Background:Randomized controlled trials (RCTs) are integral to the progress of evidenced-based medicine and help guide changes in the standards of care. Although results are traditionally evaluated according to their corresponding P value, the universal utility of this statistical metric has been called into question. The fragility index (FI) has been developed as an adjunct method to provide additional statistical perspective. In this study, we aimed to determine the fragility of 25 highly cited RCTs in the plastic surgery literature.Methods:A PubMed search was used to identify the 25 highest cited RCTs with statistically significant dichotomous outcomes across 24 plastic surgery journals. Article characteristics were extracted, and the FI of each article was calculated. Additionally, Altmetric scores were determined for each study to determine article attention across internet platforms.Results:The median FI score across included studies was 4 (2-7.5, interquartile range). The two highest FI scores were 208 and 58, respectively. Four studies (16%) had scores of 0 or 1. Three studies (12%) had scores of 2. All other studies (72%) had FI scores of 3 or higher. The median Altmetric score was 0 (0-3).Conclusion:The FI can provide additional perspective on the robustness of study results, but like the P value, it should be interpreted in the greater context of other study elements.

PURPOSE: Targeted botulinum neurotoxin A (Botox) injections and peripheral nerve blocks are frequently used to diagnose headache trigger points amenable to surgery. However, a direct comparison between the two has yet to be thoroughly explored. This study directly compares the diagnostic accuracy of peripheral nerve blocks vs. Botox for identification of headache trigger points. METHODS: A retrospective chart review was performed on all patients who received diagnostic targeted Botox and/or peripheral nerve blocks who subsequently underwent headache surgery. Pertinent patient demographics, pain location, injection outcomes, and surgical outcomes (determined by a ≥50% reduction in headache characteristics) were collected. Measures of diagnostic accuracy were calculated, and the Fisher's exact test was used to compare sensitivities across modalities. RESULTS: Forty-seven patients undergoing 87 surgeries met inclusion criteria. While 96% of all patients had a ≥50% reduction in headache characteristics, the proportion of patients achieving this was not significantly different across the Botox or block groups (97% vs. 94%,respectively;p>0.05). Further, nerve block injections exhibited a higher sensitivity than Botox, although this was not significant (79.17%, 68.2%; p= 0.508). Notably, among paired data, Botox injections had a higher PPV compared to the nerve blocks (92% vs 83%, respectively). CONCLUSION: Both targeted Botox injections and peripheral nerve blocks have enabled reliable detection of trigger points. Although Botox demonstrated a higher PPV than blocks, blocks have faster onset, reduced cost, and reduced visits needed for detection of trigger points. Considering both groups have comparable sensitivities, surgeon selection of either diagnostic modality is supported by this evidence.

Background: Venous thromboembolism (VTE) is a dangerous postoperative complication after abdominal wall reconstruction (AWR). Intraoperative core body temperature has been associated with thrombotic events in other surgical contexts. This study examines the effects of intraoperative temperature on VTE rate after AWR. Methods: A retrospective study was performed on AWR patients. Cohorts were defined by postoperative 30-day VTE. Intraoperative core body temperature was recorded as the minimum, maximum, and mean intraoperative temperatures. Study variables were analyzed with logistic regression and cutoff analysis to assess for association with VTE. Results: In total, 344 patients met inclusion criteria. Fourteen patients were diagnosed with 30-day VTE for an incidence of 4.1%. The VTE cohort had a longer median inpatient stay (8 days versus 5 days, P < 0.001) and greater intraoperative change in peak inspiratory pressure (3 mm H2O versus 1 mm H2O, P = 0.01) than the non-VTE cohort. Operative duration [odds ratio (OR) = 1.32, P = 0.01], length of stay (OR = 1.07, P = 0.001), and intraoperative PIP difference (OR = 1.18, P = 0.045) were significantly associated with 30-day VTE on univariable regression. Immunocompromised status (OR = 4.1, P = 0.023; OR = 4.0, P = 0.025) and length of stay (OR = 1.1, P < 0.001; OR = 1.1, P < 0.001) were significant predictors of 30-day VTE on two multivariable regression models. No significant associations were found between temperature metrics and 30-day VTE on cutoff point or regression analysis. Conclusions: Intraoperative core body temperature did not associate with 30-day VTE after AWR, though operative duration, length of stay, immunocompromised status, and intraoperative PIP difference did. Surgeons should remain mindful of VTE risk after AWR, and future research is warranted to elucidate all contributing factors.

