“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, 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. 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 as to key developments relative to plastic surgery. ARTICLES Effect of Gender-Affirming Facial Feminization Surgery on Psychosocial Outcomes. By Caprini RM, Oberoi MK, Dejam D, et al. Ann Surg. Published online July 4, 2022.1 In this study aimed at evaluating health-related quality of life before and after facial feminization surgery (FFS), Caprini et al. utilize 11 validated patient-reported psychosocial outcome measures to characterize the effect of gender-affirming FFS. Patients who underwent FFS reported improved psychosocial functioning in seven of the 11 measures (ie, anxiety, anger, depression, positive affect, meaning and purpose, global mental health, and social isolation). Furthermore, completion of FFS was found to be an independent predictor of improved scores in all seven measures. These findings provide clear evidence of psychosocial improvement with gender-affirming facial surgery using validated measures. Jessica D. Blum, MSc, University of California, San Diego, San Diego, CA Deaths Related to Liposuction. By Rao RB, Ely SF, Hoffman RS. N Engl J Med. 1999;340:1471–1475.2 This article aimed to identify the incidence of complications and deaths after tumescent liposuction. Rao et al. reviewed autopsy reports and death notification records at the Office of Chief Medical Examiner of The City of New York for the period between 1993 and 1998. The authors found that five out of 48,527 deaths pertained to death after tumescent liposuction. Deaths were related to hypotension and bradycardia with no definitively identified cause, fluid overload, or pulmonary thromboembolism due to deep venous thrombosis of calf veins. Lidocaine doses ranged from 10 to 40 mg/kg. Their findings suggest that lidocaine toxicity or drug interactions could be fatal in tumescent liposuction. Valeria P. Bustos, MD, MS, Beth Israel Deaconess Medical Center, Boston, MA Shared Genetic Susceptibility between Trigger Finger and Carpal Tunnel Syndrome: A Genome-Wide Association Study. By Patel B, Kleeman SO, Neavin D, et al. Lancet Rheumatol. 2022;4:e556–e565.3 In this study, the authors aimed to identify a specific genetic locus associated with trigger finger and carpal tunnel syndrome that might explain the co-occurrence of both diseases. Patel et al. conducted a case-control genome-wide association study using data from the UK Biobank. They found a marked association between carpal tunnel syndrome and trigger finger (odds ratio, 11.97). There were five independent loci for trigger finger, including one that was colocalized with carpal tunnel syndrome (DIRC3 locus on chromosome 2). Increased plasma insulin-like growth factor-1 concentrations were associated with both diseases, supporting a theory of a genetic link between these syndromes. Eliana Camacho, MD, Hospital de Clínicas, Montevideo, Uruguay Long-Term Quality of Life in Patients with Breast Cancer after Breast Conservation vs Mastectomy and Reconstruction. By Hanson SE, Lei X, Roubaud MS, et al. JAMA Surg. 2022;157:e220631.4 The objective of this study was to compare the long-term quality of life in patients diagnosed with breast cancer stage 0 through II between 2006 and 2008. Patients were treated with either breast-conserving surgery with radiation therapy or mastectomy and reconstruction. A total of 647 patients were evaluated using the BREAST-Q, the EuroQol 5 Dimensions 3 Levels questionnaire, and the Decision Regret Scale. Multivariable linear regression models showed equivalence between the two techniques; however, conservative surgery with radiation therapy was associated with better psychosocial quality and sexual well-being. This information can help the breast plastic surgeon choose the best reconstructive option according to the conditions of each patient. Alberto De Anda Coronado, MD, Hospital Universitario, Monterrey, Nuevo León, México The Safety of Same-day Discharge after Immediate Alloplastic Breast Reconstruction: A Systematic Review. By Marxen T, Shauly O, Losken A. Plast Reconstr Surg Glob Open 2022;10:e4448.5 The authors present a systematic review assessing the safety of same-day patient discharge after immediate, alloplastic breast reconstruction. Four included studies provided data for a total of 574 patients. Patient risk factors, surgical techniques, and complication rates were similar between patients discharged home on the same day as surgery and those admitted overnight. Reoperation and readmission rates were similar between the two groups (33% versus 34%, respectively). The authors conclude that, based on existing evidence, same-day discharge after immediate, alloplastic breast reconstruction is safe. Limitations of the study include the small number of publications meeting inclusion criteria and the potential for selection bias. Riley A. Dean, MD, University of California, San Diego, San Diego, CA Development and Assessment of Machine Learning Models for Individualized Risk Assessment of Mastectomy Skin Flap Necrosis. By Hassan AM, Biaggi AP, Asaad M, et al. Ann Surg. Published online January 21, 2022.6 In this study, the authors developed and evaluated the performance of machine learning in predicting mastectomy skin flap necrosis (MSFN). The authors found that