PRS Journal Club: Optimizing Outcomes and Safety across Aesthetic and Reconstructive Operations

Aesthetic and reconstructive plastic surgery has experienced a tremendous growth in new techniques over the last several decades that have enabled the delivery of superior outcomes. The articles discussed in the November 2025 edition of the PRS Journal Club epitomize these advancements. They showcase how established procedures can be optimized for improvement of outcomes, as well as how we can improve the safety of commonly performed operations to decrease the risk of feared complications. In the first article, “Learning Curve for Sensory Preservation after Transgender Mastectomy using Targeted Nipple-Areola Complex Reinnervation with Direct Nerve Coaptation,” Alston et al.1 examine sensory outcomes after use of direct coaptation or nerve allograft reconstruction, as compared with no sensory preservation procedures, in gender-affirming mastectomy. The authors examined several aspects of sensory outcomes and found that patients who received the targeted reinnervation, either with direct coaptation or nerve allograft reconstruction, had improved nipple-areola complex and chest sensation compared with patients who underwent gender-affirming mastectomy without any sensory preservation procedure. Indeed, gender-affirming mastectomy is a widely pursued operation that has been found to greatly affect the quality of life of transgender and nonbinary individuals,2 and the techniques used to perform these operations have continued to be refined to further improve aesthetic outcomes.3 Although the use of the concentric circular technique is an established method of gender-affirming mastectomy that can be used in select patients for a greater chance of retained nipple sensation,4 the use of targeted nipple-areola complex reinnervation with free nipple grafts allows for potential sensory preservation in patients receiving the more widely performed double-incision gender-affirming mastectomy. These findings have the potential to optimize this sought-after operation, and will serve to further improve surgical outcomes in transgender and nonbinary patients. The second article similarly discusses optimizing outcomes of a widely performed operation by building on established techniques. In “The External Strip and Internal Spreader Graft Combined with Dorsal Preservation Rhinoplasty,” Guncel Öztürk investigates his outcomes after using external strip and internal spreader grafts in patients undergoing dorsal preservation rhinoplasty.5 After retrospectively evaluating outcomes in 152 of his patients, he found that the use of this combination of methods improved dorsal hump and septal deviation deformities, and thus advocates for a hybrid and individualized rhinoplasty approach. Although both structural and preservation rhinoplasty approaches have emerged over the years, there has been a more recent push for a hybrid approach that incorporates aspects of both philosophies to better optimize outcomes in individual patients.6 For instance, although the spreader graft was originally popularized as a technique of structural rhinoplasty,7 rhinoplasty surgeons, including Öztürk, are now investigating the value of incorporating it into preservation rhinoplasty. This can be particularly important to help optimize outcomes in patients who would benefit from the preservation approach to correct a dorsal hump deformity,8 while also benefiting from the midvault support provided by spreader grafts. The third article moves from optimizing outcomes to improving the safety of a similarly widely performed operation. In “Venous Thromboembolism Chemoprophylaxis in Plastic Surgery: A Randomized Controlled Trial of Apixaban versus Enoxaparin,” Momeni et al.9 performed a randomized controlled trial to examine the effects of apixaban, an oral direct factor Xa inhibitor, and enoxaparin for venous thromboembolism (VTE) chemoprophylaxis in high-risk breast cancer patients undergoing autologous breast reconstruction. The authors found that patients who took apixaban had no difference in rare postoperative bleeding events or VTE events, and thus apixaban could be a safe oral alternative to enoxaparin. Although VTE events are a feared complication after autologous breast reconstruction and attributed to numerous factors, including cancer-related hypercoagulability, decreased postoperative ambulation, and lower extremity venous stasis,10 there is an overall trend of underutilization of outpatient VTE chemoprophylaxis and concern for compliance issues in patients prescribed enoxaparin injections.11 Whereas the safety and efficacy of enoxaparin have been studied in high-risk plastic surgery patients,12 oral direct factor Xa inhibitors have been less commonly investigated. This study by Momeni et al. is a meaningful contribution to the literature on VTE chemoprophylaxis, and lays the foundation for providing oral VTE chemoprophylaxis options for high-risk breast reconstruction patients. These 3 articles in the November 2025 edition of the PRS Journal Club highlight the growth of aesthetic and reconstructive plastic surgery. They also emphasize how our field focuses on meticulously improving all aspects of outcomes and ensuring that safety is optimized. These studies will not only serve to improve outcomes but also lay the foundation for future research that will push advancements across plastic surgery even further. DISCLOSURE The authors have no financial interest in any of the products, devices, or drugs mentioned in this article. There were no funding sources for this work.