In search of evidence-based plastic surgery: the problems faced by the specialty

Current Practices and Trends in Midface Rejuvenation

BACKGROUND

Cosmetic approaches to midface aging are complex and vary in their treatment methodology. The nature of cosmetic surgery limits clinical trial data, forcing surgeons to rely on small studies and professional preferences when choosing an approach. Our study aimed to quantitatively assess national trends in midface rejuvenation practices.

METHODS

We conducted a cross-sectional study consisting of a survey administered through the American Academy of Facial Plastic and Reconstructive Surgery and the American Society of Plastic Surgeons listservs. To evaluate trends, techniques were grouped into 2 categories: minimally invasive (injectable fillers, fat transfer, fat repositioning) or invasive (deep plane facelift, subperiosteal lift, malar/cheek alloplastic implant, bone grafting/bone advancement).

RESULTS

Two hundred thirty-two survey responses were received. Of the total respondents, 46.52% were certified by the American Board of Facial Plastic and Reconstructive Surgery, and 48.26% were certified by the American Board of Plastic Surgery. Minimally invasive techniques were far more preferred (66.67%) over invasive (33.33%) techniques, with injectable fillers as the most common technique (34.88%), followed by fat transfer (20.93%). Deep plane facelift was preferred over subperiosteal lift (18.60% vs 7.91%, respectively). Surgeons board certified by the American Board of Facial Plastic and Reconstructive Surgery were more inclined to perform invasive techniques over those board certified by the American Board of Plastic Surgery (P = 0.0427).

CONCLUSION

This study quantitatively assessed national trends in cosmetic approaches to midface aging. Our data suggest that trends among surgeons across the United States have shifted toward favoring minimally invasive techniques over more invasive approaches.

Evidence-Based Blepharoplasty: An Analysis of Highly Cited Research Papers

PURPOSE

The purpose of the study was to appraise the methodological quality of the highest impact blepharoplasty research and to describe prevalent research themes.

METHODS

The 100 most highly cited research papers relevant to blepharoplasty were obtained from Web of Science, with no journal or date limitations applied. Data extraction included the study design, main research topic and specialty, outcome measures, and citation count. Each paper's level of evidence was independently evaluated by 2 authors according to the Oxford Centre for Evidence-Based Medicine system.

RESULTS

Overall, the 100 most cited blepharoplasty research papers were cited by 4,194 papers. The mean number of citations for each paper was 73 (range: 42-239). Most of the papers presented level 4 (n = 51) or level 5 (n = 35) evidence, which is consistent with the predominance of case series (n = 47) and expert opinions (n = 18) amongst study designs. No papers achieved level 1 (highest) evidence. Six papers presented level 2 evidence and 8 papers presented level 3. Significant research foci included innovative surgical techniques (n = 65) and anatomical considerations (n = 10), with reconstructive and cosmetic implications. Senior authors were mainly affiliated with centers of plastic (n = 53) or ophthalmic/oculoplastic (n = 34) surgery. Only 3 papers used validated subjective or objective cosmetic outcome measures.

CONCLUSIONS

Despite a significant impact on current practice, the level of evidence of the highly cited blepharoplasty research was predominantly low. Robust research methodology, through well-designed studies and standardized outcome measures, is necessary to facilitate evidence synthesis and guide clinical practice.

AAPS Podium Presentations-Has the Level of Evidence Changed over the Past Decade?

An increase in the number and quality of randomized controlled trials (RCTs) and trends toward higher levels of evidence (LOE) in the plastic surgery literature has been reported; however, there has not been a specific focus on the LOE of presentations at scientific meetings. The purpose of this study was to ascertain trends in the LOE of studies presented at the annual meeting of the American Association of Plastic Surgeons.

METHODS

A hand search was conducted identifying all abstracts of podium presentations from 2009 to 2019. LOE, using American Society of Plastic Surgeons guidelines, were ascribed to each presentation, along with identification of any corresponding journal publications. RCTs were further analyzed using the 12-item Modified Consolidated Standard of Reporting Trials checklist.

RESULTS

Four hundred forty-one studies with a median LOE of 3 were included in the study. A non-significant improvement in the mean level of evidence was noted over time (P = 0.09) along with an increase in the number of level 2 studies (P = 0.589) and RCTs (P = 0.717). Level 1 studies were rare (0.91%) and of fair quality (median checklist score 8 out of 12). Seventy-two percent of abstracts resulted in publication, and the mean lag time to publication was 422 days.

