Tran, Nho V.

Background: Subpectoral tissue expander breast reconstruction is often associated with muscle spasms, pain, and discomfort during tissue expansion. In this study, we hypothesized that an intraoperative injection of botulinum toxin A (BTX-A) in the pectoralis major muscle reduces the pain associated with tissue expansion and improves women’s physical well-being. Methods: Between May 2012 and May 2017, women undergoing immediate subpectoral tissue expander breast reconstruction were randomized to administer 100 units of BTX-A or a placebo injection. A numeric pain intensity scale and the physical well-being scale of the BREAST-Q: Reconstruction Module were used to test our hypothesis. Data on postoperative oral narcotic consumption were not collected. Results: Of the 131 women included in the analysis, 48% were randomized to placebo and 52% to BTX-A. The preoperative median pain intensity score was 0 [interquartile range (IQR), 0–1], and the median preoperative BREAST-Q score was 91 (IQR, 81–100). The median slopes for the change in pain intensity scores from baseline throughout tissue expansion for those randomized to placebo and BTX-A were −0.01 (IQR, −0.02 to 0.00) and −0.01 (IQR, −0.02 to 0.00), respectively (P = 0.55). The median slopes for the change in BREAST-Q scores from baseline throughout tissue expansion for those randomized to placebo and BTX-A were 0.04 (IQR, −0.17 to 0.14) and 0.02 (IQR, −0.06 to 0.13), respectively (P = 0.89). Conclusion: In this study, we found that an intraoperative intramuscular injection of 100 units of BTX-A in the pectoralis major muscle did not reduce postoperative pain and patient-reported physical well-being when compared with placebo.

AbstractBackgroundTranexamic acid (TXA) has gained increasing recognition in plastic surgery as a dependable adjunct capable of minimizing blood loss, ecchymosis, and edema. To date, there have been limited data on the utilization of TXA to mitigate liposuction donor site ecchymosis.ObjectivesThe authors sought to investigate whether infiltration of TXA into liposuction donor sites safely reduces postoperative ecchymosis.MethodsA single-surgeon retrospective cohort study was performed to analyze patients undergoing autologous fat transfer for breast reconstruction between 2016 and 2019. Following lipoaspiration, patients in the intervention group received 75 mL of TXA (3 g in NaCl 0.9%) infiltrated into the liposuction donor sites, whereas the historical controls did not. Patient demographics, degree of ecchymosis, surgical complications, and thromboembolic events were examined. A blinded assessment of postoperative photographs of the donor sites was performed.ResultsOverall, 120 autologous fat grafting procedures were reviewed. Sixty patients received TXA, whereas 60 patients did not. Patient demographics and comorbidities were similar among the groups. No difference existed between groups regarding donor site locations, tumescent volume, lipoaspirate volume, or time to postoperative photograph. Ten blinded evaluators completed the assessment. The median bruising score of patients who received TXA was significantly lower than that of patients who did not (1.6/10 vs 2.3/10, P = 0.01). Postoperative complications were similar among the groups. Adverse effects of TXA were not observed.ConclusionsPatients who received local infiltration of TXA into the liposuction donor sites were found to have less donor site ecchymosis than patients who did not. Further prospective randomized studies are warranted.Level of Evidence: 4

