Portal de Periódicos da CAPES

Spotlight in Plastic Surgery: October 2019

2019; Lippincott Williams & Wilkins; Volume: 144; Issue: 4 Linguagem: Inglês

10.1097/prs.0000000000006091

1529-4242

Brett T. Phillips, Michael V. Chiodo, Min‐Jeong Cho, Austin Hembd, Christopher Homsy, Karan Mehta, Lily R. Mundy, Kashyap Komarraju Tadisina, Macarena Vizcay, Arun K. Gosain,

Body Image and Dysmorphia Studies

“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, Annals of Surgery, Journal of the American Medical Association, 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. Should any of our readers have specific suggestions of articles to review in recent issues of high-impact journals, please contact us by means of 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 Implant Based Breast Reconstruction with Acellular Dermal Matrix: Safety Data from an Open-Label, Multicenter, Randomized, Controlled Trial in the Setting of Breast Cancer Treatment. By Lohmander F, Lagergren J, Roy PG, et al. Ann Surg. 2019;269:836–841.1 The authors present 6-month safety data from a randomized controlled trial comparing implant-based breast reconstruction with acellular dermal matrix and partial muscle coverage against implant-based breast reconstruction with complete submuscular coverage. Endpoints included unplanned reoperations, surgical complications, quality of life, aesthetics, and cost-analysis. With 6-month follow-up for all participants, the incidence of surgical complications was higher in the acellular dermal matrix group; however, the difference was not statistically significant. There was no statistical difference between the two groups regarding reconstructive failure. This is the first randomized controlled trial to prospectively assess clinical outcomes of using acellular dermal matrix in implant-based breast reconstruction and will continue to provide useful outcomes data to plastic surgeons as the study progresses. Michael V. Chiodo, M.D. New York University Langone Health New York, N.Y. Inappropriate Opioid Prescription after Surgery. By Neuman MD, Bateman BT, Wunsch H. Lancet 2019;393:1547–1557.2 In this review article, the authors discuss the current trend on opioid prescription, risk factors with prolonged opioid use, and strategies to minimize inappropriate opioid prescription after surgery. The authors state that male sex, age 50 years or older, type of surgery, early postoperative opioid use, preoperative opioid use, and high dosage of prescriptions are risk factors. They recommend preoperative patient education, using nonopioids, psychiatric support, counseling on the disposal of leftover opioids, and using procedure-specific upper limits for opioid prescription. This comprehensive review can assist plastic surgeons in appropriate opioid prescription after surgery and prevent overprescription. Min-Jeong Cho, M.D. University of Texas Southwestern Medical Center Dallas, Texas Oral versus Intravenous Antibiotics for Bone and Joint Infection. By Li HK, Rombach I, Zambellas R, et al. N Engl J Med. 2019;360:425–436.3 In this prospective, randomized, multicenter trial, the authors compared oral versus intravenous antibiotic therapy used during the first 6 weeks for bone, joint, and hardware infections. At 1 year and in 1015 patients, the authors found that oral therapy (13.2 percent failure) was not inferior to intravenous therapy (14.6 percent failure), whereas intravenous therapy had more catheter complications (9.4 percent versus 1.0 percent) and longer hospital stays. This study could encourage a paradigm shift in the treatment algorithm of plastic surgery patients with osteomyelitis and hardware infections, particularly in a safety-net hospital setting or uninsured population where resources for 6 weeks of intravenous antibiotics are limited. Austin S. Hembd, M.D. University of Texas Southwestern Medical Center Dallas, Texas Chlorhexidine versus Routine Bathing to Prevent Multidrug-Resistant Organisms and All-Cause Bloodstream Infections in General Medical and Surgical Units (ABATE Infection Trial): A Cluster-Randomised Trial. By Huang SS, Septimus E, Kleinman K, et al. Lancet 2019;393:1205–1215.4 In this large randomized controlled trial, Huang et al. examined the benefit of decolonization protocols compared to routine nursing care of 194 nonintensive care units in 53 hospital in the United States. Interestingly, decolonization with chlorhexidine and targeted mupirocin for methicillin-resistant Staphylococcus aureus carriers did not significantly reduce bloodstream-related infections. A post hoc analysis showed, however, that decolonization decreased the rate of infection with methicillin-resistant S. aureus and vancomycin-resistant Enterococcus by 32 to 37 percent in patients with medical devices. Would our plastic surgery patients with implants and other prosthetic devices benefit from such decolonization strategies? This is an intriguing question worth studying in the future. Christopher Homsy, M.D. Tulane University New Orleans, La. Adjunctive Intermittent Pneumatic Compression for Venous Thromboprophylaxis. By Arabi YM, Al-Hameed F, Burns KEA, et al. N Engl J Med. 2019;380:1305–1315.5 The purpose of this study was to evaluate whether adjunctive intermittent pneumatic compression in critically ill patients receiving pharmacologic thromboprophylaxis would result in a lower incidence of proximal lower limb deep venous thrombosis compared to pharmacologic thromboprophylaxis alone. The investigators conducted a multicenter, randomized, controlled trial and found no statistically significant difference in lower