Must-read articles chosen by the Southeastern Society of Plastic and Reconstructive Surgeons:  

October 2023

Artificial Intelligence Modeling to Predict Periprosthetic Infection and Explantation following Implant-Based Reconstruction

Hassan, Abbas M. MD; Biaggi-Ondina, Andrea BSA; Asaad, Malke MD; Morris, Natalie BS; Liu, Jun PhD; Selber, Jesse C. MD, MPH; Butler, Charles E. MD

Plastic and Reconstructive Surgery, Volume 152, Issue 5, November 2023, Pages 929-938

This study out of MD Anderson Cancer Center assessed the value of Artificial Intellegence models in predicting infection and implant loss after immediate breast reconstruction.  The authors used data from 694 reconstructions over a two year period.  They applied nine different machine learning algorithms, all of which had been shown to be effective in predicting outcomes in other clinical areas.  The AI algorithms demonstrated good discriminatory performance in predicting periprosthetic infection and explantation, (with a 73% and 78% accuracy, respectively).  Nine significant predictors were identified for periprosthetic infection , and 12 were identified for explantation.  These results outperformed a multiple regression analysis and compared favorably to the previously validated breast reconstruction assessment (bra) tool.  This study provides proof of the feasibility, effectiveness, and applicability of AI in predicting complications of IBR and should encourage the incorporation of ML in the perioperative assessment of patients. 

https://journals.lww.com/plasreconsurg/fulltext/2023/11000/artificial_intelligence_modeling_to_predict.2.aspx

Topical Tranexamic Acid in Breast Reconstruction: A Double-Blind Randomized Controlled Trial

Safran, Tyler MD, MSc; Vorstenbosch, Joshua MD, PhD; Viezel-Mathieu, Alex MD, MSc; Davison, Peter MD, SMEpi; Dionisopoulos, Tassos MD

Plastic and Reconstructive Surgery, Volume 152, Issue 4, October 2023, Pages 699-706

Tranexamic Acid solution, applied directly to the operative field, has been shown to reduce bleeding complications in a variety of surgical procedures.  TXA is inexpensive and has a favorable safety profile.   The authors of this study conducted a double-blind randomized clinical trial to assess the effectiveness of TXA in reducing complications in patients undergoing bilateral mastectomy and immediate direct-to-implant reconstruction.  53 patients were enrolled in the study.  TXA was instilled into one breast during surgery, the other breast serving as the control.  Treated breasts had a statistically significant 35% reduction in mean drain output, and a significant reduction in overall complications (p=0.01).  There were no hematomas in the TXA group, and three in the control group, however this difference was not statistically significant.  This study provides Level 1 evidence of the utility and safety of TXA in immediate breast reconstruction.

https://journals.lww.com/plasreconsurg/fulltext/2023/10000/topical_tranexamic_acid_in_breast_reconstruction_.2.aspx

Safety and Efficacy of Outpatient Drainless Abdominoplasty: A Single-Surgeon Experience of 454 Consecutive Patients

Alisha B Paranzino, MD, MS, Jason Sims, RNFA, David S Kirn, MD, FACS

Aesthetic Surgery Journal, Volume 43, Issue 11, November 2023, Pages 1325–1333

This is a single surgeon retrospective cohort study looking at 454 consecutive abdominoplasties performed over a 20 year period.  In the first 194 patients, the surgeon employed a progressive tension suture technique and placed two abdominal drains.  In the latter 260 patients he used progressive tension sutures without drains.  The group without drains had a greater proportion of massive weight loss patients.  The overall complication rate and seroma rate were both significantly lower in the no-drain group.  There were no seromas in the no-drain group.  This study is limited by the retrospective nature and non-randomized and sequential treatment groups, but it provides additional evidence that drains may not be necessary in abdominplasty surgery, at least when progressive tension suturing is performed.

https://academic.oup.com/asj/article/43/11/1325/7188711

July 2023

Long-Term Outcomes in Prepectoral versus Subpectoral Two-Stage Implant-Based Breast Reconstruction after Nipple-Sparing Mastectomy

Alcon, Andre; Rosser, Micaela; Gedallovich, Jodi; Foster, Robert D.; Sbitany, Hani; Piper, Merisa L

Plastic and Reconstructive Surgery, Volume 152, Issue 2, August 2023, Pages 273-280

This retrospective cohort study out of UCSF is one of the largest and most comprehensive studies to compare outcomes from prepectoral and retropectoral reconstruction.  582 patients were identified who had implant based reconstruction over a 5 year period.  Of these 206 (35%) responded to the survey, of which 114 received subpectoral and 38 prepectoral reconstruction.  All patients had at least 6 months of follow up from their last surgical procedure.  Results of the BREAST-Q showed no difference in satisfaction between the two groups, however, there was a 16% rate of Grade 3 or 4 capsular contracture in the prepectoral group, compared to 4% in the subpectoral group.  On bivariate logistic regession, prepectoral placement, presence of a complication, and capsular contracture were identified as predictors of less overall happiness.  This study, with a longer follow up than some previous studies, contradicts the findings of previous studies that prepectoral reconstruction is not associated with higher rates of capsular contracture, a finding that will bear watching in the future.