CONCLUSIONS

A favorable trend is observed with respect to the mean LOE as well as the number of level 2 studies and RCTs over time. The importance of research meeting attendance to maintain up-to-date information is noteworthy, given the long lag time from presentation to publication.

Levels of Evidence in Rhinology and Skull Base Surgery Research

OBJECTIVE

The purpose of this study was to evaluate the quality of evidence of rhinology and rhinologic skull base surgery (RSBS) research and its evolution over the past decade.

STUDY DESIGN

Review article.

SETTING

We reviewed articles from 2007 to 2019 in 4 leading peer-reviewed otolaryngology journals and 3 rhinology-specific journals.

METHODS

The articles were reviewed and levels of evidence were assigned using the Oxford Centre for Evidence-Based Medicine 2011 guidelines. High quality was defined as level of evidence 1 or 2.

RESULTS

In total, 1835 articles were reviewed in this study spanning a 13-year period. Overall, the absolute number of RSBS publications increased significantly 22.6% per year, from 108 articles in 2007 to 481 in 2019 (P < .001; 95% CI, 7.9-37.2). In 2007, only 13 articles, or 15%, were high quality, and this grew to 146 articles, or 39%, in 2019. A 14.0% per year exponential increase in the number of high-quality publications was found to be statistically significant (P < .001; 95% CI, 7.2, 20.7). Overall, high-quality publications represented just 25.8% of RSBS articles overall. There was no significant difference in quality between rhinology-specific journals and general otolaryngology journals (χ² = 3.1, P = .077).

CONCLUSION

The number of overall publications and of high-quality RSBS publications has significantly increased over the past decade. However, the proportion of high-quality studies continues to represent a minority of total RSBS research.

Machine intelligence for nerve conduit design and production

Nerve guidance conduits (NGCs) have emerged from recent advances within tissue engineering as a promising alternative to autografts for peripheral nerve repair. NGCs are tubular structures with engineered biomaterials, which guide axonal regeneration from the injured proximal nerve to the distal stump. NGC design can synergistically combine multiple properties to enhance proliferation of stem and neuronal cells, improve nerve migration, attenuate inflammation and reduce scar tissue formation. The aim of most laboratories fabricating NGCs is the development of an automated process that incorporates patient-specific features and complex tissue blueprints (e.g. neurovascular conduit) that serve as the basis for more complicated muscular and skin grafts. One of the major limitations for tissue engineering is lack of guidance for generating tissue blueprints and the absence of streamlined manufacturing processes. With the rapid expansion of machine intelligence, high dimensional image analysis, and computational scaffold design, optimized tissue templates for 3D bioprinting (3DBP) are feasible. In this review, we examine the translational challenges to peripheral nerve regeneration and where machine intelligence can innovate bottlenecks in neural tissue engineering.

Reading between the Lines: A Plastic Surgeon's Guide to Evaluating the Quality of Evidence in Research Publications

An important component of practicing evidence-based medicine (EBM) in plastic surgery is staying current with published research, an increasingly difficult task given the rapid growth of the literature. This article reviews the methodological aspects specific to the aesthetic surgery field that should be considered when evaluating the quality of evidence in research publications in the context of the level of evidence (LOE) grading scales that are currently used by plastic surgery journals. Reporting the LOE in a research publication can help to highlight the quality of the research and the potential for bias so that the reader may prioritize information accordingly. However, LOE classifications are not an absolute index of the quality of evidence and do not preclude careful evaluation of the study’s methods and results in the context of the authors’ conclusions. As the application of evidence-based medicine expands in the plastic surgery community, surgeons must be mindful of how to appropriately interpret research findings and assess the utility of applying results to their practice.

