“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, New England Journal of Medicine, Nature, Annals of Surgery, JAMA Surgery, and Plastic and Reconstructive Surgery Global Open. Our goal is to enlighten Journal 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 brief synopses. Should any readers have specific suggestions of articles to review in recent issues of high-impact journals, please contact us by 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. Association between Gender-Affirming Surgeries and Mental Health Outcomes. By Almazan AN, Keuroghlian AS. JAMA Surg. 2021;156: 611–618.1 This study aimed to investigate the associations between gender-affirming surgery and mental health outcomes (psychological distress, substance use, and suicide risk). The study was a secondary analysis of the 2015 US Transgender Survey (n = 27,715). Results suggest that patients who underwent gender-affirming surgery were associated with lower psychological distress, past-year smoking, and suicidal ideation when compared with transgender patients with no history of gender-affirming surgery. The authors adjusted for sociodemographic factors and exposure to other types of gender-affirming care. The findings of this study may aid plastic surgeons in counseling patients who are planning to undergo gender-affirming surgery. Ronald K. Akiki, MD Brown University Providence, RI A Randomized Trial of Enteral Glutamine for Treatment of Burn Injuries. By Heyland DK, Wibbenmeyer L, Pollack JA, et al. N Engl J Med. 2022;387:1001–1010.2 This was an international, multicenter, doubleblind, randomized, placebo-controlled trial including 1209 patients with deep second or third degree burns (≥10% to ≥20% total body surface area). Patients were randomized to receive glutamine 0.5 g/kg/day (delivered enterally) or placebo. A total of 1200 patients were included in the analysis, with 596 patients in the glutamine group and 606 in the placebo group. There was no significant difference between groups in the median time to discharge (40 days in the glutamine group and 38 days in the placebo group) or mortality rate at 6 months (17.3% in the glutamine group and 16.2% in the placebo group). Amanda Fazzalari, MD Massachusetts General Hospital/Brigham and Women’s Hospital Boston, MA A Prospective Study on the Safety and Efficacy of Vascularized Lymph Node Transplant. By Brown S, Mehrara BJ, Coriddi M, et al. Ann Surg. 2022;276:635–653.3 The authors assessed the safety and efficacy of vascularized lymph node transplantation for the management of lymphedema, through a prospective study evaluating two patient-reported outcome metrics, limb volume, bioimpedance, need for compression, and incidence of cellulitis in a postoperative follow-up, including 89 patients with different donor sites. They demonstrated a significant improvement at 2 years postoperatively in all outcome measures with a low complication rate, establishing vascularized lymph node transplantation as a safe procedure with good results. As lymphedema is a common problem, vascularized lymph node transplantation should be considered by surgeons to offer an innovative, safe, and effective management alternative. Tomás Mestre García, MD Universidad Militar Nueva Granada Bogotá, Colombia Neoadjuvant Cemiplimab for Stage II to IV Cutaneous Squamous-Cell Carcinoma. By Gross ND, Miller DM, Khushalani NI, et al. N Engl J Med. 2022;387:1557–1568. E-published ahead of print September 12, 2022.4 This study describes a phase 3 double-blind, multicenter, single-group, nonrandomized trial assessing the efficacy of cemiplimab, an anti–programmed cell death 1 monoclonal antibody for neoadjuvant immunotherapy in cutaneous squamous cell carcinoma. Seventy-nine patients with stage III and IV cutaneous squamous cell carcinoma (no metastasis) received cemiplimab intravenously at a dose of 350 mg every 3 weeks for up to four doses. A pathological complete response was observed 51%, and 6% had a complete response on imaging. Thus, cemiplimab can be considered a neoadjuvant treatment before resection in advanced squamous cell carcinoma. Knowing this will greatly help plastic surgeons in making decisions. Majid Kalbasi Gharavi, MD Isfahan University of Medical Sciences Isfahan, Iran Reoperation through a Prosthetic-Reinforced Abdominal Wall and Its Association with Postoperative Outcomes and Longitudinal Health Care Utilization. By Rios-Diaz AJ, Cunning JR, Talwar AA, et al. JAMA Surg. 2022;157:908–916.5 The aim of this study was to investigate the association of prior incisional hernia repair with mesh with postoperative outcomes and health care utilization after common abdominal operations. Rios-Diaz et al. conducted a retrospective cohort study using five statewide databases. Results of this study suggested that reoperation through a previously prosthetic-reinforced abdominal wall was associated with increased surgical complications and health care utilization. This risk is independent of prior abdominal surgical history and is magnified by the mesh footprint. This important information can aid plastic surgeons in counseling patients undergoing abdominal wall surgery after prior incisional hernia repair with mesh. Francis D. Graziano, MD Icahn School of Medicine at Mount Sinai New York, NY Tissue-Engineered Grafts Exploit Axon-Facilitated Axon Regeneration and Pathway Protection to Enable Recovery after 5-cm Nerve Defects in Pigs. By Smith DH, Burrell JC, Browne KD, et al. Sci Adv. 2022;8:eabm3291.6 When one considers the shortcomings of the current peripheral nerve repair techniques, repair of long segmental