The latest medical research on Plastic Surgery

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Outcomes of Extracorporeal Septoplasty and Its Modifications in Treatment of Severe L-Strut Septal Deviation: A Systematic Review and Meta-analysis.

JAMA Facial Plastic Surgery

While extracorporeal septoplasty (ECS) and its modifications have been previously studied, to our knowledge, no systematic review of surgical outcomes and complications of this technique has been performed.

To evaluate the evidence of surgical outcomes and complications of ECS (including modified techniques) to treat severe L-strut septal deviation defined as deviation within 1.0 cm of the caudal or dorsal septum.

MEDLINE, Embase, CINAHL, CENTRAL, Scopus, and Web of Science databases and reference lists were searched from inception to April 2018 for clinical and observational studies. Search terms included extracorporeal, septoplasty, and septum.

Selection criteria were defined according to the population, intervention, comparison, and outcome framework. Relevant studies were selected by 2 independent reviewers based on abstracts and full texts.

Data were extracted using standardized lists chosen by the authors according to Cochrane Collaboration guidelines. Data were collected and synthesized with ranges reported, as well as assessment of bias and heterogeneity when applicable. Analysis started in February 2019.

Outcomes assessed included functional nasal airway improvement by objective measurements and subjective measurements (Nasal Obstruction Symptom Evaluation [NOSE] and visual analog scale scores); complications including bleeding, infection, dorsal irregularities, and other functional or cosmetic deficits; and as revision surgery rates.

Of 291 records initially obtained, 31 were considered relevant after review according to PRISMA guidelines. All studies except 1 randomized clinical trial (3.2%) were observational in nature, with 21 retrospective studies (67.7%) and 9 prospective studies (29.0%). Conventional ECS was performed in 16 studies (51.6%), and modified ECS was performed in 15 studies (48.4%). The sample size varied from 10 to 567, and the mean age varied from 22.5 to 46 years. Of 31 studies, 14 (45%) were of good methodology. Meta-analysis was performed on 5 studies reporting change in NOSE scores, with pooled effect of -60.0 (95% CI, -67.8 to -52.2) points, but heterogeneity was high, with I2 = 96%. When comparing complications between modified and conventional ECS, the relative risk for infections was 0.95 (95% CI, 0.34-2.7); for bleeding, 0; for nasal dorsal irregularities, 0.29 (95% CI, 0.16-0.53); for other cosmetic complications, 4.3 (95% CI, 0.87-21.1); for other functional complications, 0.47 (95% CI, 0.20-1.1); and for revision operations, 1.4 (95% CI, 0.83-2.3).

Of the 31 studies included in this systematic review, less than half were of good methodology, and a significant level of heterogeneity was found regarding type of outcome measure used and reporting of complications. To improve the level of evidence, better study methodology, standardization of surgical outcomes measures, and reporting of complications are needed.

Investigation of the Longevity of the Endoscopic Midface Lift.

JAMA Facial Plastic Surgery

To our knowledge, until now, the efficacy and durability of the transtemporal endoscopic preperiosteal midface lift has not been reported in the literature.

To determine the efficacy and longevity of the endoscopic preperiosteal midface lift using objective measurements and validated aesthetic scales.

This retrospective review included patients 18 years or older who were treated for aging midface by endoscopic midface lift by the senior author (A.E.W.) between June 2000 and August 2016. Patients were categorized based on length of follow-up into 3 groups: (1) short-term (1-3 years), (2) intermediate-term (3-5 years), and (3) long-term (>5 years).

Endoscopic preperiosteal midface lift.

(1) Objective measurements of midfacial height (the width of the interzygomatic distance of the midface to the medial canthus [WIZDOM-MC]), (2) validated regional aesthetic scales, and (3) global aesthetic scoring systems measured preoperatively, 3 to 6 months postoperatively, and at the most recent follow-up visit.

Adult patients 18 years or older (median [range] age, 59 [31-79] years) who were treated for aging midface by undergoing an endoscopic midface lift were included in this study. The medical records of 143 patients were reviewed (135 women and 8 men). The endoscopic midface lift resulted in objective improvement in midfacial height. The median WIZDOM-MC decreased by 3.4 mm after the endoscopic midface lift (interquartile range [IQR], 2.3-4.4 mm; P < .001), thus shortening the elongated lower eyelid. At 5 to 15 years after surgery, there was a sustained decrease in median WIZDOM-MC of 2.1 mm (IQR, 0.8-3.1 mm; P < .001). Improvement in the infraorbital hollow was also sustained in patients at more than 5 years' follow-up (IQR, 0-1.0; P < .001). Improvements in upper cheek fullness and lower cheek fullness were maintained at 3 to 5 years and tended to be at baseline at more than 5 years. Global aesthetic improvement scores remained significantly improved at 5 to 15 years' follow-up.