The quality of systematic reviews addressing peripheral nerve repair and reconstruction

While systematic reviews are regarded as the strongest level of medical evidence, inconsistency in the quality and rigor of systematic reviews raises concerns about their use as a tool in guiding quality delivery in evidence-based clinical practice. The objective of this present study was to assess methodological soundness of systematic reviews with a particular focus on peripheral nerve repair and reconstruction. We performed a comprehensive search using PubMed and Scopus to identify all systematic reviews published on peripheral nerve reconstruction in 9 high-impact surgical journals. Two authors independently performed literature searches, screened abstracts, and extracted data. Discrepancies were resolved by discussion and consensus. The quality of systematic reviews was assessed using AMSTAR criteria. Initial search retrieved 184 articles. After screening duplicates, titles, abstracts, and conducting full text reviews, 26 studies met inclusion criteria. Of those, 18 (65%) were published by Plastic Surgery, 7 (27%) by Orthopedic Surgery, and 1 (4%) by Occupational Therapy. The total number of systematic reviews published on peripheral nerves each year has shown an increasing trend from 2004 through 2015. The overall median AMSTAR score was 5, reflecting a "fair" quality. There was no evidence of AMSTAR score improvement over time. Although the number of systematic reviews published on peripheral nerve repair has risen over the last decade, their quality has not exhibited the same increase. This highlights the necessity to increase familiarity with and conform to methodological quality criteria in order to improve the integrity of evidence-based medicine in peripheral nerve repair and reconstruction.

Plastic Surgery Residents' Understanding and Attitudes Toward Biostatistics: A National Survey

BACKGROUND

An understanding of biostatistics is a critical skill for the practicing plastic surgeon. The purpose of the present study was to assess plastic surgery residents' attitudes and understanding of biostatistics.

METHODS

This was a cross-sectional study of plastic surgery residents. A survey assessing resident attitudes regarding biostatistics, confidence with biostatistical concepts, and objective knowledge of biostatistics was distributed electronically to trainees in plastic surgery programs in the United States. Bivariate and regression analyses were used to identify significant associations and adjust for confounders/effect modifiers.

RESULTS

One hundred twenty-three residents responded to the survey (12.3% response rate). Respondents expressed positive attitudes regarding biostatistics in plastic surgery practice, but only moderate levels of confidence with various biostatistical concepts. Both attitudes and confidence were positively associated with the number of plastic surgery journals read monthly and formal coursework in biostatistics (P < 0.01). Resident attitudes were positively correlated with confidence (r = 0.33, P < 0.01). The mean percentage of correct responses on knowledge-assessments was 43.6% (20.8%). Integrated residents performed better than independent track residents (P = 0.04). Residents had difficulty with study design, the correct use of analysis of variance, regression analysis, and identifying a statistically significant result. Resident confidence was moderately correlated with performance (r = 0.31, P = 0.01).

CONCLUSIONS

Plastic surgery residents place a high degree of importance on knowledge of biostatistics in the practice of plastic surgery but have only a fair understanding of core statistical concepts.

A Bibliometric Analysis of the 100 Most-cited Articles in Rhinoplasty

Supplemental Digital Content is available in the text.

Introduction:

Citation analysis aims to quantify the importance and influence of a published article within its field. We performed a bibliometric analysis to determine the most highly cited articles within rhinoplasty and their impact on current practice.

Methods:

The 100 most-cited articles relating to rhinoplasty, between and inclusive of January 1864 to September 2015, were extracted from Web of Science in October 2015. Title, source journal, publication year, total citations, average citations/year, type of article, level of evidence, country of origin, main focus, use of outcome measures, incorporation into “Selected Readings in Plastic Surgery,” and funding status were recorded.

Results:

The total number of citations per article ranged from 61 to 276 (1.5–12.1 average citations per year). Surgical technique was the focus of 53% of articles, particularly those for reconstruction (75%). The United States produced 72% of articles compared with 8% from the United Kingdom. The top 100 articles were published within 20 journals; “Plastic and Reconstructive Surgeons” contributed the most articles (n = 57). None of the articles achieved level 1 or 2 of evidence (Oxford Centre for Evidence-Based Medicine levels of evidence, 2011), with most achieving level 4 evidence (n = 64). Case-series were the most popular methodology (n = 37). Few articles used validated outcome measures (n = 21). Twenty-nine percent were referenced in “selected readings.” Eighty-nine percent were unfunded studies.

Conclusions:

These top 100 articles are used in current teaching material and underpin surgical decision making. Developing and using validated objective assessment tools will benefit surgeons, patients, and the greater scientific community in objectively evaluating techniques with the most favorable results.

Introducing the Body-QoL®: A New Patient-Reported Outcome Instrument for Measuring Body Satisfaction-Related Quality of Life in Aesthetic and Post-bariatric Body Contouring Patients

OBJECTIVE

To develop a new patient-reported outcome instrument (PRO) to measure body-related satisfaction quality of life (QoL).

