Must-read articles chosen by the Southeastern Society of Plastic and Reconstructive Surgeons:  2024

October 2024

Post–Face Lift Facial Paralysis: A 20-Year Experience

Kaufman Goldberg, Tal MD; McGonagle, Elizabeth R.; Hadlock, Tessa A. MD

Plastic and Reconstructive Surgery. 154(4):748-758, October 2024.

The authors reviewed a 20-year experience in managing iatrogenic post-facelift facial paralysis.  Twenty-five patients were identified who had been referred for evaluation. Eight patients required facial nerve exploration, and six underwent nerve repair.  All patients recovered to some degree, with 50% achieving essentially normal facial function. Fourteen patients underwent nonsurgical management, including physical therapy, chemodenervation, and filler therapy. Of these nonsurgical patients who were not lost to follow-up, 50% achieved normal facial function and 42% achieved nearly normal facial function. The authors conclude that outcome depends on injury type and location, accurate assessment, and appropriate treatment; however, the overall prognosis is favorable. FN exploration is warranted when nerve transection is suspected. Observation is suitable for patients demonstrating early signs of recovery. Patients presenting beyond a reasonable reinnervation window will need other facial reanimation techniques. https://journals.lww.com/plasreconsurg/fulltext/2024/10000/post_face_lift_facial_paralysis__a_20_year.10.aspx

American Association of Plastic Surgeons Consensus on Breast Implant–Associated Anaplastic Large-Cell Lymphoma

Clemens, Mark W. MD, MBA; Myckatyn, Terence M. MD; Di Napoli, Arianna MD; Feldman, Andrew L. MD; Jaffe, Elaine S. MD; Haymaker, Cara L. PhD; Horwitz, Steven M. MD; Hunt, Kelly K. MD; Kadin, Marshall E. MD; McCarthy, Colleen M. MD; Miranda, Roberto N. MD; Prince, H. Miles MD, PhD; Santanelli di Pompeo, Fabio MD, PhD; Holmes, Sari D. PhD; Phillips, Linda G. MD

Plastic and Reconstructive Surgery 154(3):p 473-483, September 2024.

The result of an expert consensus conference held to evaluate the existing evidence regarding the diagnosis and management of BIA-ALCL caused by textured implants. This article aims to provide evidence-based recommendations regarding the management and prevention of BIA-ALCL and should be read by everyone engaged in the care of patients with breast implants.   A comprehensive database search on BIA-ALCL identified 840 articles published between January of 2011 and January of 2023. After screening the full text of 188 articles was assessed. The authors conclude that surgeons should be aware of the elevated risks by implant surface type, implement appropriate patient surveillance, and follow the recommendations outlined in this statement to ensure patient safety and optimize outcomes. Ongoing research on the pathogenesis, genetic drivers, and preventative and prophylactic measures for BIA-ALCL is crucial for improving patient care.

https://journals.lww.com/plasreconsurg/fulltext/2024/09000/american_association_of_plastic_surgeons_consensus.2.aspx

Drains in Breast Reduction: How Good Is the Recommendation Not to Use Them?

Tara Behroozian, MD, Caroline Hircock, BSc, MD, Emily Dunn, Mkin, Achilles Thoma, MD, MSc, FRCSC

Aesthetic Surgery Journal, Volume 44, Issue 11, November 2024, Pages 1179–1185

A clinical practice guideline issued from the American Society of Plastic Surgeons recommended not to use drains in breast reduction. This recommendation was based on 3 randomized controlled trials.  The objective of this review was to double-check the methodological quality of the 3 RCTs. These RCTs were critically appraised using: (1) the “User's Guide to the Surgical Literature” checklist to critically appraise the methodological quality, (2) the CONSORT guidelines for reporting quality, and (3) the Cochrane risk-of-bias tool 2 (RoB 2) for risk of bias. Weaknesses were identified in all assessments for the 3 RCTs.  The overall adherence to the CONSORT reporting checklist across all 3 studies was moderate with 40.0%, 62.1%, and 48.3% adherence. All 3 RCTs had a similar low to moderate risk of bias, with no areas with a high risk of bias. All 3 RCTs additionally lacked clear reporting of treatment effect sizes or precision of estimates.  The authors conclude that the recommendation should have been: “We remain uncertain whether drains in breast reduction have a salutary effect.” They further recommend that a methodologically robust RCT be conducted to resolve the question of whether drains should be used in breast reduction.

https://academic.oup.com/asj/article/44/11/1179/7679329

July 2024

Venous Thromboembolism after DIEP Flap Breast Reconstruction: Review of Outcomes after a Postoperative Prophylaxis Protocol

Tuaño, Krystle R. MD; Yang, Jerry H. BS; Fisher, Marlie H. PhD; Le, Elliot MD, MBA; Khatter, Neil J. BS; Kalia, Nargis; Colakoglu, Salih MD; Cohen, Justin B. MD, MHS; Kaoutzanis, Christodoulos MD; Chong, Tae W. MD; Mathes, David W. MD

Plastic and Reconstructive Surgery 154(1):p 13e-20e, July 2024.