There is a significant, objective improvement in midfacial height after the endoscopic midface lift that persists for up to 15 years. Validated midfacial scales and global aesthetic scoring systems demonstrate sustained improvement in midface appearance over time. Surgery that minimally disrupts the zygomatic and orbicularis retaining ligaments can provide long-lasting aesthetic improvements.


Association of Demographic and Program Factors With American Board of Surgery Qualifying and Certifying Examinations Pass Rates.

JAMA Surgery

American Board of Surgery board certification requires passing both a written qualifying examination and an oral certifying examination. No studies have been conducted assessing the effect of sociodemographic variables on board passage rates.

To evaluate if trainee sociodemographic factors are associated with board passage rates.

This national and multi-institutional prospective observational cohort study of 1048 categorical general surgery trainees starting in 2007-2008 were surveyed. Data collection began in June 2007, follow-up was completed on December 31, 2016, and analysis began September 2018.

Survey responses were linked to American Board of Surgery board passage data.

Of 662 examinees who had complete survey and follow-up data, 443 (65%) were men and 459 (69%) were white, with an overall board passage rate of 87% (n = 578). In a multinomial regression model, trainees of Hispanic ethnicity were more likely to not attempt the examinations (vs passed both) than non-Hispanic trainees (odds ratio [OR], 4.7; 95% CI, 1.5-14). Compared with examinees who were married with children during internship, examinees who were married without children (OR, 0.3; 95% CI, 0.1-0.8) or were single (OR, 0.4; 95% CI, 0.2-0.9) were less likely to fail the examinations. Logistic regression showed white examinees compared with nonwhite examinees (black individuals, Asian individuals, and individuals of other races) (OR, 1.8; 95% CI, 1.03-3.0) and examinees who performed better on their first American Board of Surgery In-Training Examination (OR, 1.03; 95% CI, 1.02-1.05) were more likely to pass the qualifying examination on the first try. White examinees compared with nonwhite examinees (OR, 1.8; 95% CI, 1.1-2.8), non-Hispanic compared with Hispanic examinees (OR, 2.4; 95% CI, 1.2-4.7), and single women compared with women who were married with children during internship (OR, 10.3; 95% CI, 2.1-51) were more likely to pass the certifying examination on the first try.

Resident race, ethnicity, sex, and family status at internship were observed to be associated with board passage rates. There are multiple possible explanations for these worrisome observations that need to be explored. Tracking demographics of trainees to help understand passage rates based on demographics will be important. The American Board of Surgery already has begun addressing the potential for unconscious bias among board examiners by increasing diversity and adding implicit bias training.

Perioperative Outcomes and Trends in the Use of Robotic Colectomy for Medicare Beneficiaries From 2010 Through 2016.

JAMA Surgery

The use of robotic surgery for common operations like colectomy is increasing rapidly in the United States, but evidence for its effectiveness is limited and may not reflect real-world practice.

To evaluate outcomes of and trends in the use of robotic, laparoscopic, and open colectomy across diverse practice settings.

This population-based study of Medicare beneficiaries undergoing elective colectomy was conducted between January 2010 and December 2016. We used an instrumental variable analysis to account for both measured and unmeasured differences in patient characteristics between robotic, open, and laparoscopic colectomy procedures. Data were analyzed from January 21, 2019, to March 1, 2019.

Receipt of robotic colectomy.

Incidence of postoperative medical and surgical complications and length of stay.

