“Spotlight in Plastic Surgery” continues to provide a quarterly overview of articles from non–plastic surgery high-impact journals and Plastic and Reconstructive Surgery Global Open. Our goal is to inform our readers of relevant literature that they may not otherwise read about. Plastic and Reconstructive Surgery resident advisors, resident ambassadors, and Plastic and Reconstructive Surgery advisory board members help us to identify key articles of relevance to plastic surgeons and provide a brief synopsis of the articles. We would love to hear article suggestions or ways to improve this section of the Journal. Please contact us by means of e-mail at [email protected] with comments and article recommendations. We hope you enjoy this additional feature in Plastic and Reconstructive Surgery. Association of Nodal Metastasis and Mortality with Vermilion vs Cutaneous Lip Location in Cutaneous Squamous Cell Carcinoma of the Lip. By Wang DM, Kraft S, Rohani P, et al. JAMA Dermatology, June 2018.1 This retrospective review of 303 cases compared the risk of recurrence, nodal and distant metastasis, and disease-specific death between cutaneous and vermillion lip cutaneous squamous cell carcinomas. The authors found a significantly higher risk of nodal metastasis (5-fold greater risk) in vermillion cutaneous squamous cell carcinomas. Nodal metastasis risk is similar between cutaneous squamous cell carcinomas of the cutaneous lip and other regions (1.5 percent). Importantly for plastic surgeons, the increased risk of nodal metastasis in vermillion cutaneous squamous cell carcinomas may necessitate modified management strategies. This study suggests that further workup (i.e., imaging) to assess for nodal involvement and closer follow-up may be best practice for patients with vermillion lip cutaneous squamous cell carcinomas. Kaitlin S. Boehm, M.D. Dalhousie University Halifax, Nova Scotia, Canada Breast Cancer in Men. By Giordano SH. New England Journal of Medicine, June 2018.2 In this review article from M. D. Anderson Cancer Center, the author discusses epidemiology, risk factors, clinical presentation, prognosis, and treatment of breast cancer in men. The author states that BRCA2, radiation exposure, and elevated levels of estrogen are the risk factors. As with gynecomastia, the majority of men with breast cancer present with a painless, retroareolar mass, and imaging can be performed if concerned. Currently, there are limited studies about breast cancer treatment for men, and the majority of treatment mirrors the treatment for women. This comprehensive review can assist plastic surgeons in counseling patients undergoing gynecomastia or transgender procedures. Min-Jeong Cho, M.D. University of Texas Southwestern Medical Center Dallas, Texas Interventions to Reduce Intraoperative Costs: A Systematic Review. By Childers CP, Showen A, Nuckols T, Maggard-Gibbons M. Annals of Surgery, July 2018.3 A systematic review was performed including 12 randomized trials and 31 observational studies to assess potential interventions to reduce overall intraoperative cost. A single study on bilateral breast reconstruction with tissue expanders was included in the review. The common means for reducing surgical costs per case included standardization of instruments and providing cost feedback to surgeons, with peer comparisons demonstrating the most significant amount of savings, ranging from $145 to $574 and $38 to $732, respectively. The implementation of more strict preference cards may permit significant cost savings, with a potentially substantial summation of savings for a surgical department. James J. Drinane, D.O. Albany Medical College Albany, N.Y. Quality-of-Life Results for Accelerated Partial Breast Irradiation with Interstitial Brachytherapy versus Whole-Breast Irradiation in Early Breast Cancer after Breast-Conserving Surgery (GEC-ESTRO): \5-Year Results of a Randomised, Phase 3 Trial. By Schäfer R, Strnad V, Polgár C, et al.; Groupe Européen de Curiethérapie of European Society for Radiotherapy and Oncology (GEC-ESTRO). Lancet Oncology, June 2018.4 A multicenter randomized controlled trial demonstrated comparable 5-year patient-reported quality-of-life outcomes between accelerated partial breast irradiation using multicatheter brachytherapy and whole-breast irradiation in the treatment of early breast cancer after breast conserving surgery. Most importantly, accelerated partial breast irradiation showed a reduction in breast symptom scores both immediately after radiotherapy (difference of means, 13.6; p < 0.0001) and at 3-month follow-up (difference of means, 12.7; p < 0.0001). The increasing evidence supporting accelerated partial breast irradiation for early breast cancer will allow plastic surgeons to deliver better reconstructive results thanks to a more localized delivery of radiation, which limits the effects on surrounding tissues such as the skin. Francesco M. Egro, M.Sc., M.R.C.S. University of Pittsburgh Medical Center Pittsburgh, Pa. Long-Term Results after Oncoplastic Surgery for Breast Cancer: A 10-Year Follow-Up. By Clough KB, van la Parra RFD, Thygesen HH, et al. Annals of Surgery, July 2018.5 In this single-center, prospective study, 350 patients undergoing oncoplastic mammaplasty were observed over a 4.5-year period for recurrence of invasive ductal carcinoma, invasive lobular carcinoma, or ductal carcinoma in situ. The mean histologic tumor size was 26 mm, which resulted in a reoperation rate of 11.5 percent. The 5-year recurrence rates were 4.5 percent (ductal carcinoma in situ), 2.1 percent (invasive ductal