The authors instituted a new chemoprophylaxis protocol for all patients undergoing DIEP reconstruction consisting of 2 weeks of treatment with enoxaparin, regardless of patient risk factors. The protocol was instituted in March, 2019.  A retrospective chart review was conducted on all patients who underwent DIEP flap between January of 2014 and March of 2020 (340 patients). Patients were grouped based on whether they enrolled in the new VTE protocol in the postoperative period or not.  Risk of VTE was significantly higher in patients discharged without VTE prophylaxis compared with patients discharged with prophylaxis (3.7% versus 0%; P = 0.03). No patients in the VTE prophylaxis group developed a deep venous thrombosis or pulmonary embolism. In addition, the risk of a VTE event was 25 times greater in patients with a Caprini score greater than or equal to 6 (P = 0.0002).  The authors demonstrate the successful implementation of a 2-week VTE chemoprophylaxis protocol in DIEP flap breast reconstruction patients that significantly reduces the rate of VTE while not affecting the rate of hematoma complications.  This is important specialty-specific data to support the routine use of VTE chemoprophylaxis in microsurgical breast reconstruction.

https://journals.lww.com/plasreconsurg/fulltext/2024/07000/venous_thromboembolism_after_diep_flap_breast.6.aspx

Mental Health Trends in Patients with Symptomatic Macromastia After Reduction Mammoplasty

Park, Rachel H. MD; Odega, Ugochukwu K. BA; Kilmer, Lee H. MD; Hollenbeck, Scott T. MD; DeGeorge, Brent R. MD, PhD

Annals of Plastic Surgery 93(1):p 30-33, July 2024.

A national insurance database was used to assess the impact of breast reduction on mental health outcomes.  Patients with a diagnosis of macromastia between the years 2010 and 2021 that did or did not undergo breast reduction were included in the study.  Patients with a history of macromastia with a history of reduction were compared with those with a history of macromastia without reduction. A significantly higher percentage of patients in the reduction group reported a history of depression (48.5%), obesity (55.7%), and selective serotonin reuptake inhibitor (SSRI)/serotonin-norepinephrine reuptake inhibitor (SNRI) use (55.3%) when compared with that of the no-reduction group (46.3%, 50.8%, and 52.6%). Patients with history of depression and obesity were more likely to undergo reduction (odds ratio of 1.11 and 1.31). Patients who underwent breast reduction had significantly reduced rates of depression (38.6% to 27.4%), anxiety (4.3% to 3.1%), and SSRI or SNRI prescriptions (46.3% to 29.5%) postoperatively when compared to those who did not undergo reduction.

https://journals.lww.com/annalsplasticsurgery/fulltext/2024/07000/mental_health_trends_in_patients_with_symptomatic.6.aspx

Wide-Awake Carpal Tunnel Release in the United States: Trends in Volume and Reimbursement by Operative Setting

Kammien, Alexander J. BS; Kim, Samuel MD; Mookerjee, Vikram G. MD; Williams, Mica C. G. BA; Prsic, Adnan MD; Grauer, Jonathan N. MD; Colen, David L. MD

Plastic and Reconstructive Surgery 154(1):p 143-149, July 2024.

Wide-awake carpal tunnel release in the office setting has already been shown to reduce waste and improve efficiency.  The authors sought to determine the effects on cost, narcotic use, and complications.  Operations performed under local-only anesthesia from 2010 to 2020 were identified in a national administrative database (PearlDiver). Patients were grouped by surgical setting and matched based on age, sex, comorbidity burden, and geographic region.  From 2010 to 2020, the percentage of operations in the office increased from 1.2% to 3.4%. Matched cohorts included 21,835 operating room operations and 5459 office operations. Office surgery was associated with lower total disbursement and physician reimbursement. Fewer office patients filled narcotic prescriptions and visited the ED, and there was no difference in SSIs. Compared with operating room surgery, office surgery was associated with lower financial burden, fewer narcotics prescriptions and ED visits, and a similar incidence of SSIs. (SSIs).

https://journals.lww.com/plasreconsurg/fulltext/2024/07000/wide_awake_carpal_tunnel_release_in_the_united.30.aspx

April 2024

The Superficial Musculoaponeurotic System: Does It Really Exist as an Anatomical Entity?