We sought to assess the current literature to present a comprehensive summary of the incidence, common pathogens, and risk factors for infection after anterior cruciate ligament (ACL) reconstruction. PubMed, CINAHL, EMBASE, and Scopus databases were searched for relevant studies reporting on infection after ACL reconstruction. Two reviewers independently screened the extracted studies for adherence to inclusion and exclusion criteria. Studies were selected if they reported on the incidence of infection, pathogens cultured from infected knees, or risk factors for infection after primary ACL reconstruction. Exclusion criteria consisted of studies with fewer than 100 patients or studies that included revision ACL reconstruction. Fifty studies met the inclusion and exclusion criteria, reporting on a total of 316,214 ACL reconstructions. Included studies evaluated between 123 and 104,255 patients. The overall incidence of infection was 0.60% (0.15-2.44%). The most common pathogens were Staphylococcus aureus, S. epidermidis, and coagulase-negative Staphylococci. Five studies reported that the use of hamstring autograft was a statistically significant risk factor for infection after ACL reconstruction, thus making hamstring autograft the most commonly reported risk factor. Other reported risk factors included male sex, use of immuno-suppressive medications or intraarticular steroid injections, prior knee surgery, and diabetes. Systematic review of the literature revealed that infection after ACL reconstruction remains an infrequent event with an incidence of 0.60% (0.15-2.44%). Furthermore, the most common pathogens are from the Staphylococcus genus of bacteria, comprising 84% of all culture-positive infections. Multiple risk factors have been reported for ACL reconstruction; however, statistical significance varied across studies. Together, these findings may help guide physicians in the prevention and treatment of infection after ACL reconstruction.

Background: Trigger point deactivation surgery is a safe and effective treatment for properly selected patients experiencing migraine, with 68.3%-100% experiencing symptom improvement postoperatively. However, it is still unknown why certain patients do not respond. Obesity has been shown to be associated with worsened migraine symptoms and a decreased response to select pharmacotherapies. This study aimed to determine whether obesity may also be associated with an attenuated response to surgery. Methods: A retrospective chart review was conducted to identify patients who had undergone trigger point deactivation surgery for migraine. Patients were split into obese and nonobese cohorts. Obesity was classified as a body mass index of 30 or higher per Centers for Disease Control and Prevention guidelines. Outcomes and follow-up periods were determined with respect to individual operations. Outcomes included migraine attack frequency, intensity, duration, and the migraine headache index. Differences in demographics, operative characteristics, and operative outcomes were compared. Results: A total of 62 patients were included in the study. The obese cohort comprised 31 patients who underwent 45 total operations, and the nonobese cohort comprised 31 patients who underwent 34 operations. Results from multivariable analysis showed no impact of obesity on the odds of achieving a more than 90% reduction in any individual outcome. The overall rates of improvement (>= 50% reduction in any outcome) and elimination (100% reduction in all symptoms) across both cohorts were 89.9% and 65.8%, respectively. Conclusion: Obese patients have outcomes comparable to a nonobese cohort after trigger point deactivation surgery for migraine.

We hypothesize that larger prior tunnel size is associated with an increased risk of failure of single-stage revision anterior cruciate ligament reconstruction (ACLR) as defined by the performance of a re-revision (third) ACLR on the index knee. Retrospective review identified 244 patients who underwent single-stage revision ACLR at a single center with available preoperative radiographs. Patient and surgical factors were extracted by chart review. The maximum diameter of the tibial tunnel was measured on lateral radiographs and the maximum diameter of the femoral tunnel was measured on anteroposterior radiographs. Record review and follow-up phone calls were used to identify failure of the revision surgery as defined by re-revision ACLR on the index knee. One hundred and seventy-one patients (70%) were reviewed with a mean of 3.9 years follow-up. Overall, 23 patients (13.4%) underwent re-revision surgery. Mean tibial tunnel size was 12.6 +/- 2.8 mm (range: 5.7-26.9 mm) and mean femoral tunnel size was 11.7 +/- 2.8 mm (range: 6.0-23.0 mm). Re-revision risk increased with tibial tunnel size. Tibial tunnels 11 mm and under had a re-revision risk of 4.2%, while tunnels > 11 mm had a risk of 17.1% (relative risk: 4.1, p = 0.025). No significant association between femoral tunnel size and re-revision risk was noted. Patients with prior tibial tunnels > 11mm in diameter at revision surgery had significantly increased risk of re-revision ACLR. Further studies are needed to explore the relationship between prior tunnel size and outcomes of revision ACLR.