METHODS

Standard 3-phase PRO design was followed; in the first phase, a qualitative design was used in 45 patients to develop a conceptual framework and to create preliminary scale domains and items. In phase 2, large-scale population testing on 1340 subjects was performed to reduce items and domains. In phase 3, final testing of the developed instrument on 34 patients was performed. Statistics used include Factor, RASCH, and multivariate regression analysis. Psychometric properties measured were internal reliability, item-rest, item-test, and test-retest correlations.

RESULTS

The PRO-developed instrument is composed of four domains (satisfaction with the abdomen, sex life, self-esteem and social life, and physical symptoms) and 20 items in total. The score can range from 20 (worst) to 100 (best). Responsiveness was 100 %, internal reliability 93.3 %, and test-retest concordance 97.7 %. Body image-related QoL was superior in men than women (p < 0.001) and decreased with increasing age (p = 0.004) and BMI (p < 0.001). Post-bariatric body contouring patients score lower than cosmetic patients in all domains of the Body-QoL instrument (p < 0.001). After surgery, the score improves by on average 21.9 ± 16.9 (effect size 1.8, p < 0.001).

CONCLUSIONS

Body satisfaction-related QoL can be measured reliably with the Body-QoL instrument. It can be used to quantify the improvement in cosmetic and post-bariatric patients including non- or minimally invasive procedures, suction assisted lipectomy, abdominoplasty, lipoabdominoplasty, and lower body lift and to give an evidence-based approach to standard practice.

LEVEL OF EVIDENCE I

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.

Analysis of the 50 most cited papers in craniofacial surgery

The intent of this study is to discuss the most prominent literature in craniofacial surgery. To do so, using the ISI Web of Science, a ranking by average number of citations per year of the top 50 craniofacial surgery articles was compiled. All plastic surgery journals listed in the "Surgery" category in the ISI Web of Knowledge Journal Citation Reports 2013 Science Edition were considered. Journal of publication, country of origin, collaborating institutions, topic of interest, and level of evidence were analyzed. The total number of citations ranged from 47 to 1017. Average number of citations per year ranged from 46.2 to 8.6. The oldest article in the top 50 was published in 1988 and the most recent in 2009. The majority of the articles came from Plastic and Reconstructive Surgery with 28 of the 50. The majority of the articles, originated from the United States (56%). Reconstruction of acquired defects was the most commonly examined topic at 46.2%; followed by articles discussing reconstruction of congenital defects (23.1%). The most common level of evidence was level 3. This extensive examination of the craniofacial literature highlights the important part that craniofacial surgery takes in the field of plastic surgery.

Fat grafting: a citation analysis of the seminal articles

Background:

There has been substantial rise in the volume of published works on fat transfer in the medical literature in the past 25 years, and this is indicative of its growing popularity. However, many unanswered questions remain, and there is no consensus as to the optimum technique. Consequently, the scientific and clinical research on fat grafting continues to increase rapidly. The purpose of our study was to perform a bibliometric analysis of the most-cited articles in fat transfer.

Methods:

Through the Web of Science, all articles relating to fat grafting were identified in the plastic and reconstructive literature. The 100 most-cited articles were identified and analyzed individually.

Results:

Total citations ranged from 35 to 363 and the most-cited paper by Sidney Coleman was published in Plastic and Reconstructive Surgery. The United States produced 46% of the most-cited papers, and the University of California was the most prolific institution. Twenty-one articles focused on lipofilling to the face while 14 articles looked at fat grafting to the breast.

Conclusions:

The scientific relevance of a published work is reflected in the number of citations from peers that it receives. Therefore, the 100 most-cited papers in fat grafting have been the most influential articles on this field, and they are likely to be the ones that are remembered most.

An Analysis of the "Classic" Papers in Aesthetic Surgery

INTRODUCTION

Over the past 50 years, there has been a significant increase in published articles in the medical literature. The aesthetic surgery literature is vast, consisting of a plethora of diverse articles written by a myriad of illustrious authors. Despite this considerable archive of published material, it remains nebulous as to which precise papers have had the greatest impact on our specialty. The aim of our study was to identify and analyse the characteristics of the top 50 papers in the field of aesthetic surgery in the published literature.

