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

Five decades of research on immediate implant therapy: A modern bibliometric network analysis via Altmetric and level of evidence mapping

AIM

To conduct a bibliometric network analysis to explore the research landscape of immediate implant placement (IIP) and provide insights into its trends and contributors.

MATERIALS AND METHODS

The Scopus database was utilized as the bibliographic source, and a search strategy was implemented to identify relevant research articles. Various bibliometric parameters were extracted, including publication year, journal, authors, citations, and funding. The analysis involved examining authorship patterns, international collaborations, level of evidence, Altmetric data, and funding analysis.

RESULTS

We identified a steady annual growth rate of 6.49% in IIP research. The top three countries contributing to research output were the USA, Italy, and China. Prolific authors were identified based on publication and citation metrics. International collaborations among different countries were observed. The level of evidence analysis revealed that over 30% of the articles fell into higher levels of evidence (levels 1 and 2). Altmetric data analysis indicated no significant correlations between citation counts and Altmetric Attention Score (AAS), and conversely a significant association with Mendeley readers count. Funding and open access did not significantly impact the bibliometric indices of the papers.

CONCLUSIONS

The focus of research on IIP has been evolving as indicated by an exponential growth rate in this study. Only approximately 16% of the articles fit into level 1 evidence, therefore, emphasizing on higher quality level research study shortage in this field. Modern indices can be used as new bibliometric indicators as they also cover social media and online attention scores.

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 .

Characterizing Clinical Trials in Plastic and Reconstructive Surgery: A Systematic Review of ClinicalTrials.gov From 2007 to 2020

BACKGROUND

Clinical trials form the backbone of evidence-based medicine. ClinicalTrials.gov is the world's largest clinical trial registry, and the state of clinical trials in plastic and reconstructive surgery (PRS) within that database has not been comprehensively studied. To that end, we explored the distribution of therapeutic areas that are under investigation, impact of funding on study design and data reporting, and trends in research patterns of all PRS interventional clinical trials registered with ClinicalTrials.gov.

METHODS

Using the ClinicalTrials.gov database, we identified and extracted all clinical trials relevant to PRS that were submitted between 2007 and 2020. Studies were classified based on anatomic locations, therapeutic categories, and specialty topics. Cox proportional hazard was used to calculate adjusted hazard ratios (HRs) for early discontinuation and results reporting.

RESULTS

A total of 3224 trials that included 372,095 participants were identified. The PRS trials grew at an annual rate of 7.9%. The therapeutic classes most represented were wound healing (41.3%) and cosmetics (18.1%). Funding for PRS clinical trials is largely provided through academic institutions (72.7%), while industry and US government constituted a minority. Industry-funded studies were more likely to be discontinued early than those funded by academics (HR, 1.89) or government (HR, 1.92) and to be nonblinded and nonrandomized. Academic-funded studies were the least likely to report results data within 3 years of trial completion (odds ratio, 0.87).

CONCLUSIONS

A gulf exists in the representation of different PRS specialties among clinical trials. We highlight the role of funding source in trial design and data reporting to identify a potential source of financial waste and to stress the need for continued appropriate oversight.

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.

A Systematic Review of Electromagnetic Treatments for Body Contouring

BACKGROUND

Energy-based treatments include ultrasound, lasers, cryolipolysis, and radiofrequency. The most recent energy treatment for noninvasive body contouring is electromagnetic treatments-a hot topic in plastic surgery today. A systematic review to assess efficacy and safety has not been published.

METHODS

An electronic search was performed using PubMed to identify the literature describing electromagnetic treatments. Measurements from imaging studies were tabulated and compared.

RESULTS

Fourteen clinical studies were evaluated. Two studies included simultaneous radiofrequency treatments. In 11 studies, the Emsculpt device was used; in 2 studies, the Emsculpt-Neo device was used. One study included a sham group of patients. The usual protocol was 4 treatments given over a 2-week period. No complications were reported. Eight studies included abdominal measurement data obtained using magnetic resonance imaging, computed tomography, or ultrasound. Photographic results were typically modest. Photographs showing more dramatic results also showed unexplained reductions in untreated areas.Measurement variances were high. The mean reduction in fat thickness was 5.5 mm. The mean increment in muscle thickness was 2.2 mm. The mean decrease in muscle separation was 2.9 mm (P = 0.19). Early posttreatment ultrasound images in 1 study showed an echolucent muscle layer, compared with a more echodense layer at the baseline, consistent with tissue swelling after exercise. Almost all studies were authored by medical advisors for the device manufacturer.