A total of 191 292 procedures (23 022 robotic procedures [12.0%], 87 639 open procedures [45.8%], and 80 631 laparoscopic colectomy procedures [42.0%]) were included. Robotic colectomy was associated with a lower adjusted rate of overall complications than open colectomy (17.6% [95% CI, 16.9%-18.2%] vs 18.6% [95% CI, 18.4%-18.7%]; relative risk [RR], 0.94 [95% CI, 0.91-0.98]). This difference was driven by lower rates of medical complications (15.5% [95% CI, 14.8%-16.2%] vs 16.9% [95% CI, 16.7%-17.1%]; RR, 0.92 [95% CI, 0.87-0.96]) because surgical complications were higher with the robotic approach (3.0% [95% CI, 2.8%-3.2%] vs 2.4% [95% CI, 2.3%-2.5%]; RR, 1.18 [95% CI, 1.04-1.35]). There were no differences in complications between robotic and laparoscopic colectomy (11.1% [95% CI, 10.5%-11.6%] vs 11.0% [95% CI, 10.8%-11.2%]; RR, 1.00 [95% CI, 0.95-1.05]). There was an overall shift toward greater proportional use of robotic colectomy from 0.7% (457 of 65 332 patients) in 2010 to 10.9% (8274 of 75 909 patients) in 2016. In hospitals with the highest adoption of robotic colectomy between 2010 and 2016, increasing use of robotic colectomy (0.8% [100 of 12 522 patients] to 32.8% [5416 of 16 511 patients]) was associated with a greater replacement of laparoscopic operations (43.8% [5485 of 12 522 patients] to 25.2% [4161 of 16 511 patients]) than open operations (55.4% [6937 of 12 522 patients] to 41.9% [6918 of 16 511 patients]).

While robotic colectomy was associated with minimal safety benefit over open colectomy and had comparable outcomes with laparoscopic colectomy, population-based trends suggest that it replaced a greater proportion of laparoscopic rather than open colectomy, especially in hospitals with the highest adoption of robotics.

Association of Decreased Postsurgical Opioid Prescribing With Patients' Satisfaction With Surgeons.

JAMA Surgery

Opioid overdose is the leading cause of injury-related death in the United States. Several studies have shown that surgeons overprescribe opioids, and guidelines for appropriate opioid prescribing are available. Concern about patient-reported satisfaction scores may be a barrier to surgeons adopting guideline-directed prescribing.

To determine whether decreased opioid prescribing is associated with a decrease in patient-reported satisfaction with their surgeon.

Retrospective analysis of clinician satisfaction scores at Dartmouth-Hitchcock Medical Center obtained in 2 periods: 1 before (period A) and 1 after (period B) an educational intervention that resulted in decreased opioid prescribing. The analysis included 11 surgeons who performed 5 common outpatient general surgical operations on 996 patients. Data were analyzed between March and August 2018.

Patient-reported overall satisfaction rating of the surgeon (scale, 0-10). This was collected by a nonstudy-related, routine general institutional survey of approximately 40% of all outpatient encounters.

Of the total number of patients, 67% were women (667 of 996), and the mean patient age was 58 years. Comparing period A with B, the proportion of patients prescribed opioids decreased from 90.2% (n = 367 of 407) to 72.8% (n = 429 of 589) (P < .001). The mean number of opioid pills per prescription decreased from 28.3 to 13.3 (P < .001) and significantly decreased for each of the 11 surgeons. One hundred five of 996 patients (10.5%) undergoing index operations responded to the survey. There was no difference in the mean clinician satisfaction ratings from period A vs B (9.70 vs 9.65; P = .69). During the study periods, 640 total surveys were collected referencing these surgeons (including outpatient encounters associated with operations other than the 5 index cases). There was no difference in the mean satisfaction ratings from period A vs period B (9.55 vs 9.59; P = .62). When individual clinicians were analyzed, none had a significant difference in overall satisfaction rating from period A vs period B.

Despite a marked decrease in the proportion of patients receiving opioids and in the number of pills prescribed, there was no significant change in clinician satisfaction ratings.

"Discrepancies Between Registered and Published Primary and Secondary Outcomes in Randomized Controlled Trials Within the Plastic Surgery Literature: A Systematic Review".

Plastic and Reconstructive Surgery

Recent studies have identified a high incidence of discrepancy between registered and published outcomes in registered medical and surgical randomized controlled trials (RCTs). This has not yet been studied in the plastic surgery literature. The goal of this study was to identify the presence and type of discrepancies between plastic surgery RCTs' registered and published primary and secondary outcomes.

The authors systematically assessed plastic surgery RCTs published between 2012-2016, in seven high-impact plastic surgery journals. Data were collected from the registration website and published manuscript using a standardized data extraction form.