machine learning outperformed conventional statistical methods in discriminatory performance and identifying predictors of MSFN, providing a more robust understanding of the factors that contribute to MSFN. The incorporation of these models into the perioperative risk assessment of patients undergoing mastectomy will provide surgeons with an accurate, objective, and individualized measure of a patient’s risk of developing MSFN and aid in individualized patient counseling, perioperative optimization, and surgical planning to reduce the risk of this devastating complication. Abbas M. Hassan, MD, University of Texas M. D. Anderson Cancer Center, Houston, TX Spina Bifida. By Iskandar BJ, Finnell RH. N Engl J Med. 2022;387:444–450.7 In this review article on the current principles of spina bifida and its management, the authors discuss its embryology, pathogenesis, surgical and medical management, and future directions of care. Specifically, they discuss the importance of early, layered coverage for these patients. The authors note that with improved protocols, more of these patients are living full adult lives. However, this has led to inadequate care, particularly regarding wound care and revision surgery for this population. These are important details that can further aid plastic surgeons in the reconstruction of patients with spina bifida and their subsequent needs as they grow into adulthood. Garrison Leach, MD, University of California, San Diego, San Diego, CA Topical Therapy for Regression and Melanoma Prevention of Congenital Giant Nevi. By Choi YS, Erlich TH, von Franque M, et al. Cell 2022;185:2071–2085.e12.8 Congenital melanocytic nevi (CMNs) are skin lesions that may progress to melanoma, so traditional treatment is surgical excision. Giant CMNs can cover up to 80% of the body surface, presenting problems for complete excision. In this study, Choi et al. tested multiple topical pharmacologic agents to evaluate lesion regression in murine models with mice and xenografted human CMNs. Of the agents tested, squaric acid dibutylester achieved major regressions by triggering innate immunity that ablated nevocytes and prevented melanoma. These findings lay the foundation for future translational and clinical research on topical therapeutic agents for children with giant CMNs. Benjamin B. Massenburg, MD, University of Washington, Seattle, WA The Psychological and Somatic Consequences of Digital Amputation. By Skoff H, Skoff H. Plast Reconstr Surg Glob Open 2022;10:e4387.9 This cohort study investigates the long-term psychologic outcomes associated with single-digit amputation. Twenty-five patients without psychiatric history answered three validated questionnaires to determine somatic and psychologic outcomes after digital amputation. At 3 months, 95% of patients demonstrated symptoms of anxiety, depression, anger, and posttraumatic stress disorder. Less than 30% reported symptom resolution at 1 year, and psychologic support was required in 100% of patients with persistent symptoms. Neuroma pain was associated with poor psychologic outcome. This study demonstrates that digital amputation has significant mental health implications. Neuroma formation should be avoided with meticulous technique, and psychologic counseling should be considered for digital amputees. Nicholas C. Oleck, MD, Duke University Hospital, Durham, NC Primary Radiotherapy and Deep Inferior Epigastric Perforator Flap Reconstruction for Patients with Breast Cancer (PRADA): A Multicentre, Prospective, Non-Randomised, Feasibility Study. By Thiruchelvam PTR, Leff DR, Godden AR, et al. Lancet Oncol. 2022;23:682–690.10 In this study, the authors sought to prospectively investigate the effect of preoperative, primary radiotherapy 2 to 6 weeks before skin-sparing mastectomy with deep inferior epigastric perforator flap breast reconstruction. Radiation increases morbidity in a variety of plastic and reconstructive procedures due to fibrosis of soft tissue and microvasculature. In total, 33 patients were enrolled. At 4 weeks, four of 33 (12.1%) had an open wound of greater than 1 cm, with only one requiring operative débridement (3%). This feasibility study is promising for future studies that may show the morbidity of radiation therapy in deep inferior epigastric perforator flaps is lower than previously thought. Sammy Othman MD, Northwell Health, New York, NY The Human Acellular Vessel for Vascular Reconstruction or Bypass: A Novel Biologic Conduit for Vascular Bypass and Repair. By Lauria AL, Sen I, Rasmussen TE. JAMA Surg. 2022;157:731–732.11 In this study, a novel biological vascular conduit was created using human vascular smooth muscle cells from tissue donors and seeded in a tubular biodegradable lattice scaffold. The extracellular matrix, which includes collagen types I and III, fibronectin, and vitronectin, forms when the scaffold breaks down, and it is decellularized to remove immunogenic material while maintaining the tensile strength, durability, and structural integrity of the new vessel. As of 2021, 500 patients had received human acellular vessels over 900 patient-years of follow-up. Human acellular vessels have favorable compliance matching and populates with patient cells, characteristics that support patency, structural integrity, and infection resistance. Ricardo A. Torres-Guzman, MD, Mayo Clinic, Jacksonville, FL