DISCUSSION

Measurement data show small reductions in fat thickness, occurring almost immediately after the treatments. Adipocyte removal without tissue swelling would be unique among energy-based treatments. Similarly, muscle hypertrophy is not known to occur acutely after exercise; muscle swelling likely accounts for an early increment in muscle thickness. Any improvement in the diastasis recti is likely fictitious.

CONCLUSIONS

Electromagnetic treatments, either administered alone or in combination with radiofrequency, are safe. However, the evidence for efficacy is tenuous. Measured treatment effects are very small (<5 mm). Conflict of interest and publication bias are major factors in studies evaluating energy-based alternatives. The evidence-based physician may not be satisfied that an equivocal treatment benefit justifies the time and expense for patients.

Customized cost-effective polymethylmethacrylate cranioplasty: a cosmetic comparison with other low-cost methods of cranioplasty

BACKGROUND

Intraoperative hand-moulded cranioplasty and polymethylmethacrylate (PMMA) prostheses made from bone impressions are economical but the cosmetic results are less than satisfactory. Commercially available customized prostheses perform better but are prohibitively expensive. We evaluate the performance of a locally developed, low-cost customized PMMA cranioplasty prosthesis.

OBJECTIVE

To compare the cosmetic outcome of 3 types of PMMA cranioplasty as well as with objective measurements on postoperative CT scans METHODS: This study includes 70 patients who underwent cranioplasty between March 2016 and June 2020. In this period, patients had their cranioplasty prostheses made by intra-operative hand moulding (HM), by using the removed bone as a template and making a bone impression (BI) or by 3D printing the prosthesis based on a CT scan. Cosmetic outcomes were assessed by the patient and the operating surgeon on an 8-point scale. The degree of measured anthropometric asymmetry was measured on a postoperative CT scan and correlated with the cosmetic outcome.

RESULTS

Our locally produced 3D-printed cranioplasty prostheses showed a statistically better performance in cosmetic scores when compared to the HM and BI (p value < 0.001). CT anthropometric measurements significantly correlated with cosmetic outcome (p value 0.01) CONCLUSION: Our 3D cranioplasty prostheses had better cosmetic outcomes than HM and BI prostheses, and our technique is able to produce them at 10% of the cost of the currently available commercial customized prostheses.

The 100 Most-cited Articles in Abdominoplasty: A Bibliometric Analysis

Background:

Abdominoplasty is one of the most common aesthetic procedures performed globally. Research in this field is evolving, with recent emphasis on evidence-based surgery optimizing informed consent. This bibliometric analysis aimed to characterize emerging research trends and to assess the methodological quality of the highest impact abdominoplasty research.

Methods:

The 100 most-cited articles in abdominoplasty were identified on Web of Science, across all available journals and years (1950–2019). Study details, including the citation count, main subject, and outcome measures, were extracted from each article by 2 independent reviewers. The level of evidence of each study was also assessed.

Results:

The 100 most-cited articles in abdominoplasty were cited by a total of 2545 articles. Citations per article ranged from 206 to 34 (mean 65). Overall, 50 articles were assessed to be level of evidence 3, which is representative of the large number of cohort studies (n = 59) on the list. Similar numbers achieved levels 2, 4, and 5 (n = 16, 20, and 14), though none reached level 1. The main subject was operative technique in 50 articles, followed by outcomes in 34 articles. Only 7 articles utilized objective cosmetic outcome measures. Patient-reported outcome measures were employed in 25 articles, though only 5 incorporated validated questionnaires.

Conclusions:

The most-cited research in abdominoplasty largely comprised low-to-moderate quality studies, with no article achieving the highest level of evidence. Contemporary high-quality evidence incorporating validated outcome measures is crucial to enhance shared decision-making, particularly in aesthetic procedures.

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.

Management of Capsular Contracture in Cases of Silicone Gel Breast Implant Rupture with Use of Pulse Lavage and Open Capsulotomy

INTRODUCTION

Pulse lavage (PL) irrigation of prosthesis pockets has prior been described for breast implant salvages. However, PL for removal of leaked silicone from prosthesis pockets after implant ruptures has not been studied yet. Since open capsulotomies are regarded as equal treatment of capsular contracture (CC) than capsulectomies, this study analyzed the clinical outcome of PL for silicone removal and subsequent capsulotomy in cases of concurrent CC and breast implant rupture.

METHODS

Between 2012 and 2017, 55 patients (75 breasts) with suspected silicone implant rupture and CC (Baker grade III/IV), after primary breast augmentation or implant-based breast reconstruction, were included in a retrospective, observational study. Mean patient follow-up was 12.2 ± 3.6 months.