carcinoma), and 0 percent (lobular carcinoma in situ), with a cumulative 5-year local recurrence rate of 2.2 percent. Oncoplastic reductions resulted in superior cosmetic outcomes with comparable complication and recurrence rates with a lower rate of positive margins requiring reoperation. Gianfranco Frojo, M.D. Saint Louis University St. Louis, Mo. Informed Consent and the Role of the Treating Physician. By Fernandez Lynch H, Joffe S, Feldman EA. New England Journal of Medicine, June 2018.6 The Pennsylvania Supreme Court case Shinal v. Toms resulted in the landmark decision that the operating physician bears the responsibility for obtaining consent and cannot do so through an intermediary. Much has been written on “what” must be disclosed in informed consent, but considerably less attention has been paid to questions of “who” and “how.” Surgeons must understand state-specific laws and national trends in the consent process. As the importance of social media presence becomes increasingly undeniable within plastic surgery practice, one must consider the implications such changes will have on consent for photography, social media publication, and practice workflow. Joshua J. Goldman, M.D. University of Nevada, Las Vegas School of Medicine Las Vegas, Nev. A Clinical Prediction Model for Cancer-Associated Venous Thromboembolism: A Development and Validation Study in Two Independent Prospective Cohorts. By Pabinger I, van Es N, Heinze G, et al. Lancet Haematology, July 2018.7 The authors developed and then externally validated a 6-month venous thromboembolism clinical risk calculator for cancer patients using data from large prospective observational cohort studies (the Vienna Cancer and Thrombosis Study and the Multinational Cohort Study to Identify Cancer Patients at High Risk of Venous Thromboembolism). The risk calculator is composed of two variables: continuous D-dimer concentration and categorical tumor-site venous thromboembolism risk. C-indices comparing predicted and true 6-month incidences of venous thromboembolism were 0.66 (Vienna Cancer and Thrombosis Study) and 0.68 (Multinational Cohort Study to Identify Cancer Patients at High Risk of Venous Thromboembolism). Although not developed to account for increased venous thromboembolism risk in the setting of surgery, this model represents a straightforward method of assessing presurgical, baseline venous thromboembolism risk. Plastic surgeons may find this informative when determining the role of anticoagulation in oncologic reconstruction patients. Lily R. Mundy, M.D. Duke University Hospital Durham, N.C. Development and Psychometric Evaluation of the FACE-Q Scales for Patients Undergoing Rhinoplasty. By Klassen AF, Cano SJ, East CA, et al. JAMA Facial Plastic Surgery, January-February, 2016.8 This article reports on the development and psychometric evaluation of the FACE-Q scales and adverse effects checklist in an effort to better measure outcomes in rhinoplasty surgery. One hundred fifty-eight patients who underwent rhinoplasty in the United States, England, and Canada completed a questionnaire evaluating satisfaction with appearance and adverse effects. For validation purposes, patients also completed three additional FACE-Q scales. In developing the FACE-Q rhinoplasty module, the authors’ goal was to incorporate the patient perspective in outcome assessments. Indeed, this study demonstrated that the FACE-Q rhinoplasty module was valid and can be used in clinical practice, research, and quality improvement. Chad M. Teven, M.D. Memorial Sloan Kettering Cancer Center New York, N.Y. A Prospective Study Investigating Fistula Rate following Primary Palatoplasty Using Acellular Dermal Matrix. By Gilardino M, Aldekhayel S, Govshievich A. Plastic and Reconstructive Surgery Global Open, June 2018.9 This study examines fistula rates following the use of acellular dermal matrix as an adjunct to cleft palate repair for Veau type II, III, and IV palates. The study compared 65 prospective patients operated on by a single surgeon in which acellular dermal matrix was used (study group), with 65 control patients operated on by multiple surgeons outside of the study period, 31 percent of whom had acellular dermal matrix used in the repair. The study group had a significantly lower fistula rate than the control group (1.5 percent versus 12.3 percent). However, limitations include the use of acellular dermal matrix in both groups, different time periods for the two groups, and different surgeons involved in the two groups. Arun K. Gosain, M.D. Lurie Children’s Hospital Chicago, Ill. The Utility of a Master of Business Administration Degree in Plastic Surgery: Determining Motivations and Outcomes of a Formal Business Education among Plastic Surgeons. By Lee CS, Ooi AS, Zenn MR, Song DH. Plastic and Reconstructive Surgery Global Open, June 2018.10 Physician knowledge base expansion is important for our ever-changing medical field. More and more plastic surgeons have chosen to pursue additional degrees in business administration. In this study, a survey was sent out to assess motivations and outcomes of plastic surgeons who obtained an M.B.A. degree. Most respondents were in an academic practice and completed their degree during medical school or after 5 years of practice. All plastic surgeons would recommend pursuing this valuable degree, citing its importance in improving skills in leadership, management, and hospital administration. Limitations of this study are its subjective nature, small sample size, and response rate. Brett T. Phillips, M.D., M.B.A. Duke University Hospital Durham, N.C.