Background: Antifibrinolytic medications, such as tranexamic acid, have recently garnered increased attention. Despite its ability to mitigate intraoperative blood loss and need for blood transfusion, there remains a paucity of research in breast reconstruction. The authors investigate whether intravenous tranexamic acid safely reduces the risk of hematoma following implant-based breast reconstruction. Methods: A single-center retrospective cohort study was performed to analyze all consecutive patients undergoing immediate two-stage implant-based breast reconstruction following mastectomy between 2015 and 2016. The incidence of postoperative hematomas and thromboembolic events among all patients was reviewed. The patients in the intervention group received 1000 mg of intravenous tranexamic acid before mastectomy incision and 1000 mg at the conclusion of the procedure. Fisher’s exact test and the Mann-Whitney-Wilcoxon test were used. Multivariate logistic regression models were performed to study the impact of intravenous tranexamic acid after adjusting for possible confounders. Results: A total of 868 consecutive breast reconstructions (499 women) were reviewed. Overall, 116 patients (217 breasts) received intravenous tranexamic acid, whereas 383 patients (651 breasts) did not. Patient characteristics and comorbidities were similar between the two the groups. Patients who received tranexamic acid were less likely to develop hematomas [n = 1 (0.46 percent)] than patients who did not [n = 19 (2.9 percent)] after controlling for age, hypertension, and type of reconstruction (prepectoral and subpectoral) (p = 0.018). Adverse effects of intravenous tranexamic acid, including thromboembolic phenomena were not observed. Multivariate analysis demonstrated that age and hypertension independently increase risk for hematoma. Conclusions: Intravenous tranexamic acid safely reduces risk of hematoma in implant-based breast reconstruction. Further prospective randomized studies are warranted to further corroborate these findings. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Background The journal impact factor (IF) is one of the most widely adopted metrics to assess journal value. We aimed to investigate the trends in the IF and ranking of plastic surgery journals (PSJs) over a 22-year period. Methods The Journal Citation Report 2018 was used to identify all journals within the field of plastic surgery from 1997 to 2018. We analyzed the IF of PSJs and that of the category surgery. Results A total of 34 PSJs were identified. The mean IF increased from 0.584 (median, 0.533) in 1997 to 1.58 (median, 1.399) in 2018 (P < 0.0001). Over the same time, the median IF of the journals in the category surgery increased from 0.914 to 1.883. The mean journal IF percentile of PSJs within surgery remained fairly stable (P = 0.999). A strong positive correlation was identified between the IF of PSJs and both the 5-year IF (r = 0.943, P < 0.0001) and the immediacy index (r = 0.736, P < 0.0001). The percentage of self-citations across the study period was fairly stable at a mean of 19.2%. A weak positive correlation was found between the IF and the percentage of self-citations (r = 0.171, P < 0.0001). Conclusions The mean journal IF in PSJs has been trending upward over the last 22 years. Ranking of PSJs IF within the category surgery has remained unchanged. The self-citation rate has been fairly stable and correlated weakly with the IF. A strong positive correlation exists between the IF and both the immediacy index and the 5-year IF.

Abstract Background Altmetrics (alternative metrics) have become one of the most commonly utilized metrics to track the impact of research articles across electronic and social media platforms. Objectives The goal of this study was to identify whether the Altmetric Attention Score (AAS) is a good proxy for citation counts and whether it can be employed as an accurate measure to complement the current gold standard. Methods The authors conducted a citation analysis of all articles published in 6 plastic surgery journals during the 2016 calendar year. Citation counts and AAS were abstracted and analyzed. Results A total of 1420 articles were identified. The mean AAS was 11 and the median AAS was 1. The journal with the highest mean AAS was Aesthetic Surgery Journal (31), followed by Plastic and Reconstructive Surgery (19). A weak positive correlation was identified (r = 0.33, P &lt; .0001) between AAS and citations. Articles in the top 1% in terms of citation counts showed strong positive correlation between AAS and citation counts (r = 0.64, P = .01). On the contrary, articles in the top 1% of AAS had no significant correlation with citation counts (r = −0.31, P = .29). Conclusions Overall correlation between citations and AAS was weak, and therefor AAS may not be an accurate early predictor of future citations. The 2 metrics seem to measure different aspects of the impact of scholarly work and should be utilized in tandem for determining the reach of a scientific article.

Summary:Most magnetic resonance lymphangiography techniques employ intravenous gadolinium-based contrast agents, which carry a US Food and Drug Administration warning about gadolinium retention in the body when used intravenously. Because of this, there may be reluctance to perform intradermal injections of gadolinium-based contrast agents in patients with obstructed lymphatic drainage due to concerns about gadolinium retention in the skin and soft tissues and potential-related toxicity. The aim of this study was to show proof of concept of 2 preoperative lymphangiographic techniques that do not use gadolinium-based contrast agents. One technique used contrast-enhanced ultrasound with intradermal injections of microbubbles (Lumason) in a patient with stage 3, nonpitting left upper extremity edema. Another technique used magnetic resonance imaging with intradermal injections of 0.03 mg/mL or 0.003% ferumoxytol (Feraheme) in a patient with stage 3, nonpitting right lower extremity edema. Both contrast-enhanced ultrasound with microbubbles and magnetic resonance lymphangiogram with ferumoxytol were able to identify candidates for lymphovenous bypass surgery. These candidates were not identified by conventional indocyanine green injections. The authors conclude that (1) low-dose ferumoxytol is a potentially effective non-gadolinium–based contrast alternative to gadolinium-based contrast agent in magnetic resonance lymphangiography and (2) contrast-enhanced ultrasound can identify candidate lymphatic vessels for anastomosis.