leg deep venous thrombosis in patients with both intermittent pneumatic compression devices and chemical prophylaxis (3.9 percent) compared to those with chemical prophylaxis alone (4.2 percent). These findings demonstrate that postoperative plastic surgery patients with prolonged intensive care unit stays may not require pneumatic compression devices if already receiving chemical thromboprophylaxis. Karan Mehta, M.D. Montefiore Medical Center Bronx, N.Y. Migraine Surgery: An All or Nothing Phenomenon? Prospective Evaluation of Surgical Outcomes. By Gfrerer L, Hulsen JH, McLeod MD, Wright EJ, Austen WG Jr. Ann Surg. 2019;269:994–999.6 Migraine headaches represent a heterogenous group of disorders. With peripheral nerve compression, it has not been established whether the migraine is secondary to a combination of central and peripheral pathways, or peripheral compression alone. In a single-institution, single-surgeon, prospective study of 85 patients who underwent surgery for refractory migraines, the authors found a binary response to surgery, with 69 percent (n = 57) demonstrating greater than 80 percent improvement and 14 percent (n = 12) demonstrating less than 5 percent improvement. The authors conclude that the binary response supports the peripheral compression–alone cause, suggesting that surgical release when indicated has the potential to provide substantial benefits to patients. Lily R. Mundy, M.D. Duke University Hospital Durham, N.C. Association of Overlapping Surgery with Perioperative Outcomes. By Sun E, Mello MM, Rishel CA, et al. JAMA 2019;321:762–772.7 In this retrospective cohort study, the authors examined the effect of overlapping surgery, a common occurrence at teaching hospitals, on surgical outcomes. Sixty-six thousand four hundred thirty cases were examined across 8 years from eight hospitals in the United States and The Netherlands and analyzed using multivariate linear regression analysis. Overall, overlapping surgery was not associated with increased in-hospital mortality or complication rates, but was associated with increased operative time. Subgroup analysis found that for high-risk patients, overlapping surgery was associated with increased mortality and complications. These results set up future studies to examine patient subsets for overlapping surgery to optimize both surgical education and patient outcomes. Kashyap K. Tadisina, M.D. Saint Louis University School of Medicine St. Louis, Mo. Potential Consequences of Patient Complications for Surgeon Well-Being: A Systematic Review. By Srinivasa S, Gurney J, Koea J. JAMA Surg. 2019;154:451–457.8 In this systematic review, the authors examined how patient complications affect surgeon health. Results found that, contrary to prior studies, surgeons are consistently affected emotionally after adverse outcomes. Psychological consequences can be significant and longstanding, with surgeons typically coping in isolation because of perceived downstream personal and professional consequences. This study may help bring to light this occupational hazard and current barriers to effective support, and help create paths to prevent it. This is particularly relevant to plastic surgeons, whose surgical outcomes are often a qualitative judgment. Macarena Vizcay, M.D. Hospital Nacional Prof. A. Poasadas Buenos Aires, Argentina Evaluation of Long-Term Outcomes of Facial Sensation following Cranial Vault Reconstruction for Craniosynostosis. By Dengler J, Ho ES, Klar EL, Phillips JH, Forrest CR. Plast Reconstr Surg Glob Open 2019;7:e2135.9 The authors investigate the long-term sensory outcome of cranial vault reconstruction for craniosynostosis performed in infancy. The authors recalled 28 patients, now aged 6 years and older, and compared sensory findings in the face to 16 age-matched controls. They examined the sensory distribution of the supraorbital, supratrochlear, zygomaticofacial, and zygomaticotemporal nerves, and found no difference in sensation between groups. Criticism of the study is that the authors could not identify which patients with craniosynostosis had nerve injury during surgery. However, the study does indicate that if nerve injury occurred during initial surgery, this does not result in a long-term sensory deficit. Arun K. Gosain, M.D. Lurie Children’s Hospital Chicago, Ill. Routine Laser-Assisted Indocyanine Green Angiography in Immediate Breast Reconstruction: Is It Worth the Cost? By Mirhaidari S, Azouz V, Wagner DS. Plast Reconstr Surg Glob Open 2019;7:e2235.10 This study examined the cost-effectiveness of routine indocyanine green analysis of mastectomy skin flaps after immediate breast reconstruction in 206 breasts over a 1-year period. They retrospectively reviewed prospectively gathered data and compared them to historical controls. Patients analyzed with indocyanine green had a statistically significant decreased full-thickness necrosis, implant loss, and unexpected operation. Indocyanine green analysis decreased full-thickness necrosis by 6.4 percent. If the average cost of necrosis was $15,000, the break-even point would be 248 cases with an expected 6 percent decrease in necrosis. Limitations of this study are its retrospective nature, unmatched controls, and inclusion of other surgical applications that may further reduce the break-even point. Brett T. Phillips, M.D., M.B.A. Duke University Hospital Durham, N.C. Brett T. Phillips, M.D., M.B.A.Michael V. Chiodo, M.D.Min-Jeong Cho, M.D.Austin S. Hembd, M.D.Christopher Homsy, M.D.Karan Mehta, M.D.Lily R. Mundy, M.D.Kashyap K. Tadisina, M.D.Macarena Vizcay, M.D.Arun K. Gosain, M.D.