BACKGROUND: Head and neck lymphedema (HNL) after head and neck cancer treatment can significantly impact patient quality of life by causing difficulty with swallowing and speech, increasing cost of treatment, leading to facial disfiguration, and decreasing psychosocial wellness. Currently, The M. D. Anderson Cancer Center (MDACC) HNL evaluation protocol is the most commonly used to tool to evaluate the severity and status of head and neck lymphedema by utilizing a series of face and neck tape measurements. However, there is no gold standard assessment tool that reliably and consistently measures HNL despite over 35 assessment tools having been reported in the literature to date. With the continued integration of advanced technology in medicine, three-dimensional (3D) imaging has shown that it's an effective and reliable tool to assess volume changes. Therefore, we studied the efficacy of 3D imaging as a novel method of tracking changes in head and neck volume in patients with head and neck lymphedema. The aim of this study was to compare changes in 3D measurements against traditional MDACC protocol tape measurements. METHODS: Patients undergoing treatment for head and neck cancer were prospectively enrolled, and 3dMD images were captured at the initial and each subsequent appointment. The MDACC protocol was also used to obtain a composite bilateral hemifacial score from the sum of all facial tape measurements at each appointment. Additionally, the MDACC rating scale was used to determine the degree of lymphedema. Following study completion, the changes in 3dMD imaging measurements and bilateral hemifacial scores from first to last visit were compared for each patient. Pearson's correlation coefficients were used to assess the strength and direction of the relationship between the two measures. RESULTS: A total of 230 patients were included in the study. The mean age at time of first visit was 61.5 ± 9.4 (SD) years. Most primary cancers originated from the oropharynx (35%), oral cavity (26%), or larynx (17%), with the remaining 22% originating in other locations. 31% of patients received radiotherapy, 8% received surgery, and 61% received both radiotherapy and surgery. 20% of patients were categorized as level 1a lymphedema, 71% as 1b, and 9% as level 2. The median time from first visit to last visit was 3.3 months (2.1-5.8, interquartile range). The average changes in lymphedema measurements were 1.9 ± 25.8 using 3dMD scans and -1 ± 5.2 using the MDACC protocol. The Pearson correlation coefficient for these two variables was 0.207 (p =.002), indicating that there is a low, positive correlation between tape and 3D measurements. CONCLUSIONS: Use of 3D imaging for volume measurement in head and neck lymphedema has not been previously studied. Our study demonstrates that while traditional tape measurement is frequently used to measure HNL, efficacy and accuracy are low. The reliability and accuracy of 3D volume measurement has been validated in other studies, and we believe it is an effective tool in evaluating head and neck lymphedema.

Summary:. This practical review critically evaluates the evidence behind the widespread use of postoperative compression therapy intended to improve surgical outcomes, such as reduced edema, ecchymosis, pain, and seroma formation. A literature search of PubMed was conducted to identify relevant studies concerning the use of compression garments after aesthetic surgery, including rhinoplasty, facelift, neck lift, mammoplasty, abdominoplasty, limb contouring, and others. Additionally, reconstructive and therapeutic procedures closely related in anatomy or technique to these cosmetic operations, such as breast reconstruction, mastectomy, and hernia repair, were also considered to provide further perspective. After study extraction, the volume, quality, and agreement of the evidence found was highly heterogenous depending on the context of specific operations and outcomes evaluated. The most well-supported indications for the use of postoperative compression garments are to mitigate edema and ecchymosis after rhinoplasty and to reduce postoperative pain after breast and abdominal procedures, although no effect on seroma rate was demonstrated. Any potential benefit must be balanced against the associated costs and possible complications of compression, including patient discomfort, increased venous stasis, and skin defects. Thus, we encourage surgeons to critically reassess their use of compression garments. In many settings, such as brachioplasty, there is limited high-quality evidence to inform best practice, and we urge the community to continue researching this important topic so that more definitive and comprehensive guidelines may be established.