METHODS

The 50 most cited papers were identified in several surgical journals through the Web of Science. The articles were ranked in order of the number of citations received. These classic 50 papers were analysed for article type, their journal distribution, level of evidence as well as geographic and institutional origin.

RESULTS

Six journals contributed to the top 50 papers in aesthetic surgery with Plastic and Reconstructive Surgery contributing the most with 31 papers.

Plastic surgery and the breast: a citation analysis of the literature

Background:

A large proportion of the plastic surgery literature is dedicated to the breast. It is one of the most common topics in our specialty, yet it is unclear which articles have been the most influential. The purpose of this study was to identify the top 100 most-cited articles on breast in the plastic surgery literature and examine the characteristics of each individual article.

Methods:

Using an electronic database through the Web of Science, we were able to determine the 6 journals that contributed to the 100 most-cited articles on breast in the plastic surgery literature.

Results:

Each article was examined individually looking at characteristics such as subject matter, article type, country of origin, institution, authorship, and year of publication. Plastic and Reconstructive Surgery contributed the most articles to the top 100 with 81 articles including the most-cited article which has been referenced 673 times to date. The United States produced 73% of the top 100 articles, and the most prolific institution was the University of Texas M. D. Anderson Cancer Center with 15 articles.

Conclusions:

This study has identified the most influential articles on breast in the plastic surgery literature over the past 68 years and highlighted many important scientific breakthroughs and landmarks that have occurred during this time.

Plastic surgery residents' attitudes and understanding of biostatistics: a pilot study

OBJECTIVE

To assess plastic surgery residents' knowledge, attitudes, and comfort with biostatistics.

DESIGN

Cross-sectional study.

SETTING

Department of Plastic and Reconstructive Surgery at Johns Hopkins Hospital.

PARTICIPANTS

A total of 22 plastic surgery residents (91% response rate) completed the study.

RESULTS

The study sample consisted of 18 residents in the integrated training path and 4 in the independent training track and was equally divided between junior and senior residents. Most respondents (>54%) had taken at least 1 course in biostatistics or epidemiology. More than 90% of residents reported reading at least 1 plastic surgical journal on a regular basis (mean 2.1 ± 1.5 journals/month). Most residents expressed a desire to learn more about biostatistics (68.2%), reported using statistical information in forming clinical opinions (86.3%), and placed a high value on knowledge of biostatistics in appraising the surgical literature (90.9%). However, only 45% of respondents reported being able to understand all the statistical terms encountered in journal articles. Only 50% of respondents felt comfortable with assessing whether the appropriate statistical tests were used to answer a research question. In case studies, the mean percentage of correct responses was 53.0 ± 24.5% (range: 0-83.3). Higher performance scores were associated with a prior course in biostatistics (p = 0.04) and the number of journals read monthly (p = 0.003). Respondents had difficulty with study design (45.5% correct), analysis of variance (45.5% correct), time to event analysis (9.1% correct), and interpreting a 95% confidence interval (45.5% correct). The number of correct responses strongly correlated with respondent confidence in biostatistics (r = 0.70, p < 0.001).

CONCLUSION

Plastic surgery residents place a high degree of importance on biostatistics but have only a fair understanding of core statistical concepts.

A feasible computer-based evaluation tool for reduction mammaplasty patients: indications for operation and monitoring of guidelines

In Sweden, evidence-based national guidelines for the indication for reduction mammaplasty in the public health-care system have been developed by a group of experts. They were defined as breast volume≥800 ml at normal weight. Furthermore, a volume asymmetry of 25% or at least 200 ml or an extreme ptosis may be an indication in some cases. The aim of the present paper was to describe an easy-to-use computer-based tool that has been developed to assure that patients with mammary hyperplasia are evaluated and offered care in a standardized fashion and that the adherence to the guidelines is monitored. Included variables were based on a model for priority grouping originally presented by Strömbeck and Malm in 1986 and comprise body mass index (BMI), BMI-corrected breast volume, ptosis, asymmetry, and general breast-related factors preoperatively and 1 year postoperatively and complications postoperatively. Between June 2007 and January 2013, 377 patients were evaluated. Of which, 275 qualified for operation. With the help of the computer-based tool, compliance to the indications for operation can be easily followed, and hence the intended patients offered a reduction mammaplasty in the public health-care system.

