A First for Plastic Surgery, the American Board of Plastic Surgery, the American Society of Plastic Surgeons, and Plastic and Reconstructive Surgery: 20 Evidence-Based Maintenance of Certification Articles, Beginning with This Issue

Beginning in December of 2010, Plastic and Reconstructive Surgery is pleased to publish the first 10 of 20 evidence-based review articles on the 20 topics required for American Board of Plastic Surgery Maintenance of Certification. This is the second round of 20 Maintenance of Certification articles to come out in Plastic and Reconstructive Surgery; the first round was published in early 2008. The first 10 new articles are on the following: (1) breast augmentation/augmentation mammaplasty, (2) breast reduction, (3) breast reconstruction, (4) carpal tunnel, (5) abdominoplasty, (6) blepharoplasty, (7) cleft palate, (8) face lift, (9) metacarpal fractures, and (10) Dupuytren contracture. This is the first time in the history of Plastic and Reconstructive Surgery that a series of review articles covering some of the most common plastic surgery procedures will be evidence based. Each of these articles has been carefully peer reviewed by a large panel of the Journal's Editorial Board members and ad hoc reviewers, and then also by American Society of Plastic Surgeons staff member Jennifer Swanson, B.S., M.Ed., who provided extensive project management, evidence-based medicine advice, and editorial support. In addition, we gratefully acknowledge American Society of Plastic Surgeons staff member Karie O'Connor, M.P.H., for literature searches, and Victoria Briones Chiongbian, Ph.D., and Michelle Secic, M.S., of Secic Statistical Consulting, Inc., for critical appraisal of studies included in these reviews. This team of evidence-based experts dispassionately analyzed most of the references in each article to give you an unbiased view of the level of evidence that the articles provide. For example, in the breast augmentation Maintenance of Certification article by Thorne, the following sentence appears: “Romundstad et al. demonstrated that methylprednisolone 125 mg intravenously given before breast augmentation had analgesic sparing effects compared with nonsteroidal anti-inflammatory drugs and had the additional benefit of reducing nausea, vomiting, and fatigue (Therapy: Level I, II Evidence).”1,2 You as the Plastic and Reconstructive Surgery reader now will be able to believe a Level 1 Evidence (prospective, randomized, double-blind, controlled trial) or Level II Evidence (prospective, nonrandomized, nonblinded comparison of two techniques) article much more readily and take it to your practice with much more confidence than if you had just read yet another much less valid article of a case series (Level IV Evidence) of someone reviewing 300 charts of patients who received steroids. Until now, both readers of Plastic and Reconstructive Surgery and plastic surgeons as a group have experienced many days when someone stands at the front of a room and says: “We have six studies that say this and six studies that say that” and we leave confused. In 2010, we are championing evidence-based medicine in our Journal; we will publish articles that show that Level I Evidence studies supersede Level IV Evidence or Level V Evidence (expert opinion) studies. This is our overall goal for Plastic and Reconstructive Surgery and our entire specialty; we will all be better for it.3 If we do not know or analyze the level of evidence of an article, we do not understand how important it is in determining whether we should let it change our practice. Part of the problem is that we cannot always agree or understand what the true level of evidence of an article is unless we spend a little time learning about it. In these 20 articles, the levels of evidence have been decided on by those who truly understand the labels. This 20-article collaborative effort among the American Board of Plastic Surgery (20 directors wrote the articles and multiple choice questions), the American Society of Plastic Surgeons (funded and provided the level of evidence expertise), and Plastic and Reconstructive Surgery (provided peer review, editing, and publishing the articles and online courses with the American Society of Plastic Surgeons) is clearly going to add to the body of knowledge on evidence-based medicine for plastic surgery. We now have a foundation of evidence for common procedures on which to build. Young, bright plastic surgeons will see that in a given area of breast reduction, we already may have 10 Level IV Evidence studies so we do not need another one. What we need is a higher Level III, II, or I Evidence study to improve and change. Perhaps we can now finally stop using antibiotics for 3 to 5 days postoperatively in a clean, elective plastic surgery case. We both hear that we do not have high level evidence in plastic surgery. The reasons for this are multifactorial. We do not have many high level evidence articles, or