Minelli, Lennert MD, PhD; van der Lei, Berend MD, PhD; Mendelson, Bryan C. AM, FRCSE, FRACS, FACS

Plastic and Reconstructive Surgery 153(5):p 1023-1034, May 2024.

In what is likely to be a controversial study, the authors performed standardized layered dissections complemented by histologic analysis on 50 cadaveric specimens (34 fresh and 16 preserved). They observed that there was no continuous musculoaponeurotic layer separating the subcutaneous fat of the superficial fascia from the deep fat of the deep fascia in the face.  They observed such a layer only over the superficial flat mimetic muscles (such as the platysma and orbicularis oculi) and as the platysma-auricular fascia over the posterior part of the parotid gland. Over the remainder of the face, the subcutaneous fat is in direct contact with the deep fat without the interposition of a musculoaponeurotic layer.  The authors conclude that the SMAS does not exist, at least as classically described as a continuous layer extending from the frontalis muscle to the platysma.  The structure surgeons refer to as “SMAS” is actually a surgically created compound layered flap composed of a variable thickness of subcutaneous fat, mimetic muscles (eg, platysma, orbicularis oculi), and a thin layer of deep fascia.

https://journals.lww.com/plasreconsurg/citation/2024/05000/discussion__the_superficial_musculoaponeurotic.10.aspx

The Positive and Negative Predictive Value of Targeted Diagnostic Botox Injection in Nerve Decompression Migraine Surgery

ElHawary, Hassan MD, MSc; Kavanagh, Kaitlin; Janis, Jeffrey E. MD

Plastic and Reconstructive Surgery 153(5):p 1133-1140, May 2024.

In this prospective study, a sensitivity analysis was performed on 40 patients receiving Botox for migraine trigger site localization followed by a surgical decompression of affected peripheral nerves with at least 3 months’ follow-up.  Patients with successful Botox injections (defined as at least 50% improvement in Migraine Headache Index scores after injection) had a significantly higher average reduction in migraine intensity, frequency, and Migraine Headache Index.  The use of Botox injection as a diagnostic modality for migraine headaches was shown to have a sensitivity of 56.7% and a specificity of 80.0%. The positive predictive value was 89.5% and the negative predictive value was 38.1%.  They conclude that diagnostic targeted Botox injections have a very high positive predictive value and is a useful diagnostic modality that can help identify migraine trigger sites and improve preoperative patient selection.

https://journals.lww.com/plasreconsurg/fulltext/2024/05000/the_positive_and_negative_predictive_value_of.34.aspx

Implant-Based Breast Reconstruction After Nipple-Sparing and Skin-Sparing Mastectomy in Breast-Augmented Patients: Prepectoral or Submuscular Direct-to-Implant Reconstruction?

Marzia Salgarello, MD,  Mariachiara Fabbri, MD,  Giuseppe Visconti, MD, PhD,  Liliana Barone Adesi, MD

Aesthetic Surgery Journal, Volume 44, Issue 5, May 2024, Pages 503–515

A retrospective review was conducted on 38 patients with previous breast augmentation who underwent either skin-sparing mastectomy or nipple-sparing mastectomy for breast cancer followed by DTI reconstruction over an 8 year period. The authors used mastectomy flap thickness to guide choice of reconstruction plane.  Patients with a history of subglandular breast augmentation and a flap thickness greater than 1 cm were candidates for prepectoral reconstruction. When the MFT was less than 1 cm but flap vascularity was sufficient by ICG imaging, a prepectoral reconstruction was performed, otherwise, retropectoral reconstruction was preferred. Patients with submuscular breast augmentation were evaluated similarly, with submuscular reconstruction chosen when the MFT was less than 1 cm and prepectoral reconstruction preferred when the MFT exceeded 1 cm.  Rates of minor complications in the series were low, with no patients experiencing implant loss.  The authors demonstrate the safety of DTI reconstruction for patients with previous breast augmentation, when ICG imaging and flap thickness are used to guide reconstructive plane choice.

https://doi.org/10.1093/asj/sjad383

January 2024

Textured versus Smooth Tissue Expanders: A Comparison of Complications in 3526 Breast Reconstructions

