Diversity, Equity, and Inclusion in Plastic Surgery: A Systematic Review.

BACKGROUND: The number of publications on the subject of diversity, equity, and inclusion has surged in the last 5 years. However, a systematic review of this topic has not been published. METHOD: Six top plastic surgery journals were queried from 2018 to 2023 using the search term "diversity." Methods, conclusions, and recommendations were tabulated. RESULTS: A total of 138 publications were identified; 68 studies presented data suitable for analysis. All studies were retrospective. Currently, over 40% of plastic surgery residency applicants are women. The proportion of women in integrated plastic surgery residents is now 43%. In 2021 and 2022, the percentage of female first-year residents exceeded men. The percentage of female presenters at meetings (34%) is double the number in the workforce (17%). Twenty-five percent of academic faculty positions and 22% of program director positions are now held by women. Underrepresented minorities account for fewer than 10% of applicants to integrated plastic surgery residencies. DISCUSSION: The proportion of Black and Hispanic applicants to integrated plastic surgery residencies (6% and 8%, respectively) mirrors the proportion of Black and Hispanic medical students (7% and 6%, respectively). Numerous recommendations have been made to increase the proportion of underrepresented minorities in plastic surgery programs. CONCLUSIONS: The representation of women in plastic surgery has increased dramatically. A lack of Hispanics and Blacks reflects a small pool of applicants, as opposed to a "leaky pipeline."

Reply: Comment on BIA-ALCL: Comparing the Risk Profiles of Smooth and Textured Breast Implants.

Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Optical Coherence Tomography-History, Evolution, and Future Prospects: 2023 Lasker-DeBakey Clinical Medical Research Award.

In this Viewpoint, 2023 Lasker-DeBakey Clinical Medical Research Award winners James G. Fujimoto, David Huang, and Eric A. Swanson discuss their invention­optical coherence tomography, which allows rapid detection of diseases of the retina that impair vision.

Conflict of Interest and Plastic Surgery Journal Editors: The Problem and the Solution.

ABSTRACT: Journals insist that authors disclose their financial conflicts. However, the same standard is rarely imposed on journal editors. Surprisingly, most high-impact medical journals (about 88%) do not publish editor conflicts of interest (COIs).The Sunshine Act makes it possible to query physician payments from industry. Importantly, some companies are exempted. The leading 5 US-based plastic surgery journals were investigated. Only chief editors and coeditors were included, for a total of 10 editors. The range of payments was US $0 to US $297,000 between 2015 and 2021. The mean payment was $90,890, or $12,984 per year. This amount may be compared with the average industry payments to all plastic surgeons, which is approximately $5000 annually.Examples of editor COIs are considered. In one case, an article detailing important factual deficiencies in an article defending Allergan macrotextured breast implants was rejected by coeditors that included a coeditor who received payments from Allergan. An article promoting radiofrequency treatments containing previously reported data was accepted by a chief editor with a COI, who was also a coauthor.Articles claiming improved scarring for a wound adhesive device and numerous benefits for an Allergan implant insertion funnel also found acceptance by conflicted chief editors, despite serious deficiencies.Editor COIs should be published. Attempts to manage editor COI have not been successful. No data support a dollar limit or expiry date for COIs. Relevance and breadth of COIs are unsolved problems. The ethics of industry payments to physicians are questionable at best. An alternative option is recommended-elimination of COI for journal editors. This remedy would restore editorial integrity and avoid the need for recusals. There is precedence. About half of high-impact medical journal editors have no COIs. Industry subsidies in general should be reconsidered. Abandoning them would be in the best interest of our patients and our specialty.

The Keller Funnel, Capsular Contracture, and Conflict of Interest: A Review.