BACKGROUND:Elevated posterior tibial slope (PTS) has been identified as an important risk factor in anterior cruciate ligament (ACL) injuries and ACL graft failures. The cutoff value to recommend treatment with slope-reducing osteotomy remains unclear and is based on expert opinion and small case series.PURPOSE:(1) To determine whether there is a difference in PTS shown on lateral knee radiographs and magnetic resonance imaging (MRI) scans in a group of patients who experienced revision ACL graft failure versus a control group of patients who underwent successful revision ACL reconstruction, (2) to identify cutoff values of PTS measurements that predict risk of revision ACL graft failure, and (3) to examine whether there is a correlation between radiographic and MRI measurements of PTS.STUDY DESIGN:Case-control study; Level of evidence, 3.METHODS:A total of 38 patients who experienced revision ACL graft failure were identified from a revision ACL database. These patients were matched 1:1 by age, sex, and graft type to a group of 38 control patients who underwent revision ACL reconstruction with no evidence of graft failure at a minimum 2 years of follow-up. Medial and lateral PTS were measured by lateral knee radiographs and MRI scans of the affected limb. Demographics, surgical characteristics, and PTS were compared between the groups. The optimal cutoff values of medial and lateral PTS per radiographs and MRI scans for predicting increased risk of revision ACL graft failure were determined by receiver operating characteristic curves. Conditional multivariable logistic regression was used to assess the relative contribution of PTS cutoff values as a predictor of revision graft failure.RESULTS:The mean PTS values in the failure group were significantly higher than those in the control group on radiographs (medial, 13.2°± 2.9° vs 10.3°± 2.9°; P < .001; lateral, 12.9°± 3.0° vs 9.8°± 2.8°; P < .001) and MRI scans (medial, 7.2°± 3.1° vs 4.8°± 2.9°; P < .001; lateral, 8.4 ± 3.1° vs 5.9 ± 3.0°; P < .001). A radiographic medial PTS ≥14° had the highest increased risk of revision ACL graft failure with sensitivity equal to 50% and specificity to 92.1% (odds ratio, 18.71; 95% CI, 2.0-174.9; P = .01).CONCLUSION:Elevated PTS was a significant risk factor for revision ACL graft failure. Patients with radiographic medial PTS ≥14° had 18.7-times increased risk of revision ACL failure.

Purpose To evaluate the association of posterior tibial slope (PTS) with anterior cruciate ligament (ACL) reinjury following primary ACL reconstruction. Methods PubMed, Scopus, Embase, and CINAHL databases were searched from inception through March 1, 2021, to retrieve relevant studies. Comparative studies reporting PTS measurements in a cohort of patients experiencing ACL graft failure versus patients with intact primary ACL reconstruction or studies comparing patients undergoing revision ACL reconstruction versus primary ACL reconstruction were included for analysis. A random-effects model was used to calculate the overall standardized mean difference (SMD) between groups. The following inclusion criteria were used: English language; full text available; Level I, II, or III evidence; studies in humans; and skeletally mature patients. Results After we systematically screened 1,912 studies, 15 studies met the inclusion/exclusion criteria. Radiographic measurements were used in 6 studies reporting medial PTS in 411 ACL failures versus 2808 controls. Patients with ACL failure had significantly greater medial PTS compared with controls (SMD 0.50; 95% confidence interval [CI] 0.23-0.77; P < .001). Magnetic resonance imaging (MRI) was used in 9 studies reporting lateral PTS measurements in 641 patients with a failed ACL reconstruction compared with 705 controls. Seven of the MRI studies also measured medial PTS in 552 failures versus 641 controls. Patients with ACL failure had significantly greater lateral PTS on MRI (SMD 0.58; 95% CI 0.13-1.03; P = .012) and medial PTS on MRI (SMD 0.59; 95% CI 0.23-0.96; P = .001) compared with controls. Conclusions The present meta-analysis demonstrated that patients with elevated PTS on radiographs and MRI are at increased risk for ACL graft failure after primary ACL reconstruction. Level of Evidence Level III, meta-analysis of Level III studies.