Evidence-based medicine in plastic surgery: where did it come from and where is it going?

OBJECTIVES

Evidence-based medicine, particularly randomized controlled trials, influence many of the daily decisions within plastic surgery as well as nearly every other medical specialty, and will continue to play a larger role in medicine in the future. Even though it is certainly not a new idea, evidence-based medicine continues to remain a hot topic among members of the healthcare community. As evidence-based medicine continues to grow and evolve, it is becoming more important for all physicians to understand the fundamentals of evidence-based medicine: how evidence-based medicine has changed, and how to successfully incorporate it into the daily practice of medicine.

RESULTS

Admittedly, the wide acceptance and implementation of evidence-based medicine has been slower in surgical fields such as plastic surgery given the difficulty in performing large scale blinded randomized controlled trials due to the inherent nature of a surgical intervention as a treatment modality. Despite these challenges, the plastic surgery literature has recently begun to respond to the demand for more evidence-based medicine.

CONCLUSIONS

Today's plastic surgeons are making a concerted embrace evidence-based medicine by increasing the amount of out of high-level clinical evidence and should be encouraged to continue to further their endeavors in the field of evidence-based medicine in the future.

Levels of Evidence in Cosmetic Surgery: Analysis and Recommendations Using a New CLEAR Classification

BACKGROUND

The Level of Evidence rating was introduced in 2011 to grade the quality of publications. This system evaluates study design but does not assess several other quality indicators. This study introduces a new "Cosmetic Level of Evidence And Recommendation" (CLEAR) classification that includes additional methodological criteria and compares this new classification with the existing system.

METHODS

All rated publications in the Cosmetic Section of Plastic and Reconstructive Surgery, July 2011 through June 2013, were evaluated. The published Level of Evidence rating (1-5) and criteria relevant to study design and methodology for each study were tabulated. A new CLEAR rating was assigned to each article, including a recommendation grade (A-D). The published Level of Evidence rating (1-5) was compared with the recommendation grade determined using the CLEAR classification.

RESULTS

Among the 87 cosmetic articles, 48 studies (55%) were designated as level 4. Three articles were assigned a level 1, but they contained deficiencies sufficient to undermine the conclusions. The correlation between the published Level of Evidence classification (1-5) and CLEAR Grade (A-D) was weak (ρ = 0.11, not significant). Only 41 studies (48%) evaluated consecutive patients or consecutive patients meeting inclusion criteria.

CONCLUSIONS

The CLEAR classification considers methodological factors in evaluating study reliability. A prospective study among consecutive patients meeting eligibility criteria, with a reported inclusion rate, the use of contemporaneous controls when indicated, and consideration of confounders is a realistic goal. Such measures are likely to improve study quality.

Improvement of success rates for abdominal component reconstructions using bovine fetal collagen

Between February 2008 and December 2010, the author performed 15 standardized component repairs in patients reinforced with bovine fetal collagen. Of 15 repairs, 14 (93%) were intact at an average follow-up of 18 months. This success rate is a significant improvement from the author's previous success rate with this procedure (67%) and may represent a specific contribution of bovine fetal collagen reinforcement.

Evidence-based practice: functional rhinoplasty

The cause of nasal obstruction can often be attributed to pathologic conditions of the nasal valve. The key physical examination finding in nasal valve compromise is inspiratory collapse of the nasal sidewall. Validated subjective and objective measures evaluating nasal obstruction exist, although with weak correlation. Functional rhinoplasty encompasses the surgical techniques used to address obstruction occurring in this area. These techniques aim to increase the size of the nasal valve opening and/or strengthen the lateral nasal wall and nasal ala, preventing dynamic collapse. Much of the supporting evidence for functional rhinoplasty consists of observational studies that are universally favorable.

Citation classics in obstetrics and gynecology: the 100 most frequently cited journal articles in the last 50 years

OBJECTIVE

Our objective was to characterize the most frequently cited articles published in obstetrics and gynecology journals during the last 50 years.

STUDY DESIGN

We utilized the 2008 edition of Journal Citation Reports and Social Sciences Citation Index database to determine the most frequently cited articles published after 1956. Articles were evaluated for several characteristics, and an unadjusted categorical analysis was performed to compare pre- and post-1980 articles.