One-hundred and forty-five RCTs were identified, with a 39% trial registration rate (57 RCTs). Forty-nine RCTs were included in the final analysis. Forty-three trials (88%) had a discrepancy between registered and published outcomes - 26 trials (53%) for primary outcome(s), and 39 trials (80%) for secondary outcome(s). The number of discrepancies in an individual trial ranged from 1-7 (primary) and 1-12 (secondary). Aesthetic surgery had the largest number of trials with outcome discrepancies (n=15). The prevalence of unreported registered outcomes was 13% (primary) and 38% (secondary). Registered non-significant primary outcomes were published as non-significant secondary outcomes in 30% of trials. Publishing new non-registered secondary outcomes (65%) and changing the assessment timing of published primary outcomes (61%) were the most common types of discrepancies. Discrepancies favored a statistically significant positive outcome in nineteen of the 43 trials with an outcome discrepancy (44%). Discrepancies that resulted in published outcomes with improved patient relevance were found in eight trials (16%) for primary outcome discrepancies and 14 trials (29%) for secondary outcome discrepancies. There were no significant differences in the number of primary and secondary outcome discrepancies between retrospectively and prospectively registered RCTs, years of publication, as well as between unfunded, industry funded, and non-industry funded RCTs.

The plastic surgery literature has high rates of discrepancies between registered and published trial outcomes. Outcome reporting discrepancy is even more problematic for secondary outcomes, an area of analysis that has previously been poorly studied. The high rate of discrepancy change favoring a statistically significant outcome and more patient relevant outcomes may indicate the pressure to demonstrate significant results in order to be accepted for publication in high impact journals.

"Matched Comparison of Microsurgical Anastomoses Performed with Loupes Magnification Versus Operating Microscope in Traumatic Lower Extremity Reconstruction".

Plastic and Reconstructive Surgery

While the surgical microscope remains the most common method for visual magnification for microsurgical anastomoses in free tissue transfer, loupes-only magnification for free flap breast reconstruction has been demonstrated to be safe and effective. In order to evaluate the loupes-only technique in lower extremity free flap reconstruction, we compared perioperative outcomes between microsurgical anastomoses performed with loupes magnification versus a surgical microscope.

Two-institution retrospective study of soft tissue free flaps for traumatic below-knee reconstruction. Optimal subgroup matching was performed using patient age, defect location, flap type (muscle vs. fasciocutaneous), and time from injury (acute <30 days vs. remote >30 days) for conditional logistic regression analysis of perioperative outcomes.

373 flaps met inclusion criteria for direct matched comparison of anastomoses performed with loupes magnification (n=150) versus a surgical microscope (n=223). Overall major complication rates were 15.3%: takeback for vascular compromise 7.8%, partial flap failure 7.8%, and total flap loss 5.4%. No differences were observed between the loupes and microscope groups in regards to major complications (14.0% vs. 16.1%;OR=0.78(0.38-1.59)), takeback for vascular compromise (5.3% vs. 9.4%;OR=0.51(0.19-1.39)), any flap failure (13.3% vs. 13.0%;OR=1.21(0.56-2.64)), partial flap failure (7.3% vs. 8.1%;OR=1.04(0.43-2.54)), and total flap loss (6.0% vs. 4.9%;OR=1.63(0.42-6.35)).

Perioperative complication rates, takebacks for vascular compromise, partial flap losses, and total flap failure rates were not significantly different between the matched loupes and microscope groups. Overall microsurgical success rates in traumatic lower extremity free flap reconstruction appear to be independent of the microsurgical technique used for visual magnification.

Knowledge and Skills Acquisition by Plastic Surgery Residents Through Digital Simulation Training: A Prospective Randomized Blinded Trial.

Plastic and Reconstructive Surgery

Simulation is a standard component of residency training in many surgical subspecialties, yet its impact on knowledge and skills acquisition in plastic surgery training remains poorly defined. We evaluated the potential benefits of simulation-based cleft surgery learning in plastic surgery resident education through a prospective, randomized, blinded trial.

Thirteen plastic surgery residents were randomized to a digital simulator or textbook demonstrating unilateral cleft lip (UCL) repair. The following parameters were evaluated before (pre-intervention) and after (post-intervention) randomization: knowledge of surgical steps, procedural confidence, markings performance on a three-dimensional (3D) stone model, and surgical performance using a hands-on/high-fidelity 3D haptic model. Participant satisfaction with either educational tool was also assessed. Two expert reviewers blindly graded markings and surgical performance. Intra-class correlation coefficients (ICC) were calculated. Wilcoxon signed-rank and Mann-Whitney U tests were used.

Interrater reliability was strong for pre-intervention and post-intervention grading of markings (ICC=0.97; p<0.001 and ICC=0.96; p<0.001) and surgical (ICC=0.83; p=0.002 and ICC=0.81; p=0.004) performance. Post-intervention surgical knowledge (40.3±4.4 vs. 33.5±3.7; p=0.03), procedural confidence (24.0±7.0 vs. 14.7±2.3; p=0.03), markings performance (8.0±2.5 vs. 2.9±3.1; p=0.03), and surgical performance (12.3±2.5 vs. 8.2±2.3; p=0.04) significantly improved in the digital simulation group compared to pre-intervention, but not in the textbook group. All participants were more satisfied with the digital simulator as an educational tool (27.7±2.5 vs. 14.4±4.4; p<0.001).

