Revisiting Level of Evidence Ratings in Plastic Surgery: A Call to Action.

BACKGROUND: Evidence-based medicine underpins medical and surgical practice, with level of evidence (LOE) being a key aspect that allows clinicians and researchers to better discriminate the methodological context by which studies are conducted and appropriately interpret their conclusions, and more specifically the strength of their recommendations. OBJECTIVES: The aim of this study was to reassess the LOE of articles published in plastic surgery journals. METHODS: To assess the overall LOE of publications from January 1 to December 31, 2021, a review of the following plastic surgery journals was performed: Aesthetic Surgery Journal (ASJ), Annals of Plastic Surgery (Annals), Journal of Plastic Reconstructive and Aesthetic Surgery (JRPAS), Plastic and Reconstructive Surgery (PRS), and Plastic and Reconstructive Surgery Global Open (PRS GO). RESULTS: Of 3698 PUBMED articles, 1649 original articles and systematic reviews were analyzed. The average LOE for each journal was: ASJ 3.02 ± 0.94, Annals 3.49 ± 0.62, JPRAS 3.33 ± 0.77, PRS 2.91 ± 0.77, and PRS GO 3.45 ± 0.70. The collective average LOE was 3.28 ± 0.78. Only 4.4% were LOE 1 and 7.3% were LOE 2. Compared to past studies, PRS showed a significant LOE improvement (P = .0254), while ASJ and JPRAS saw nonsignificant changes; Annals experienced a significant decrease (P = .0092). CONCLUSIONS: ASJ and PRS showed the highest LOE among the journals analyzed. Despite this, low LOE studies remain prevalent in plastic surgery. This paper serves as a call to action for both researchers and academic journals to elevate the standard, offering several strategies to help improve the LOE in plastic surgery.

A Procedure and Complication-Specific Assessment of Smoking in Aesthetic Surgery: A Systematic Review and Meta-Analysis.

Background: The popularity of aesthetic surgery is on the rise, as is patients' expectations towards excellent surgical results. In order to meet these expectations, risk factors that hinder desired outcomes, such as smoking, need to be identified and addressed. To that end, the present study summarizes an updated systematic review focused on the effects of smoking on cosmetic surgical procedures and outcomes. Methods: A systematic review of studies comparing aesthetic surgical outcomes by procedure, between tobacco smokers and non-smokers was carried out, querying PubMed, Embase and the Cochrane databases. Data regarding surgical outcomes were extracted and meta-analyzed by a random effects model in conjunction with the Mantel-Haenszel statistical method. Results: Eighty-two studies were included in the final synthesis. Abdominoplasty/panniculectomy (n = 19 cohorts) and breast reduction (n = 27 cohorts) were the most common types of procedures included in this review. Other than mastopexy and rhinoplasty, smoking conferred a statistically significant increased risk of overall complications for all studied aesthetic procedures. Conclusions: The data demonstrates that smoking is a clear risk factor for the vast majority of aesthetic plastic surgeries studied. Although our meta-analysis suggests that smoking is not a risk factor for complications in mastopexies and rhinoplasties, these two specific analyses may have been biased, and should therefore be re-evaluated with future additional evidence. The results of this systematic review confirm the importance of smoking cessation and education relative to the outcomes of common cosmetic surgical procedures.

Historique : La popularité de la chirurgie esthétique est en hausse, tout comme les attentes des patients envers l'excellence des résultats chirurgicaux. Pour répondre à ces attentes, il est nécessaire de nommer et de résoudre les facteurs de risque qui entravent les résultats souhaités, tels que le tabagisme. À cet effet, la présente étude résume une analyse systématique à jour des effets du tabagisme sur les interventions et les résultats en chirurgie esthétique. Méthodologie: Dans une analyse systématique des études, les chercheurs ont comparé les résultats de la chirurgie esthétique chez des fumeurs et des non-fumeurs en fonction de l'intervention, après une fouille dans les bases de données de PubMed, d'Embase et de Cochrane. Ils ont extrait les données relatives aux résultats des opérations et ont procédé à la méta-analyse à l'aide d'un modèle à effets aléatoires, conjointement avec la méthode statistique de Mantel-Haenszel. Résultats : Au total, les chercheurs ont inclus 82 études dans la synthèse définitive. Les interventions les plus fréquentes étaient les abdominoplasties et les panniculectomies (n = 19 cohortes), de même que les réductions mammaires (n = 27 cohortes). À part dans les cas de mastopexie et de rhinoplastie, le tabagisme provoquait une augmentation statistiquement significative du risque de complications globales dans tous les cas d'interventions esthétiques à l'étude. Conclusions : Les données ont démontré que le tabagisme est un facteur de risque évident dans la majorité des chirurgies esthétiques à l'étude. Même si la méta-analyse a indiqué que le tabagisme n'est pas un facteur de risque de complications dans les cas de mastopexie et de rhinoplastie, ces deux analyses peuvent avoir été biaisées et devraient donc être réévaluées d'après de futures données complémentaires. Les résultats de cette analyse systématique confirment l'importance de l'arrêt du tabagisme et de l'éducation sur les résultats des interventions chirurgicales esthétiques courantes.

The Fragility of Landmark Randomized Controlled Trials in the Plastic Surgery Literature.

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.

Successful Applicant and Program Director Perspectives on the Virtual Residency Selection Process for Canadian Surgical Subspecialties.