RESULTS

The 100 most frequently cited articles were published in 11 journals between 1957 and 2004. Most articles were published by US-based authors. Forty-four articles were related to obstetrics and 56 were related to gynecology. The most common study design was observational. There were only 7 randomized controlled trials, and randomized controlled trials were not more common after 1980 (6.3% vs 8.1%; P = .71).

CONCLUSION

Most "citation classics" in obstetrics and gynecology are observational studies published in high-impact journals by US-based authors after 1980.

Clinical research in hand surgery

Clinical research designed to enhance the quality of health care has always received a great deal of national attention. Outcomes studies, clinical trials, and evidence-based research are key components of clinical research that have advanced the field of hand surgery. The purpose of the Weiland Award is to encourage innovations and progress in clinical research in hand surgery for the betterment of patients and to promote hand surgery's visibility in American medicine. This article will highlight my efforts in clinical research through 3 specific research themes: (1) outcomes research, (2) economic analysis, and (3) evidence-based research and quality assessment in health care.

Archie Cochrane and his vision for evidence-based medicine

Archibald (Archie) Cochrane's most influential mark on health care was his 1971 publication, Effectiveness and Efficiency. This book strongly criticized the lack of reliable evidence behind many of the commonly accepted health care interventions at the time. His criticisms spurred rigorous evaluations of health care interventions and highlighted the need for evidence in medicine. His call for a collection of systematic reviews led to the creation of The Cochrane Collaboration. Archie Cochrane was a visionary person who helped lay down much of the foundation for evidence-based medicine. This article introduces evidence-based medicine to plastic surgery by tracing its history to the seminal efforts by Archie Cochrane.

Levels of evidence in research published in The Journal of Bone and Joint Surgery (American Volume) over the last thirty years

BACKGROUND

The recent emphasis on evidence-based medicine has led to increasing levels of evidence being published in surgical journals. The purpose of the present study was to review the levels of evidence in reports published in The Journal of Bone and Joint Surgery (American Volume) over the last thirty years.

METHODS

We reviewed all of the articles published in The Journal in the years 1975, 1985, 1995, and 2005. Cadaver studies, animal studies, basic-science studies, review articles, Instructional Course Lectures, and correspondence were excluded. Articles were scored according to The Journal's levels of evidence for a primary research question.

RESULTS

A total of 1058 articles were reviewed. Of these, 134, 123, 120, and 174 articles met the inclusion criteria for the years 1975, 1985, 1995, and 2005, respectively, and were ranked according to level of evidence. The number of articles for each level of evidence rating was then expressed as a percentage of the total number of articles meeting the inclusion criteria for that year. There was a significant trend toward higher levels of evidence, with the combined percentage of Level-I, II, and III studies increasing from 17% to 52% (p < 0.01). The percentage of Level-I studies increased from 4% in 1975 to 21% in 2005. The average level of evidence rating improved from 3.72 to 2.90 during the study period.

CONCLUSIONS

The level of evidence in The Journal has improved significantly over the last thirty years.

Where do we find the best evidence?

SUMMARY

As pressure on resources increases, decision makers in health care are increasingly seeking high-quality, scientific evidence to support clinical and health policy choices. Ultimately, legislators will look to develop performance measures based on evidence, rather than on consensus or commonality of practice. As plastic surgeons, we can take an increased role in producing impartial evidence on the efficacy of our surgical interventions. We can move away from the retrospective reporting of cases and nonrandomized studies and instead rely on prospective, randomized trials addressing important clinical issues. In doing so, we will challenge the common practice of basing clinical decisions solely on what we are taught, procedures we are most comfortable doing, or procedures that are most financially rewarding. These efforts will not only afford us the best opportunity to provide optimal care to patients but also allow us to demonstrate the inherent quality of our surgical specialty.

Evidence-based medicine: the fourth revolution in American medicine?

SUMMARY

The use of evidence has become a force in American medicine to improve the quality of health care. Funding decisions from payers will demand studies with high-level evidence to support many of the costly interventions in medicine. Plastic surgery is certainly not immune to this national tidal wave to revamp the health care system by embracing evidence-based medicine in our practices. In scientific contributions of plastic surgery research, application of evidence-based principles should enhance the care of all patients by relying on science rather than opinions. In this article, the genesis of evidence-based medicine is discussed to guide plastic surgery in this new revolution in American medicine.

