PRS Journal Club: Trends in Planning, Placement, and Prophylaxis

Substantial innovations have been made in breast pedicle designs and breast implant manufacturing. Nevertheless, core principles in procedural planning remain key to ensuring optimal outcomes. Similarly, thromboembolic risk assessments have been standardized for decades, yet slight adjustments in utilization of prophylactic medications in the current era continue to be made and require evidence for safety. The articles reviewed in this month’s PRS Journal Club highlight the importance of an objective determination of the breast meridian, the benefits of direct-to-implant (DTI) breast reconstruction in the prepectoral plane, and the safety of direct oral anticoagulants after body-contouring procedures. Breast reduction and mastopexy procedures rely on an accurate meridian marking to ensure optimal nipple placement. Previous historic studies have sought to determine ideal breast dimensions.1–3 The vertical position of the nipple has been demonstrated to be an upper pole to lower pole ratio of 45:55,4 but the horizontal position of the nipple continues to be debated. Although studies have suggested that a slightly lateral nipple position is ideal,5,6 no standardized guideline has been universally adopted for the optimal horizontal position of the nipple relative to body dimensions. In the first March Journal Club article, “Simplifying Breast Reduction: An Effective Approach to Defining the Ideal Breast Meridian,” Kim et al.7 determined that the center of the nipple is ideally 11% of the underbust circumference. DTI breast reconstruction after mastectomy has been demonstrated to be safe in select patient populations,8–10 but studies that directly compare prepectoral DTI with prepectoral 2-stage reconstruction are limited. In the second March Journal Club article, “A Closer Look at Prepectoral Implant-Based Breast Reconstruction: A Matched-Pair Comparison of Direct-to-Implant versus Two-Stage Outcomes,” Amro et al.11 utilized propensity matching to retrospectively compare these 2 cohorts and achieved similar preoperative variables. They found that prepectoral 2-stage and DTI reconstruction have similar risk profiles, but DTI may be more beneficial in the correctly identified patient. Prepectoral 2-stage reconstruction is associated with higher rates of seromas and surgical-site complications compared with DTI reconstruction. Although seromas are also the most common complication after abdominoplasty, these procedures carry a higher risk of venous thromboembolism (VTE) events due to several factors, such as rectus plication increasing intra-abdominal pressure and, thereby, decreasing lower extremity venous return.12,13 Low-molecular-weight heparin has been shown to reduce postoperative thrombotic complication rates in excisional body-contouring surgery,14 and society task force statements advocate for VTE risk stratification,15 yet it remains unknown which anticoagulation protocol is best. In addition, several surgeons remain apprehensive about the use of anticoagulants given the potential risks of postoperative bleeding complications after these procedures. In the third March Journal Club article, “Apixaban (Eliquis) for Venous Thromboembolic Prophylaxis following Abdominoplasty: Establishing a Safety and Efficacy Profile,” Bricker et al.16 demonstrate that apixaban is a safe and effective alternative to enoxaparin for VTE prophylaxis after abdominoplasty. Additional studies will be needed to compare the efficacy of low-molecular-weight heparin with that of factor Xa inhibitors. In conclusion, the articles discussed in this month’s PRS Journal Club provide data-driven determination of fundamental geometric principles in plastic surgery, emphasize a more streamlined approach for prepectoral breast reconstruction after mastectomy, and provide an opportunity for novel anticoagulation regimens that may be more convenient for patient compliance. DISCLOSURE The authors have no financial or nonfinancial conflicts of interest to disclose.