BACKGROUND: The Keller funnel (Allergan; AbbVie Inc, North Chicago, IL) is commonly used to insert breast implants as part of a "no touch" protocol. Many plastic surgeons believe that this device reduces the risk of capsular contracture. This review was undertaken to evaluate the evidence regarding any reduction in capsular contracture rate, other possible benefits, safety and to investigate financial conflict of interest. METHODS: A PubMed electronic literature search was conducted to identify studies comparing capsular contracture rates with and without the Keller funnel. The Open Payments database was accessed for information regarding corporate payments to plastic surgeons. RESULTS: Two retrospective historical case-control studies, published in 2016 and 2018, were identified. Both studies had important confounders, including implant type and placement, which are known to affect capsular contracture rates. Major financial conflicts of interest were present. Most authors did not disclose these conflicts, which totaled more than $1 million and were usually categorized as gifts from Allergan, which purchased the Keller funnel in 2017. DISCUSSION: Financial conflict of interest, along with publication bias, creates a bias toward publication of positive findings. No reliable evidence supports a "no touch" technique, which is a misnomer because manual handling of implants is unavoidable, even when using a funnel. Recent microbiological studies do not support a specific bacterial etiology for capsular contracture. No evidence supports contamination by the surgeon touching the implant. Among other proposed benefits, such as reduced operating time, less contamination, a shorter incision, and less implant trauma, only a slightly shorter incision (1 cm) is supported by the evidence. The cost is $150 per funnel. CONCLUSIONS: No reliable evidence supports the use of a Keller funnel to reduce the risk of capsular contracture. Both supportive studies contain confounding variables, limited follow-up time, and no plausible scientific basis for efficacy. Institutional review board approval of studies on human subjects is not optional. Financial conflicts of interest are extraordinary in their magnitude and potential for creating undue influence. Greater transparency and honest disclosures are needed.

Clinical Evaluation of 310 Abdominoplasties and Measurement of Scar Level.

BACKGROUND: Most published studies on abdominoplasty focus on methods to reduce the risk of seromas. These methods include limited dissection (lipoabdominoplasty), quilting sutures, and preservation of the Scarpa fascia. Quantitative evaluation of the aesthetic result has been lacking. METHODS: A retrospective study was undertaken of all patients undergoing abdominoplasty in the author's practice from 2016 to 2022. A full abdominoplasty was performed, usually with liposuction (87%). All patients were treated under total intravenous anesthesia without paralysis or prone positioning. A single closed suction drain was removed 3 or 4 days after surgery. All procedures were performed as outpatients. Ultrasound surveillance was used to detect any deep venous thromboses. No patient received chemoprophylaxis. The operating table was flexed, often to 90°. Deep fascial anchoring sutures were used to attach the Scarpa fascia of the flap to the deep muscle fascia. Measurements of the scar level were made at intervals after surgery up to 1 year. RESULTS: Three hundred ten patients were evaluated, including 300 women. The mean follow-up time was 1 year. The overall complication rate, which included minor scar deformities, was 35.8%. Five deep venous thromboses were detected. There were no hematomas. Fifteen patients (4.8%) developed seromas that were successfully treated by aspiration. The mean vertical scar level 1 month after surgery was 9.9 cm (range, 6.1-12.9 cm). There was no significant change in scar level at subsequent follow-up times up to 1 year. By comparison, the scar level in published studies ranged from 8.6 to 14.1 cm. DISCUSSION: Avoidance of electrodissection reduces tissue trauma that causes seromas. Flexed patient positioning during surgery and deep fascial anchoring sutures are effective in keeping the scar low. By avoiding chemoprophylaxis, hematomas can be avoided. Limiting the dissection (lipoabdominoplasty), preserving the Scarpa fascia, and adding quilting (progressive tension) sutures are unnecessary. CONCLUSIONS: Total intravenous anesthesia offers important safety advantages. Avoiding electrodissection is effective in keeping seroma rates at a tolerable level (5%), and the scar low and more easily concealed. Alternative methods present disadvantages that may contribute to a suboptimal aesthetic result and require additional operating time.

Three pathologic criteria for reproducible diagnosis of colonic sessile serrated lesion versus hyperplastic polyp.

Colonic SSLs are thought to predispose to ∼30% of colonic adenocarcinomas. This increased risk, compared to benign HPs, makes their distinction vitally important. However, no gold standard exists to differentiate them, and wide observer variability is reported. To better distinguish these polyps, we investigated 94 serrated polyps (53 SSLs and 41 HPs) using an easy-to-apply pathologic scoring system that combines, for the first time, three established distinguishing features: polyp morphology, location, and size. As an additional novel approach, polyp size was assessed by serrated biopsy number compared to endoscopic size. RNA expression profiling served as an additional biomarker. The considerable morphologic overlap across serrated polyps was quantitated for the first time. Interobserver variability was assessed by 8 expert gastrointestinal pathologists. By ROC analysis, polyp size by biopsy number performed best, followed by polyp location and morphology (areas under the curves [AUCs] = 85.9%, 81.2%, and 65.9%, respectively). Optimal discrimination combined all 3 features (AUC = 92.9%). For polyp size, the biopsy number proved superior to endoscopic size (AUC = 85.9% versus 55.2%, P = .001). Interobserver variability analysis yielded the highest reported Fleiss and Kappa statistics (0.879) and percent agreement (96.8%), showing great promise toward improved diagnosis. The proposed 3-criteria pathologic system, combining size by biopsy number, location, and morphology, yields an improved, easy-to-use, and highly reproducible diagnostic approach for differentiating SSLs and HPs.