articles with large case series in cosmetic surgery. This lack of good evidence poses a challenge to the specialty, and we need to conduct and publish more evidence-based studies. In this new 20-article Maintenance of Certification series, Thorne cites three Level I Evidence, 11 Level II Evidence, and three Level III Evidence studies in breast augmentation.4 Noone documents one Level I Evidence, 14 Level II Evidence, and six Level III Evidence studies in breast reduction.5 In the blepharoplasty article by Friedland et al., there are one Level I Evidence, nine Level II Evidence, and eight Level III Evidence studies.6 In the carpal tunnel article by Shores and Lee, there are 11 Level I Evidence and 25 Level II Evidence studies.7 Part of the problem is that when we read a new Level II Evidence article on face lifting, we are not accustomed to fixing that in our mind as the new standard until better Level II or I Evidence studies come along to displace it. We keep equating new Level II Evidence with lower Level IV or V Evidence studies by more prolific writers and well-known plastic surgery “experts” instead of putting it at the top of the ladder where it remains until something better displaces it. The multiple choice questions that come with these 20 articles are also evidence-based in their discussions. For example, Slezak's breast reconstruction article8 comes with the following multiple choice question and bolded level of evidence discussion if you take the Plastic and Reconstructive Surgery test online: Question: Which of the following patient characteristics is the most significant predictor of increased risk of complications following breast reconstruction? A) Age older than 50 years B) Diabetes C) History of smoking D) High body mass index Correct answer: D. Discussion: Obesity was found to be a risk factor for complications in two large studies. The Michigan Breast Reconstruction Outcome Study is a prospective, multicenter cohort study of 460 women that involved 23 plastic surgeons at 12 hospitals and followed patients for 2 years (Level II Evidence).1 Data for implants/expanders, TRAM flaps, and free TRAM flaps were analyzed. In this study, logistic regression showed that increased body mass index of the patient showed a significantly increased risk (p < 0.001) of a major complication. McCarthy analyzed a retrospective comparative study of 1170 expander implant patients over 2 years (Level III Evidence).2 Obese patients had a 25 percent complication rate versus 14 percent for patients with a body mass index less than 30 kg/m2. The effect of active smoking was seen in this study and not in the Michigan study, but no study found a history of smoking to be a risk factor. Diabetes was not found to be a risk factor in any study. Age older than 65 years was found to be a risk factor in one study, but patients in their 50s had no increased risk. References Alderman AK, Wilkins EG, Kim HM, Lowery JC. Complications in postmastectomy breast reconstruction: Two-year results of the Michigan Breast Reconstruction Outcome Study. Plast Reconstr Surg. 2002;109:2265–2274. McCarthy CM, Mehrara B, Riedel E, et al. Predicting complications following expander/implant breast reconstruction: An outcomes analysis based on preoperative clinical risk. Plast Reconstr Surg. 2008;121:1886–1892. These multiple choice questions and discussions written by American Board of Plastic Surgery will not only appear for those who take the Maintenance of Certification online tests to satisfy parts II and IV of Maintenance of Certification requirements, they will also appear on the American Society of Plastic Surgeons Maintenance of Certification study guide for the 10-year American Board of Plastic Surgery Maintenance of Certification examination. In this way, plastic surgeons will see over and over the higher level of evidence quoted studies so they become part of our lexicon to displace the Level IV and V Evidence mentality of the past. We also hear that we cannot write good evidence-based articles on subjective topics such as cosmetic and breast surgery where aesthetic results are debatable. We encourage young writers and plastic surgeons to follow the lead of the likes of Kevin Chung,9–12 Achilles Thoma,13–16 Andrea Pusic,17,18 and others who are developing validated questionnaires such as FACE-Q19 and BREAST-Q18 so we can quantify and compare aesthetic outcomes as we continue the quest to measure our results with better science as we practice the art of plastic surgery. These studies are of great value, and we can and will make evidence-based medicine in plastic surgery a part of our daily practice because we will all be better plastic surgeons and provide better and higher quality long-term care to our patients. We invite you to join with the American Society of Plastic Surgeons, American Board of Plastic Surgery, and Plastic and Reconstructive Surgery on this journey, and ask you to participate to make it a wonderful and exciting experience.