Migraine headaches and obesity are both prevalent disorders, resulting in a high socioeconomic burden. To better understand the relationship between obesity and migraine, the aim of this study was to investigate the association between migraine severity, metabolic syndrome and estrogen-associated variables.A retrospective analysis of adult patients with refractory migraine seen by our senior author (J.E.J.) was performed. Patient demographics and migraine char-acteristics, including migraine intensity, duration, and number of headaches per month were collected from medical records. Migraine headache index (MHI) was calculated by multiplying frequency, intensity and duration of headaches. Weight and height were used to calculate body mass index (BMI) and these were divided per Center for Disease Control (CDC) classifications. Univariate linear regression models were used to evaluate associations.Patients (n = 223) were predominantly female (78%) with a mean age of 44 years at presentation. Patients with a BMI higher than 40 (class 3 obesity) had a higher MHI (p = 0.01) and experienced a higher number of migraines per month (p = 0.007), compared to patients with a healthy BMI, respectively. Migraine frequency was found to be significantly higher in post-menopausal women compared to pre-menopausal women (p = 0.02). No other significant associations were found.This study found that severe obesity (BMI > 40) is associated with increased migraine severity and frequency. Post-menopausal patients are also found to have increased migraine frequency, which could be explained by the estrogen-withdrawal hypothesis. Future studies are needed to evaluate the outcomes of individuals with obesity after nerve deactivation surgery.

Background: Case reports provide a salient contribution to the field of plastic surgery through the timely dissemination of knowledge on previously underreported topics. Once a time-honored hallmark of the surgical literature, the perceived value of case reports has decreased with the ongoing prioritization of higher levels of evidence. In this study, we aimed to assess long-term trends in case report publication rates and discuss the continued merits of case reports in the modern-day landscape. Methods: A PubMed search was used to identify articles published in six prominent plastic surgery journals since 1980. Articles were separated as case reports versus all other publication types. The total number of articles published by group was tracked, and citation rates were compared across groups. Additionally, the most cited articles from each journal were identified for both groups. Results: A total of 68,444 articles were included for analysis. In 1980, there were 181 case reports published compared with 413 other articles across all six journals. In 2022, there were 188 case reports published compared with 3343 other articles. When comparing citations per year of case reports versus other article types across all journals since 1980, case reports were found to be cited significantly less frequently (P < 0.001). Conclusions: Case reports have been published and cited less frequently than other types of literature over the last 42 years. However, despite these trends, they have demonstrated significant historical contributions and provide continued value as an impactful forum for highlighting novel clinical entities.

BACKGROUND: Migraine headaches and obesity are both prevalent disorders, resulting in a high socioeconomic burden. To better understand the relationship between obesity and migraine, the aim of this study was to investigate the association between migraine symptomatology, metabolic syndrome and estrogen-associated variables. MATERIALS AND METHODS: A retrospective analysis of adult patients with refractory migraine seen by our senior author was performed. Patient demographics and migraine characteristics, including migraine attack intensity, duration, and number of headaches per month, were collected from medical records. Migraine headache index (MHI) was calculated by multiplying frequency, intensity and duration of headaches. Weight and height were used to calculate body mass index (BMI) and these BMI groups were categorized per Center for Disease Control (CDC) classifications. Univariate linear regression models were used to evaluate associations between migraine characteristics and obesity. RESULTS: A total of 224 patients that presented to migraine clinic were identified. For one patient, baseline migraine characteristics were not available, thus this patient was excluded. Patients (n=223) were predominantly female (78%) with a mean age of 44 years (range of 15-86 years) at presentation. Patients with a BMI higher than 40 (class III obesity) had higher MHI scores (p=0.01) and experienced a higher number of migraine attacks per month (p=0.007), compared to patients with a healthy BMI, respectively. Migraine attack frequency was found to be significantly higher in post-menopausal women compared to pre-menopausal women (p=0.02). No other significant associations were found. CONCLUSIONS: This study found that severe obesity (CDC Class III) is associated with an increased MHI score and migraine attack frequency. Post-menopausal patients are also found to have increased migraine attack frequency, which is explained by the estrogen-withdrawal hypothesis. These findings provide new insights into the association between obesity and migraine headaches and future studies are needed to evaluate the outcomes of individuals with obesity after trigger point deactivation surgery.