RESULTS

In all preoperatively suspected ruptured silicone breast implants, around a quarter were intact. In contrast to previously published data, implant exchanges in cases of implant ruptures did not lead to significantly higher CC recurrence rates (27.6% vs. 22.2% in cases of intact implants, p = 0.682), if the prosthesis pockets were treated with PL irrigation followed by open capsulotomy. PL reduced the amount of encapsulated silicone remnants histologically. The age of patients with CC after failed implant-based reconstruction was significant lower for salvage surgeries with flap reconstruction than for implant exchanges, p < 0.05.

CONCLUSIONS

PL irrigation of prosthesis pockets prior to open capsulotomy is a safe and effective treatment of CC with concurrent silicone leakage. Remaining silicone remnants in breast capsules may affect the development of a recurrent CC. To avoid CC recurrences, patients should consider conversion to autologous tissue.

LEVEL OF EVIDENCE IV

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 .

The Past Informs the Present, Academic New Media Pitfalls: A Primer for Plastic Surgeons

Mass communication has undergone a “new media” revolution, which includes the rise of digital, online, and social media. The impact of new media on academic processes, however, has been underappreciated. The rise of Web-based virtual platforms has profoundly impacted the way plastic surgeons publish, store, exchange, and analyze scholarly biomedical information. This new media academic phenomenon refers to electronic mechanisms with the capacity to supplant traditional publication methods, which typically rely on printed documents in the physical domain. Although such tools can be efficient and user-friendly, they also make users vulnerable to exploitation. Notable examples reveal a relative lack of regulation, oversight, reliable rating scales, user authentication, and ethical accountability in the virtual space. As with any new technique, education is key and knowledge is power. In this article, online resources related to healthcare and the practice of plastic surgery are reviewed and summarized, including open access, mega-indices, whitelists, and electronic alerts. New media provides powerful knowledge-sharing tools that can help execute scholarly endeavors, communicate between professionals, and educate the public. However, it is essential for plastic surgeons to appreciate the caveats of new media academic processes to avoid unscrupulous practices of those that may seek to manipulate these Web-based systems. This article outlines the key pitfalls associated with online information streams to better inform plastic surgeons how to navigate new media-based scholarly processes.

[Quality of publications in plastic surgery]

INTRODUCTION

The objective of this study is to describe plastic surgery publications in terms of methodology, level of evidence, approval by institutional review board, method of consent, and subspecialty.

METHODS

The 8 top-ranked plastic surgery journals were selected. We manually reviewed the last 40 original articles in each plastic surgery journal, to represent more than 2 months of publications for all journals (range: 3-17 months). Only clinical original articles on human subjects were included. Each article was read at least twice by two different reviewers to ensure accurate data transcription, and then graded by written criteria. One of the senior authors was asked to make a final decision in case of doubt.

RESULTS

Among the articles reviewed, 320 were analyzed. The geographical origin of these publications were Asia (32.5%), Europe (30%), US (28.4%), South America (5.6%), Africa (2.5%), and finally Oceania (1%). Reconstructive surgery remains the specialty area most represented in the journals with almost half of the publications, followed by breast surgery (24%) and plastic surgery (19%). A total of 75.6% were retrospective studies. Nearly 80% of the studies were of low level of evidence. Only 3.5% were randomized trials. Less than 40% of the publications mentioned approval by an institutional committee, and 22.6% a patient's informed consent.

CONCLUSION

This study aimed to analyze the quality of plastic surgery publications, taking into account the criteria of Evidence Based Medicine. This work showed that more than half of the studies did not mention an institutional review board approval (Ethics Committee), and that three quarter of the studies did not indicate the presence of patient's informed consent. Ultimately, over 80% of the studies were of low level of evidence. The top-ranked journals have already imposed guidelines corresponding to the methodology requirements to publish clinical studies in their pages, such as EQUATOR criteria for the PRS journal. Efforts are therefore to be done to raise the scientific level of the publications of our specialty.

Validity, reliability, and the questionable role of psychometrics in plastic surgery

SUMMARY

This report examines the meaning of validity and reliability and the role of psychometrics in plastic surgery. Study titles increasingly include the word "valid" to support the authors' claims. Studies by other investigators may be labeled "not validated." Validity simply refers to the ability of a device to measure what it intends to measure. Validity is not an intrinsic test property. It is a relative term most credibly assigned by the independent user. Similarly, the word "reliable" is subject to interpretation. In psychometrics, its meaning is synonymous with "reproducible." The definitions of valid and reliable are analogous to accuracy and precision. Reliability (both the reliability of the data and the consistency of measurements) is a prerequisite for validity. Outcome measures in plastic surgery are intended to be surveys, not tests. The role of psychometric modeling in plastic surgery is unclear, and this discipline introduces difficult jargon that can discourage investigators. Standard statistical tests suffice. The unambiguous term "reproducible" is preferred when discussing data consistency. Study design and methodology are essential considerations when assessing a study's validity.