https://journals.lww.com/plasreconsurg/Fulltext/2023/08000/Long_Term_Outcomes_in_Prepectoral_versus.6.aspx

Current Status of Early Complications Caused by Hyaluronic Acid Fillers: Insights From a Descriptive, Observational Study of 41,775 Cases

Ayaka Nishikawa, MD, Yoshiyuki Aikawa, MD, Taro Kono, MD, PhD

Aesthetic Surgery Journal, Volume 43, Issue 8, August 2023, Pages 893-904

This is a large database study out of Japan which pooled data from 41,775 hyaluronic acid filler treatments.  29 early complications were identified.  The most common complications were vascular compromise (18), infection (5), and allergic reaction (3).  The sites with the highest rates of complications were the upper eyelid, forehead, and lips.  (There was only one complication following upper eyelid injection in the series; it was however a rather rare injection site).  Hyaluronidase was administered in 17 of 18 cases of vascular compromise.  This study outlines the common complications of HA filler treatments, but by the rareity of these complications highlights just how safe these procedures are.

https://doi.org/10.1093/asj/sjad039

Predictors for Necrosis after Single-Digit Replantation: A Retrospective Analysis of 946 Patients

Wang, Tao; Xiong, Fei; Tan, Ji Yang; Qiu, Yang; Mi, Jing-Yi

Plastic and Reconstructive Surgery, Volume 152, Issue 1, July 2023, Pages 117-123

This was a retrospective cohort study of 946 adult patients who underwent single-digit replantation over a 6 year period, by 20 surgeons.  The overall success rate was 79%.  The successful and unsuccessful replantation patients were separated into cohorts to determine predictors of failure.  Age greater than 35, longer surgical time, cases occurring overnight, distal injury level, elevated serum d-dimer level, and patients who were on their menstrual period were all found to be predictors of failure.  Gender, ischemia time, use of a vein graft, and mechanism of injury were not predictors of failure.  This is one of the largest studies of its kind and contradicts the findings of previous studies that ischemia time and crush/avulsion mechanism were not predictors of failure.  The authors postulate that the higher rate of failure in women who were menstruating (> 50% failure) was due to circulating estrogen and a hypercoaguable state.  This will require additional study as it may have consequences for the timing of elective microvascular procedures.

https://journals.lww.com/plasreconsurg/Fulltext/2023/07000/Predictors_for_Necrosis_after_Single_Digit.27.aspx

April 2023

Immediate Breast Cancer Reconstruction with or without Dermal Matrix or Synthetic Mesh Support: A Review and Network Meta-Analysis

Murphy, Donal; O’Donnell, John P.; Ryan, Éanna J.; Lane O’Neill, Billy; Boland, Michael R.; Lowery, Aoife J.; Kerin, Michael J.; McInerney, Niall M.

Plastic and Reconstructive Surgery: 151(4):p 563e-574e, April 2023.

This is a large meta-analysis comparing results of implant-based breast reconstruction without ADM, to human ADM, xenograft ADM, and synthetic mesh.  31 articles met the inclusion criteria, including data from over 12,000 patients.  There were 4211 patients in the human ADM group, 1309 in the xenograft group, and 614 in the synthetic mesh group.  All reconstructions were submuscular.  There was no significant difference seen in implant loss among the four groups.  Human ADM was associated with higher rates of overall complications, infection, and seroma, when compared to no-ADM, xenograft, and synthetic mesh.  A subset analysis

Link: https://journals.lww.com/plasreconsurg/Fulltext/2023/04000/Immediate_Breast_Cancer_Reconstruction_with_or.7.aspx

Measuring Success in Headache Surgery: A Comparison of Different Outcomes Measures

Albano, Nicholas J.; Israel, Jacqueline S.; Carbullido, Mary K.; Stilp, Emmaline K.; Leverson, Glen; Voils, Corrine I.; Afifi, Ahmed M.

Plastic and Reconstructive Surgery: 151(3):469e-476e, March 2023

This is a review of 34 patients who underwent surgery for the treatment of headaches.  All patients had a Migraine Headache Index (MHI) calculated and completed the Headache Impact Test, the Migraine Disability Assessment Test, the Migraine-Specific Quality-of-Life Questionnaire, and an institutional ad hoc survey preoperatively and postoperatively.  Twenty-seven patients (79%) experienced greater than or equal to 50% MHI reduction. Scores on the MHI, Headache Impact Test, Migraine Disability Assessment, and The Migraine-Specific Quality-of-Life Questionnaire all demonstrated significant improvement. The authors’ ad hoc survey demonstrated that participants “strongly agreed” that (1) surgery helped their symptoms, (2) they would choose surgery again, and (3) they would recommend headache surgery to others.  This is additional compelling evidence that headache surgery is effective, and hopefully it will inform conversations with neurologists and third party payors.

