transplantation. Plastic surgeons, pivotal in reconstructive procedures, can benefit from understanding WET’s feasibility, gaining insights into surgical techniques, and inspiring innovative approaches in oculoplastic surgery. In addition, comprehending the challenges and ethical considerations empowers plastic surgeons to contribute to interdisciplinary dialogue and shape the future of sight-restoring procedures. Shivangi Saha, MBBS, MS All India Institute of Medical Sciences New Delhi, India Effect of Gender-Affirming Facial Feminization Surgery on Psychosocial Outcomes. By Caprini RM, Oberoi MK, Dejam D, et al. Ann Surg. 2023;277:e1184–e1190.10 The article examines the effect of gender-affirming facial feminization surgery (FFS) on quality of life and perceived gender presentation in transgender women. A retrospective study of 50 transgender women who underwent FFS found that surgery was associated with significant improvements in quality of life and perceived gender presentation. The article is important because understanding FFS and its impact on patient outcomes is critical for providing effective care. FFS is becoming increasingly important as the demand for gender-affirming care grows. Plastic surgeons who perform FFS can use this information to inform patient counseling and improve the care they provide. Luis Gerardo Sandoval-Ortiz, MD Universidad Peruana Cayetano Heredia Lima, Peru DISCLOSURE The authors have no financial interest in any of the products, devices, or drugs mentioned in this article.

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