Randomized controlled trials in plastic surgery: a 20-year review of reporting standards, methodologic quality, and impact

BACKGROUND

Randomized controlled trials in plastic surgery have not been analyzed comprehensively. We analyzed plastic surgical randomized controlled trials with respect to reporting standards, methodologic quality, and impact on the specialty.

METHODS

Randomized controlled trials published from 1986 to 2006 in three major plastic surgery journals were scored for quality and impact using the Consolidated Standards of Reporting Trials checklist, the Jadad criteria, citation numbers, and other parameters. The associations between the quality scores and multiple independent parameters, including trial impact, were explored. The relative impact of randomized controlled trials in plastic surgery was compared with that in other specialties.

RESULTS

A total of 163 randomized controlled trials were evaluated. The average Consolidated Standards of Reporting Trials and Jadad scores were 49 percent and 2.3, respectively. There were deficiencies in the reporting of parameters that influence bias and statistical significance. Randomized controlled trials with high impact or high methodologic quality had higher reporting scores. However, the quality and impact scores did not correlate with the number of participants, subject category, country of origin, or year or journal of publication. Nonsurgical trials had significantly higher quality and impact than surgical trials. Randomized controlled trials in plastic surgery had relatively lower impact as compared with randomized controlled trials in other specialties.

CONCLUSIONS

The reporting and methodologic standards of randomized controlled trials in plastic surgery need improvement. Standards could be improved if well-accepted reporting and methodologic criteria are considered when designing and evaluating randomized controlled trials. Instituting higher standards may improve the impact of randomized controlled trials and make them more influential in plastic surgery.

Levels of evidence in plastic surgery research over 20 years

BACKGROUND

Evidence-based medicine, particularly randomized controlled trials, influences many daily decisions within the medical specialties. The structure of questions asked during the history and selection of physical examination maneuvers, diagnostic tests, and treatment regimens are all guided by evidence-based medicine. Implementation of evidence-based medicine has been slower in surgical practice. The purpose of this study was to survey published plastic surgery literature to evaluate changes in the level of evidence from pre-evidence-based medicine popularization to the present time.

METHODS

Articles from Plastic and Reconstructive Surgery for the years 1983, 1993, and 2003 were ranked by a five-point level of evidence scale. The highest level of evidence value (1) was given to randomized clinical trials and the lowest value (5) was given to individual case reports; 989 articles were ranked.

RESULTS

The average level of evidence of an article published in 1983 was lower than that of one published in 2003 (4.42 versus 4.16, respectively), and the majority of research (86.9 percent in 2003) remained largely uncontrolled and descriptive in nature. However, there was a trend toward higher-quality research. The percentage of studies with control or placebo groups nearly doubled from 1983 to 2003 (from 7.21 percent to 13.7 percent), and the number of randomized clinical trials increased (zero versus seven).

CONCLUSION

The plastic surgery literature has responded to the demand for more evidence-based medicine, but the rate of change has been slow and the field will likely never enjoy the high level of evidence of medical fields.

Levels of evidence for the treatment of keloid disease

INTRODUCTION

Keloid disease presents a significant burden for patients and a significant therapeutic challenge for clinicians. Multiple treatments have been proposed, but with the increasing drive towards effective use of resources, therapeutic options need to be evaluated in terms of the levels of evidence supporting their use.

AIM

To retrieve and review the primary clinical studies evaluating keloid disease therapy over the last 25 years and assign levels of evidence for the treatment modalities evaluated.

METHOD

A Medline search was conducted to identify all primary clinical studies evaluating the treatment of keloid disease, published in English since 1980 (excluding single case reports). Studies were assigned a level of evidence (LOE-1, highest quality to LOE-5, lowest) adapted from the Oxford Centre for Evidence-based Medicine.

RESULTS

13 (12%) of 112 studies retrieved were assigned LOE-2, 99 (88%) assigned LOE-4. There were no LOE-1 studies. Ten of the LOE-2 studies evaluated silicone-based therapy or laser therapy. Most studies evaluating steroids, cryosurgery, laser therapy and post-surgical adjuvant therapy provide level 4 evidence.

CONCLUSION

High quality research in evaluating keloid therapy is lacking. There is a definite need for well designed and properly reported randomised controlled trials, to provide clinicians with a sound body of evidence on which to inform decision making.