Link:https://journals.lww.com/plasreconsurg/Abstract/2023/03000/Measuring_Success_in_Headache_Surgery__A.36.aspx

Do Compression Garments Prevent Subcutaneous Edema After Abdominoplasty?

Betina Zimmermann Fontes de Moraes, MS,  Lydia Masako Ferreira, MD, PhD, MBA, Maria Roberta Cardoso Martins, MD, MS,  Lucas Rostom, MD, Hugo Alexandre Sócrates de Castro, MD, PhD,  Fabio Xerfan Nahas, MD, PhD, MBA

Aesthetic Surgery Journal:  Volume 43, Issue 3, March 2023, Pages 329–336

This is a prospective randomized study assessing the effectiveness of compression garments in reducing subcutaneous edema after abdominoplasty.  Thirty-two women aged 19 to 50 years were selected and randomly allocated to either the garment (n = 16) or no-garment (n = 16) group. All patients underwent abdominoplasty and received 10 sessions of manual lymphatic drainage during the postoperative period. Postoperative edema formation was assessed by perimetry and bioimpedance, and seroma formation was assessed by ultrasound.  The no-garment group showed significantly lower waist circumference after postoperative day 35 compared with the garment group (P < .001). The mean total body water was slightly lower in the no-garment group than in the garment group 7 days after surgery (P = .05).  Compression garments may not be as helpful in the control of postoperative edema as commonly believed.

Link:

https://academic.oup.com/asj/article-abstract/43/3/329/6772920?redirectedFrom=fulltext

January 2023

Association between Immediate Breast Reconstruction and the Development of Breast Cancer–Related Lymphedema

Jeon, Hong Bae; Jung, Ji Hyuk; Im, Sang Hee; Kim, Yong Bae; Chang, Jee Suk; Song, Seung Yong; Lew, Dae Hyun; Roh, Tai Suk; Lee, Won Jai; Lee, Dong Won.

Plastic and Reconstructive Surgery, Volume 151, Issue 2, February 2023, Pages 214e-222e

This is a retrospective cohort study of 5900 consecutive patients who underwent mastectomy for primary breast cancer with or without reconstruction.  Patients were followed for a minimum of 5 years, and 630 patients developed clinical lymphedema.  Immediate breast reconstruction was associated with a reduced risk of lymphedema, reducing the 5-year cumulative incidence from 12.2% to 9.6%.  This effect was seen for both implant-based and autologous reconstruction.  While not the first study to show an association between immediate reconstruction and prevention of lymphedema, it is the largest and most scientifically rigorous.

https://journals.lww.com/plasreconsurg/Fulltext/2023/02000/Association_between_Immediate_Breast.11.aspx

Brazilian Butt Lift–Associated Mortality: The South Florida Experience

Pat Pazmiño, MD, Onelio Garcia, Jr., MD

Aesthetic Surgery Journal, Volume 43, Issue 2, February 2023, Pages 162–178

A thorough and scientific review of mortality from BBL which should be required reading for all plastic surgeons, whether they perform the procedure or not.  Since 2010 there have been 25 BBL-related deaths in South Florida, however the incidence is difficult to calculate due to incomplete records of the numbers of procedures being performed.  Large-volume low-budget centers are identified as having a high association with mortality.  8 deaths have occurred after the 2019 emergency state legislation requiring subcutaneous-only injection.  Real-time ultrasound is advanced as a potential solution for surgeons to ensure patient safety.

https://academic.oup.com/asj/article/43/2/162/6661367

Outcomes of Extended Pedicle Technique vs Free Nipple Graft Reduction Mammoplasty for Patients with Gigantomastia

Ankoor A Talwar, MBA, Libby R Copeland-Halperin, MD, Landis R Walsh, BS, Adrienne N Christopher, MD, Jessica Cunning, MD, MBA, Robyn B Broach, PhD, Michael D Baratta, MD, Michelle Copeland, DMD, MD, Vidya Shankaran, MD, Paris D Butler, MD, MPH, FACS

Aesthetic Surgery Journal, Volume 43, Issue 2, February 2023, Pages NP91–NP99

This was a retrospective cohort study of two groups of patients with gigantomastia who underwent reduction mammoplasty over a 3 year period.  For this study gigantomastia was defined as having a nipple to sternal notch distance of 40 cm or greater, or requiring a reduction of 1500 g on a single side.  21 patients underwent a free nipple graft technique with 6 different surgeons, and 31 patients underwent and extended pedicle technique (either superomedial or inferior) with a single surgeon.  The average resection in the free nipple graft group was 1072 g, and in the extended pedicle group was 1486 g.  At a mean follow up of 6 months, there was a greater incidence of cellulitis in the free nipple graft group, but no difference in nipple or wound complications.  There was one case of nipple necrosis in the extended pedicle group and two in the free nipple graft group.  BREAST-Q patient-assessments showed no differences between the groups in the Satisfaction with Breasts, Psychosocial Well-being, Physical well-being or Sexual Well-being domains.  However “satisfaction with nipples” was greater in the extended pedicle group.

https://academic.oup.com/asj/article/43/2/NP91/6717638