nerve defects still constitutes a challenge for plastic surgeons. The authors developed tissue-engineered nerve grafts (TENGs) to bridge the long nerve gaps. TENGs are mechanobioreactor generated via axonal “stretch growth” of the embryonic murine or swine sensory dorsal root ganglion neurons. In a porcine long (>5 cm) nerve gap model, TENGs demonstrated a level of electrophysiological recovery and axonal regeneration comparable or superior to that of autografts. Therefore, successful clinical translation of TENGs, an off-the-shelf product, may cause a paradigm shift in the management of long-segment defects. Gunel Guliyeva, MD The Ohio State University Columbus, OH Does Fitzpatrick Score Predict Flap Loss? Microsurgical Breast Reconstruction Outcomes of Varying Skin Color. By Perez K, Steppe C, Teotia SS, Haddock NT. Plast Reconstr Surg Glob Open. 2022;10:e4637.7 In this study, the authors aimed to evaluate the influence of Fitzpatrick skin tone on flap loss due to unsalvaged vascular compromise in patients who underwent autologous breast reconstruction. Perez et al. identified 56 patients from their institution who met the inclusion criteria. The Cochran-Armitage test showed a statistically significant linear trend (P = 0.006), with darker skin tones in the Fitzpatrick score indicating higher percentage of flap loss. The current study highlighted that these patients had a higher rate of flap loss after vascular injury. The authors recommend that more aggressive flap monitoring be considered in the immediate postoperative period. Samarth Gupta, MBBS, MS, MCh St Andrew’s Center of Plastic Surgery and Burns Chelmsford, United Kingdom Functional and Psychosocial Outcomes following Innervated Breast Reconstruction: A Systematic Review. By Abbas F, Klomparens K, Simman R. Plast Reconstr Surg Glob Open 2022;10:e4559.8 In this study, the authors conducted a systematic review to gain insight into the efficacy of nerve coaptation during breast reconstruction. Twenty-three studies were included—seven for DIEP flaps, nine for TRAM flaps, two for implant reconstruction, and five for other reconstruction. Monofilament testing was the most common modality to test sensation, and various tools were used to assess the psychosocial impact, including the BREAST-Q. Even though the methods in the studies were heterogeneous, the studies showed improved outcomes following neurotization, both clinically and psychosocially. This highlights the need to further explore neurotization in a multicenter study with a standardized methodology. Ayush K. Kapila, MD Brussels University Hospital (UZ Brussel) Brussels, Belgium A Statewide Approach to Reducing Re-excision Rates for Women with Breast-Conserving Surgery. By Schumacher JR, Lawson EH, Kong AL, et al. Ann Surg. 2022;276:665–672.9 This study retrospectively assessed the effect of statewide implementation of a quality improvement (QI) initiative on re-excision rates after breast-conserving surgery using discharge data through a difference-in-difference statistical approach. The QI initiative involved (1) benchmarked performance reporting, (2) a collaborative learning environment for surgeons to share experiences, and (3) education on evidence-based practices. Authors demonstrated reduced re-excision rates in patients operated on at hospitals participating in the QI initiative compared with those from nonparticipating hospitals (odds ratio, 0.69). Implementation of this breast QI initiative can help surgeons better manage resources such as operative time and avoid delays in starting adjuvant therapy. Ann-Sophie Lafreniere, MD University of Calgary Calgary, Alberta, Canada Routine Sterile Glove and Instrument Change at the Time of Abdominal Wound Closure to Prevent Surgical Site Infection (ChEETAh): A Pragmatic, Cluster-Randomised Trial in Seven Low-Income and Middle-Income Countries. By NIHR Global Research Health Unit on Global Surgery. Lancet 2022;400:1767–1776.10 In the ChEETAh study, a pragmatic, clustered, randomized trial, the authors aimed to evaluate whether routine change of gloves before abdominal wound closure reduced surgical site infection (SSI) rates within 30 days of operation. A total of 13,301 patients at 81 hospitals in seven low-income countries were included in the study. Routine change of gloves and instruments before abdominal wound closures reduced the rate of SSI by 13%. SSI remains the most common health care–associated infection. This valuable information allows plastic surgeons all over the world to implement a simple routine that leads to a lower incidence of SSI. M. Diya Sabbagh, MD Loyola University Medical Center Maywood, IL Aqueous Skin Antisepsis before Surgical Fixation of Open Fractures (Aqueous-PREP): A Multiple-Period, Cluster-Randomised, Crossover Trial. By PREP-IT Investigators. Lancet 2022;400:1334–1344.11 In a multiperiod, cluster-randomized, crossover trial involving 14 hospitals in the United States, Spain, and Canada, 1683 patients with open extremity fractures were randomized 1:1 to receive either 10% povidone-iodine or aqueous 4% chlorhexidine gluconate for skin preparation before surgical incision. Overall, the odds of surgical site infection (SSI) did not differ between patients assigned aqueous 10% povidone-iodine (7% SSI rate) or aqueous 4% chlorhexidine gluconate (7% SSI rate) for skin antisepsis. On the basis of this study, hand surgeons treating open extremity fractures may choose either povidone-iodine or chlorhexidine for skin preparation without significant effects on SSI rates. Amanda R. Sergesketter, MD Duke University Hospital Durham, NC