PURPOSE: To foster common communication between plastic surgeons and neurologists alike by assessing the effect of trigger site deactivation surgery on monthly migraine days (MMD), the preferred outcome measure of neurologists, compared to outcomes traditionally reported in the plastic surgery literature. METHODS: An updated literature search was performed according to the PRISMA guidelines. The National Library of Medicine (PubMed), Scopus, and EMBASE were systematically searched for relevant articles. Data was extracted and analyzed from studies which met the inclusion criteria. RESULTS: A total of 19 studies were included in this review. There was a significant overall reduction in monthly migraine days (mean difference [MD] 14.11, 95% CI 10.95 to 17.27; I2 = 92%), migraine headache index (MD 76.59, 95% CI 60.85 to 92.32; I2 = 98%), migraine intensity (MD 3.84, 95% CI 3.35 to 4.33; I2 = 98%), and migraine duration (MD 11.80, 95% CI 6.44 to 17.16; I2 = 99%) at follow-up (range 6-38 months). CONCLUSION: This study demonstrates the efficacy of trigger site deactivation surgery on outcomes reported by both the plastic surgery and neurology communities. We hope this will open a common conversation and lead to optimized management for treatment-refractory migraine patients.

PURPOSE: Migraine headaches are a chronic disease for millions worldwide. Metabolic syndrome including obesity and hypertension are hypothesized to be linked to an increased prevalence of migraine and to an increased migraine attack frequency. The aim of this study was to evaluate the association between obesity, menopausal status and migraine characteristics. METHODS: In this retrospective chart review, data from medical records between July 2013-July 2022 of patients who presented with migraine headache at the plastic and reconstructive surgery department at The Ohio State University were reviewed. Demographic data, body mass index (BMI) and blood pressure were recorded. Migraine headache characteristics were extracted and the migraine headache index (MHI) was calculated. The MHI was calculated by multiplying frequency, duration and intensity of migraine headaches. Univariate linear regression models were used to evaluate the associations between measures of migraine, metabolic syndrome and menopausal status. RESULTS: A total of 211 patients with migraine headaches were identified. Seventy-eight percent were female and 22% were male, with an average age of 44.6±12.8 years (average ± SD). Center for Disease Control and Prevention (CDC) classification of BMI was used. Higher MHI and number of headaches per month were significantly associated with class 3 obesity (BMI >40, p<0.01), but not with other BMI classes (p>0.05). Intensity and duration of headaches were not associated with BMI, respectively (p>0.05). Postmenopausal status was associated with a significantly lower number of migraines per month (p=0.02). Hypertension was not associated with migraine characteristics (p>0.05). CONCLUSION: A higher BMI is associated with increased MHI and frequency of migraines, but not with the intensity and duration of headaches experienced. Furthermore, number of headaches decreased after menopause. As fat mass increases in obesity, aromatase expression and consequently estrogen levels are also elevated, which impacts migraine headaches. Moreover, higher BMI may also impact compression neuropathy. These findings provide new insights into the association between obesity and migraine headaches. Future multicenter studies are needed to explore these associations in a larger group of patients.

PURPOSE: Metabolic syndrome is hypothesized to be linked to an increased prevalence and attack frequency of migraine headaches. The aim of this study was to evaluate the association between obesity and migraine characteristics. METHODS: A retrospective chart review was performed between 2015-2022. Demographic data, body mass index (BMI, classified per CDC obesity categories) and migraine characteristics, including migraine headache index (MHI, calculated by multiplying frequency, intensity and duration of headaches) of patients aged ≥18 years were recorded. Univariate linear regression models were used to evaluate the associations between measures of migraine severity and obesity. RESULTS: A total of 212 patients with migraine headaches were identified. Seventy-eight percent was female and 22% was male, with an average age of 44.6±12.7 years (average±SD). Higher MHI and number of headaches per month were significantly associated with class 3 obesity (BMI >40, p=0.009), but not with other BMI classes (p>0.05). Intensity and duration of headaches were not associated with severity or number of headaches, respectively. Postmenopausal status was associated with a significantly lower number of migraines per month (p=0.02). CONCLUSION: A higher BMI is associated with increased severity (i.e. MHI) and frequency of migraines, but not with the intensity and duration of headaches experienced. Furthermore, number of headaches decreased after menopause. As fat mass increases in obesity, aromatase expression and consequently estrogen levels are also elevated. Moreover, it is believed that a higher BMI increases entrapment neuropathy. These findings provide new insights into the association between obesity and migraine headaches.