Nelson, Jonas A. MD, MPH; Rubenstein, Robyn N. MD; Vorstenbosch, Joshua MD, PhD; Haglich, Kathryn MS; Poulton, Richard T. BS; McGriff, De’von MBA, MHA; Stern, Carrie S. MD; Coriddi, Michelle MD; Cordeiro, Peter G. MD; McCarthy, Colleen M. MD, MS; Disa, Joseph J. MD; Mehrara, Babak J. MD; Matros, Evan MD, MPH, MMSc

Plastic and Reconstructive Surgery 153(2):p 262e-272e, February 2024

The authors present a retrospective review of tissue expander to implant reconstruction from two large institutions over a three year period, comparing outcomes between smooth and textured expanders. A propensity score–matched analysis was used to decrease the effects of confounders, such as plane of expander placement, comparing textured and smooth TEs. The authors analyzed 3526 TEs (1456 textured and 2070 smooth).  Univariate analysis suggested higher rates of infection/cellulitis, malposition/rotation, and exposure in smooth TEs (all P < 0.01). Rates of TE loss did not differ. After propensity matching, no differences were noted in infection or TE loss. Prepectoral smooth expanders had increased rates of malposition/rotation.  The authors conclude that accepting a slightly higher rate of malposition is probably an acceptable trade-off for avoiding potential risk of ALCL.

https://journals.lww.com/plasreconsurg/fulltext/2024/02000/textured_versus_smooth_tissue_expanders__a.4.aspx

Prepectoral versus Submuscular Implant-Based Breast Reconstruction: A Matched-Pair Comparison of Outcomes

Talwar, Ankoor A. MBA; Lanni, Michael A. MD; Ryan, Isabel A. BS; Kodali, Pranav BS; Bernstein, Elizabeth BS; McAuliffe, Phoebe B. BA; Broach, Robyn B. PhD; Serletti, Joseph M. MD; Butler, Paris D. MD, MPH; Fosnot, Joshua MD

Plastic and Reconstructive Surgery 153(2):p 281e-290e, February 2024.

Patients treated with implant-based breast reconstruction after mastectomy from January of 2018 through October of 2021 were retrospectively reviewed. Patients were propensity score exact matched to control demographic, preoperative, intraoperative, and postoperative differences. Outcomes assessed included surgical-site occurrences, capsular contracture, and explantation of either expander or implant. A total of 634 breasts were included (prepectoral, 197; submuscular, 437). A total of 292 breasts were matched (146 prepectoral:146 submuscular) and analyzed for clinical outcomes. Prepectoral reconstructions were associated with greater rates of SSI (prepectoral, 15.8%; submuscular, 3.4%; P < 0.001), seroma (prepectoral, 26.0%; submuscular, 10.3%; P < 0.001), and explantation (prepectoral, 23.3%; submuscular, 4.8%; P < 0.001). Subanalysis of infections revealed that prepectoral implants have shorter time to infection, deeper infections, and more Gram-negative infections, and are more often treated surgically (all P < 0.05).  Prepectoral breast reconstruction has clear advantages, but this well-designed study suggests that these need to be balanced against a higher risk of complications. https://journals.lww.com/plasreconsurg/fulltext/2024/02000/prepectoral_versus_submuscular_implant_based.8.aspx

Body Mass Index Is Associated With Myocutaneous Free Flap Reliability: Overcoming the Obesity Obstacle With a Proposed Clinical Algorithm to Identify and Manage High-Risk Patients Undergoing Gracilis Free Flap With Skin Paddle Harvest

Donnelly, Megan R. MD; Noh, Karen J. BA; Silverman, Jeremy BA; Donnelly, John H. BS MSE; Azad, Ali MD; Nicholas, Rebecca MBBS, MS, FRCS(Plast), Dip.Hand Surg.(Eu); Reavey, Patrick MD; Dane, Bari MD; Hacquebord, Jacques Henri MD

Annals of Plastic Surgery 92(1):p 68-74, January 2024.

The authors accessed the National Surgical Quality Improvement Program database to collect data for 1549 patients who underwent musclulocutaneous free flap transfer from 2015 to 2021. Body mass index was correlated with outcome measures to determine its role in predicting myocutaneous free flap reliability.  Being in obesity class III (BMI ≥40 kg/m2) was associated with a 4-times greater risk of flap complications necessitating a return to the operating room compared with being within the normal BMI range.  The authors also obtained measurements of perigracilis anatomy in patients who underwent computed tomography angiography bilateral lower extremity and showed that perforator location variability increased with adipose tissue thickness.  The authors conclude that BMI and adipose thickness be used to risk stratify patients under consideration for musculocutaneous free flap reconstruction.

https://journals.lww.com/annalsplasticsurgery/fulltext/2024/01000/body_mass_index_is_associated_with_myocutaneous.14.aspx