We present evidence suggesting that digital cognitive simulators lead to significant improvement in surgical knowledge, procedural confidence, markings performance, as well as surgical performance.

Bridging the Knowledge Gap: An Examination of the Ideal Postoperative Autologous Breast Reconstruction Educational Material with A/B Testing.

Plastic and Reconstructive Surgery

Poor health literacy is an epidemic in the United States, associated with higher mortality rates and poor postoperative care. Autologous breast reconstruction is highly complex, and the identification of complications is difficult even for non-plastic surgeon practitioners. We sought to explore the problem of health literacy in this context and identify the ideal postoperative patient education materials(PEMs).

Available online postoperative PEMs for autologous breast reconstruction and corresponding readability scores were assessed. To derive the ideal formula for materials, we crowdsourced quizzes with A/B testing, a method to examine the outcome of two versions of a single variable. We implemented our findings and compared performance on postoperative quizzes with and without oral reinforcement.

Of the 12 postoperative flap complication PEMs found through an internet search, the average grade level readability level was 9.9. Only 1/12(8.3%) mentioned symptoms and signs of flap compromise. The A/B tests result revealed that text approximately 400-800 words written on a 6 grade level led to the highest quiz scores. Patients scored significantly higher on the POD2 quiz when PEMS, modeled after these findings, were reinforced with oral presentation(p=0.0059). Retention of high quiz scores remained at POD10.

Currently available PEMs are at a high reading level and lack specific information on the identification of flap compromise. We propose the most effective postoperative instructions to be approximately 400-800 words written on a grade 6 level with images and oral reinforcement.

"DaxibotulinumtoxinA in the treatment of glabellar lines: Results from each of two multicenter, randomized, double-blind, placebo-controlled, phase 3 studies (SAKURA 1 and SAKURA 2).'

Plastic and Reconstructive Surgery

DaxibotulinumtoxinA for injection is a novel botulinum toxin type A formulation in clinical development. A phase 2 dose-ranging study identified an optimal dose and demonstrated efficacy with a median duration of 24 weeks.

In two phase 3 multicenter, randomized, double-blind, placebo-controlled studies (SAKURA 1, SAKURA 2), subjects with moderate or severe glabellar lines at maximum frown were randomly assigned to receive placebo or 40U daxibotulinumtoxinA for injection. Glabellar lines were evaluated at least every 4 weeks for ≥ 24 weeks until severity returned to baseline (≤ 36 weeks).

Overall, 609 subjects enrolled (405 daxibotulinumtoxinA, 204 placebo). DaxibotulinumtoxinA was significantly more effective than placebo in achieving the primary efficacy outcome (≥ 2-point improvement in glabellar line severity at maximum frown at week 4 according to both investigator and subject ratings) - 73.6% vs. 0.0% (SAKURA 1), 74.0% vs. 1.0% (SAKURA 2) (both p<0.0001). Composite investigator and subject ratings of maximum frown after daxibotulinumtoxinA treatment showed none or mild glabellar line severity was maintained for a median of 24.0 weeks (SAKURA 1) and 23.9 weeks (SAKURA 2) and glabellar line severity did not return to baseline levels for a median of 27.7 and 26.0 weeks. DaxibotulinumtoxinA was generally well tolerated, the most common adverse events related to daxibotulinumtoxinA treatment being headache (7.0% [SAKURA 1], 5.9% [SAKURA 2]), and injection site pain (5.0%, 2.4%).

Results from both studies were highly consistent. DaxibotulinumtoxinA for injection may offer a prolonged duration of response (median ≥ 24 weeks) and is generally well tolerated.

Changes in Opioid Prescribing Habits for Patients Undergoing Rhinoplasty and Septoplasty.

JAMA Facial Plastic Surgery

Opioid prescriptions have increased substantially over the last 2 decades, contributing to the opioid epidemic. Physician practices and legislative changes play a key role in decreasing prescription opioid use.

To evaluate changes in opioid prescribing habits for patients undergoing rhinoplasty and/or septoplasty before and after the adoption of new opioid legislation.