Peer Review: How to Review a Plastic Surgery Manuscript.

ABSTRACT: Little information is available regarding how to review a plastic surgery manuscript. This vital responsibility ensures that publications meet an acceptable scientific standard. Thoughtful and thorough reviews are essential to protect patients and surgeons from unscientific practices and products. This discussion provides information for the reviewer, gained from the author's experience, including examples of a thorough review, likely to be useful to the editor, and a cursory one that is unhelpful.The first consideration is relevance. Prerequisites for publication include institutional review board approval, disclosure of financial conflicts, and discussion of the regulatory status of devices. Particular attention is needed to check for conflicts of interest, which are endemic in plastic surgery today. In view of the common practice of using computer-generated imaging, reviewers need to be especially vigilant for inauthentic "photoshopped" photographs. Examples of published images that have been digitally altered are provided.If data are available, it may be possible to check the statistical tests. Reviewers need to be aware of the practice of p-hacking. A quick literature search can identify relevant but unreferenced publications. The manuscript needs to be properly organized into sections. Minor points may be made regarding style. The study design and methodology need to be evaluated to be sure that the conclusions are well supported by data. Randomized studies are rarely feasible. Fortunately, well-done prospective observational studies in consecutive patients can be just as useful. Realistic complication rates are expected. Meta-analyses in plastic surgery are often subject to confounding variables. Comments should be available to the authors; confidential comments hidden from authors are discouraged. Like honesty, transparency is the best policy. Manuscripts should be evaluated solely for merit, not the identity of the author or institution. Timeliness of submission of the review is appreciated by authors.Evidence-based medicine is concerned solely with the facts. The 2 basic criteria are a solid scientific basis and reliable evidence of efficacy. Reviewers need to keep an open mind. Studies that challenge the status quo are often the most valuable ones and are needed for the advancement of the specialty.

Incision and Capsular Contracture Risk: Is There a Relationship in Breast Augmentation and Augmentation/Mastopexy?

BACKGROUND: Breast implants can be introduced through a variety of incisions, most commonly an inframammary incision, but also a periareolar incision or an axillary incision. Usually, the implant is inserted through the same incision used in performing an augmentation/mastopexy. Some authors use a separate inframammary incision. Capsular contracture is the most common complication of breast augmentation. One theory holds that it is caused by an infected biofilm, prompting surgeons to minimize implant handling, known as the "no touch" technique. This review was undertaken to investigate the relationship, if any, between the access incision and the risk of capsular contracture. METHODS: An electronic literature search was conducted to identify publications comparing capsular contracture rates by the access incision. RESULTS: Ten studies were evaluated. Most were retrospective series. Three were prospective core studies. Some studies reported an increased risk of capsular contracture for a periareolar incision; a similar number did not. One study supported a separate inframammary incision at the time of vertical augmentation/mastopexy. DISCUSSION: Bacterial studies in the last decade show that the resident bacteria on the skin surface and within breast tissue are similar. Sophisticated microbiological evaluation of breast capsules reveals that the microbiome relates to the patient, as opposed to a specific bacterial profile for capsular contracture. A review of the statistics used in determining an advantage for a separate incision at the time of vertical augmentation/mastopexy reveals that there is no statistically significant risk reduction when using an additional inframammary incision, which adds an unnecessary scar. CONCLUSIONS: The access incision at the time of breast augmentation or augmentation/mastopexy is unlikely to affect the capsular contracture risk. There is no need to make a separate incision to insert the implant at the time of augmentation/mastopexy, or to isolate the implant from contact with breast parenchyma. Little evidence supports the "no touch" technique. The etiology of capsular contracture remains unknown.