Background: Xanthelasma palpebrarum is the most common type of xanthomatous lesion. Various methods for treating Xanthelasma palpebrarum have been reported. We conducted a systematic review to evaluate the efficacy and associated complications of different treatment methods, and we summarized these findings as a practical review designed to be clinically useful, accessible, and impactful. Methods: The PubMed and Embase databases were searched to identify clinical studies that reported on outcomes and complications of different methods of Xanthelasma treatment. The electronic databases were searched from January 1990 to October 2022. Data on study characteristics, lesion clearance, complications, and recurrences were collected. Results: Forty-nine articles (including 1329 patients) were reviewed. The studies reported on surgical excision, laser modalities, electrosurgical techniques, chemical peeling, cryotherapy, and intralesional injection. The majority of studies were retrospective (69%) and single-arm (84%). Surgical excision combined with blepharoplasty and skin grafts showed excellent outcomes for large Xanthelasma. CO2 and erbium yttrium aluminum garnet (Er:YAG) were the most commonly studied lasers and showed more than 75% improvement in over 90% and 80% of patients, respectively. Comparative studies reported better efficacy for CO2 laser than both Er:YAG laser and 30%–50% trichloroacetic acid. Dyspigmentation was the most encountered complication. Conclusions: Different methods for the treatment of Xanthelasma palpebrarum have been reported in the literature, with moderate to excellent efficacy and safety profiles depending on the size and location of the lesion. Surgery is more appropriate for larger and deeper lesions, whereas laser and electrosurgical techniques can be used in smaller and more superficial contexts. Only a limited number of comparative studies have been conducted, and novel clinical trials are necessary to further augment appropriate treatment selection.

Background: Nerve deactivation surgery for the treatment of migraine has evolved rapidly over the past 2 decades. Studies typically report changes in migraine frequency (attacks/month), attack duration, attack intensity, and their composite score—the Migraine Headache Index—as primary outcomes. However, the neurology literature predominantly reports migraine prophylaxis outcomes as change in monthly migraine days (MMD). The goal of this study was to foster common communication between plastic surgeons and neurologists by assessing the effect of nerve deactivation surgery on MMD and motivating future studies to include MMD in their reported outcomes. Methods: An updated literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The National Library of Medicine (PubMed), Scopus, and Embase were systematically searched for relevant articles. Data were extracted and analyzed from studies that met the inclusion criteria. Results: A total of 19 studies were included. There was a significant overall reduction in MMDs [mean difference (MD), 14.11; 95% CI, 10.95 to 17.27; I2 = 92%], total migraine attacks per month (MD, 8.65; 95% CI, 7.84 to 9.46; I2 = 90%), Migraine Headache Index (MD, 76.59; 95% CI, 60.85 to 92.32; I2 = 98%), migraine attack intensity (MD, 3.84; 95% CI, 3.35 to 4.33; I2 = 98%), and migraine attack duration (MD, 11.80; 95% CI, 6.44 to 17.16; I2 = 99%) at follow-up (range, 6 to 38 months). Conclusion: This study demonstrates the efficacy of nerve deactivation surgery on the outcomes used in both the plastic and reconstructive surgery and neurology literature.

Primary tumors can communicate with the liver to establish a microenvironment that favors metastatic colonization prior to dissemination, forming what is termed the “pre-metastatic niche” (PMN). Through diverse signaling mechanisms, distant malignancies can both influence hepatic cells directly as well as recruit immune cells into the PMN. The result is a set of changes within the hepatic tissue that increase susceptibility of tumor cell invasion and outgrowth upon dissemination. Thus, the PMN offers a novel step in the traditional metastatic cascade that could offer opportunities for clinical intervention. The involved signaling molecules also offer promise as biomarkers. Ultimately, while the existence of the hepatic PMN is well-established, continued research effort and use of innovative models are required to reach a functional knowledge of PMN mechanisms that can be further targeted.