This single-institution case-control study examined opioid prescribing habits for 80 patients who were undergoing rhinoplasty and septoplasty with or without turbinate reduction at the University of Vermont between March 2016 and May 2018. Patients were excluded if they underwent concomitant endoscopic sinus surgery or were younger than 14 years. Patients were divided by surgery date before or after legislative changes on July 1, 2017.

Rhinoplasty and septoplasty with or without turbinate reduction.

Patient demographics and opioid prescriptions were recorded. Patients were evaluated if they reported pain during follow-up, called the office, or received a second prescription. The Vermont Prescription Monitoring System was queried to determine if opioid prescriptions were filled within 30 days of the procedure. The 2 groups were compared to test the hypothesis that opioid prescriptions had decreased after legislative changes.

Of a total of 80 participants, the mean (SD) age in the before (15 women [37.5%]) and after (16 women [40.0%]) groups were 41.4 years and 40.6 years, respectively. There was a statistically significant decrease in the number of pills prescribed to the after group (17.5 to 9.7; P < .001) as well as a decrease in the morphine milligram equivalents that were prescribed (130.9 to 73.2; P < .001). There was no statistical difference in the number of postoperative telephone calls for pain, second prescriptions, or increased complaints of pain at the postoperative visit.

Recent laws in Vermont regarding opioid prescribing were implemented in 2017 to curb the ongoing opioid epidemic. Our observations of patients undergoing septoplasties and rhinoplasties found a significant reduction in opioid prescriptions. This was not associated with an increase in patient complaints about postoperative pain or the need for a second prescription after surgery. This shows that we may safely be able to decrease the number of narcotic medications that we prescribe.


Parathyroidectomy for Patients With Primary Hyperparathyroidism and Associations With Hypertension.

JAMA Surgery

Hyperparathyroidism is associated with cardiovascular disease. However, evidence for a beneficial consequence of parathyroidectomy on hypertension is limited.

To investigate if parathyroidectomy improves hypertension in patients with primary hyperparathyroidism (PHPT).

In this cohort study and retrospective database review, patients with PHPT and hypertension between January 1, 2008, and December 31, 2016, were identified. The mean arterial pressure (MAP) and number of antihypertensive medications were compared between those who did and did not undergo parathyroidectomy. The setting was a large health care system. Primary hyperparathyroidism was defined using biochemical data, and hypertension was identified by International Classification of Diseases, Ninth Revision codes.

Parathyroidectomy was identified in the database by Current Procedural Terminology codes.

The MAP and use of antihypertensive medications were compared for patients who underwent parathyroidectomy and those who did not at 6 months, 1 year, and 2 years. Multivariable logistic regression was used to assess the adjusted odds ratios for both increased and decreased use of antihypertensive medications.

In this cohort study of 2380 participants (79.0% female), patients undergoing parathyroidectomy (n = 501) were younger (mean [SD] age, 65.3 [9.7] vs 71.9 [10.4] years; P < .001) and took fewer antihypertensive medications at baseline (mean [SD] number of medications, 1.2 [1.1] vs 1.5 [1.3], P < .001) than nonsurgical patients (n = 1879). Patients with parathyroidectomy showed greater improvement in their MAP at all follow-up time points (the median [SD] MAP change from baseline to 1 year was 0.1 [8.7] mm Hg without parathyroidectomy vs -1.2 [7.7] mm Hg after parathyroidectomy, P = .002). Nonsurgical patients were more likely vs those with parathyroidectomy to require more antihypertensive medications at 6 months (15.9% [n = 298] vs 9.8% [n = 49], P = .001), 1 year (18.1% [n = 340] vs 10.8% [n = 54], P < .001), and 2 years (17.6% [n = 330] vs 12.2% [n = 61], P = .004). By multivariable analysis, parathyroidectomy was independently associated with freedom from an increased number of antihypertensive medications at all periods (eg, adjusted odds ratio, 0.49; 95% CI, 0.34-0.70; P < .001 at 1 year). Among patients who were initially not taking antihypertensive medications, patients with parathyroidectomy were less likely vs no surgery to start antihypertensive medication treatment at all periods (eg, 10.2% [13 of 127] vs 30.4% [136 of 447], P < .001 at 1 year).

This study's findings suggest that, among hypertensive patients with PHPT, parathyroidectomy may be associated not only with greater decreases in their MAP but also with reduced requirements for antihypertensive medications. Parathyroidectomy decreased the number of patients who began taking antihypertensive medications. Additional study will be required to find whether there are downstream cardiovascular benefits of parathyroidectomy. Preexisting hypertension, particularly in those not already taking antihypertensive medications, should be considered when weighing surgical treatment.