Introduction: The COVID-19 pandemic imparted an important shift in strategies postgraduate surgical programs use to recruit, interact with, and select medical students applying through the Canadian Resident Matching Service (CaRMS). With this unprecedented shift toward virtual applicant selection, this study sought to explore and analyze perspectives of the first cohort of program directors (PDs) and applicants who participated in this process. Methods: A cross-sectional survey study was designed using Google Forms for both PDs and applicants participating in the 2021 CaRMS surgical subspecialty selection process. Questions pertained to format and content of virtual engagement methods, the interview itself, as well as advice for future applicants. Results: Thirty-five PDs and 40 successful applicants (n = 75) participated in the study. Cost reduction was the most commonly reported benefit of online interviewing by PDs (85%), followed by efficiency (71%), enhanced resource management (49%), and ability to conduct more interviews (23%). Strong letters of reference (80%) and interview performance (74%) remained the most significant factors in virtual applicant selection. Attendance to virtual recruitment events did not increase the likelihood of offering interviews (n = 24, 69% of PDs), although the ability to perform in-person electives held tremendous value. Most applicants (90%) reported on virtual information sessions as the best method for learning about programs; work culture and environment were topics most valued as discussion points (90%). Successful applicants provided an average confidence of 76% regarding their suitability with their matched programs. Seventy-three percent of applicants (n = 29) had either a preference for virtual interviews or were equivocal, while 51.4% of PDs (n = 18) preferred interviews to be conducted virtually for future cohorts. Conclusion: Trainees are entering residency with confidence following a virtual selection process, and PDs feel confident in their selections. Although no clear consensus exists regarding preference for virtual or in-person interviews, several advantages for virtual resident selection exist. The influence of an in-person elective was found difficult to replace, regardless of interview format. The importance of applicant engagement with programs prior to interviews is highlighted and discussed with recommendations provided for best practices.

Introduction: La pandémie de COVID-19 a induit un important changement de stratégies de l'utilisation des programmes chirurgicaux de 3e cycle pour recruter, interagir avec les étudiants en médecine et sélectionner les étudiants déposant une candidature par le biais du CaRMS, le service d'affectation des résidents canadiens. Avec ce mouvement sans précédent vers une sélection virtuelle des candidats, l'étude a cherché à explorer et analyser les points de vue de la première cohorte de directeurs de programmes (DP) et de candidats ayant participé à ce processus. Méthodes: Une enquête transversale a été conçue à l'aide de Google Forms pour, à la fois, les DP et les candidats participant au processus de sélection de sous-spécialité chirurgicale 2021 du CaRMS. Des questions portaient sur le format et le contenu des méthodes de contact virtuelles, l'entretien proprement dit ainsi que sur des conseils pour les candidats futurs. Résultats: Trente-cinq DP et quarante candidats acceptés (n = 75) ont participé à l'étude. La réduction des coûts a été l'avantage des entretiens en ligne le plus souvent cité par les DP (85 %) suivie de l'efficacité (71 %), d'une meilleure gestion des ressources (49 %) et de la capacité à réaliser plus d'entretiens (23 %). De solides lettres de recommandation (80 %) et la performance au cours de l'entretien (74 %) restaient les facteurs les plus significatifs pour la sélection virtuelle des candidats. La participation aux événements virtuels de recrutement n'augmentait pas la probabilité d'offre d'un entretien (n = 24, 69 % des DP), même si la possibilité de réaliser des entretiens facultatifs en personne avait une valeur considérable. La plupart des candidats (90 %) ont indiqué que les séances d'information virtuelles étaient la meilleure méthode pour en savoir plus sur les programmes; la culture et l'environnement de travail étaient les thèmes ayant le plus de valeur comme sujets de discussion (90 %). Les candidats ayant réussi ont indiqué à 76 % qu'ils s'estimaient confiants sur le fait de bien correspondre aux programmes auxquels ils étaient affectés. Soixante-treize pour cent des candidats (n = 29) avaient une préférence pour les entretiens virtuels ou étaient dans le doute, tandis que 51,4 % des DP (n = 18) préféraient que les entretiens des cohortes futures soient menés virtuellement. Conclusion: Les stagiaires commencent leur résidence avec confiance après un processus de sélection virtuel et les DP se sentent confiants quant à leurs choix. Même s'il n'existe pas un franc consensus concernant une préférence pour les entretiens virtuels ou en face à face, la sélection à distance des résidents présente plusieurs avantages. L'influence d'un entretien optionnel en personne s'est avérée difficile à remplacer, quelle que soit la forme donnée à l'entretien. L'importance de l'engagement du candidat dans des programmes antérieurs aux entretiens est soulignée et discutée avec des recommandations fournies pour de meilleures pratiques.

Level of evidence in high impact surgical literature: the way forward.

Evidence-based medicine stipulates that clinical decision-making should revolve around scientific evidence. The goal of the present study is to evaluate the methodological quality of surgical research recently published in JAMA Surgery, International Journal of Surgery, and British Journal of Surgery, the three surgical journals with the highest impact factor. An electronic search of the PUBMED database was performed to retrieve all articles published in the JAMA Surgery, International Journal of Surgery, and British Journal of Surgery in the year 2022. Three authors independently reviewed all retrieved articles and methodological designs of the publications were analyzed and rated using a modification of the Oxford Centre for Evidence-Based Medicine Levels of Evidence (Oxford Levels of Evidence scale). The initial search identified 1236 articles of which 809 were excluded after title and abstract screening. The remaining 427 underwent full text/methods read, of which 164 did not meet the inclusion/exclusion criteria. A total of 273 studies were included in the analysis. The average level of evidence was 2.5 ± 0.8 across all studies assessed. The majority of study designs were comprised of retrospective cohorts (n = 119), prospective cohorts (n = 47), systematic reviews of non RCTs (n = 39), and RCTs (n = 37). There was no significant difference in the average level of evidence between the top three journals (p = 0.50). Most clinical studies in the highest impact factor surgical journals are of level III evidence, consistent with earlier literature. However, our analysis demonstrates a relatively higher percentage of LOE I and II compared to what was previously published in the literature.