The current study by Chang et al is a commendable effort to clarify the state of evidence-based medicine (EBM) in aesthetic surgery practice during the last 10 years. Congruent with the expansion of aesthetic surgery publications identified by the authors, the results of several literature searches conducted during the composition of this commentary allow this conclusion to be broadened. These searches revealed that the rate of biomedical literature publication as a whole is increasing. Since 1950, this rate has increased approximately 3.5% annually on average; over the last 10 years, the increase has been approximately 4.8%.
More specifically and relevantly, literature related to “surgery” seems to be expanding at a rate somewhere between 4.0% and 5.2% per annum since 1950. The rate of publication of literature specifically related to “plastic surgery” or “reconstruction” has been trending upwards between 4.3% and 10.2% per year since 1950, with higher compounding rates within the last decade. These numbers represent the total number of reports in these areas, including all levels of evidence as outlined by Chang et al. In 2005 alone, more than 100,000 reports were recorded with the keyword “surgery” and more than 3000 published papers related to “plastic surgery.” Taken at face value, these numbers represent encouraging progress towards placing increased emphasis on the incorporation of the “science of surgery” into patient care. However, as cogently argued by Chang et al, this dramatic increase in the quantity of surgery-related investigations has not necessarily translated into the development of a scientifically sound body of knowledge that aesthetic surgeons (and surgeons as a whole) can draw upon to guide their surgical practice. Therefore, one is prompted to inquire further as to both the source of this disparity and what needs to be done to improve the “quality” of aesthetic surgery literature.1,2
Aesthetic surgery—and surgery in general—has long been faced with criticism of its evidence base. Surgeons, unlike other medical practitioners, are faced with a number of physical and/or mechanical “problems” in their practices that are often not encountered in the treatment of nonsurgical disease. Nowhere is this truer than in the fields of aesthetic and reconstructive plastic surgery. Plastic and reconstructive surgery, since its inception before recorded history, has been concerned with restoration of the physical human form; its very name comes from the Latin and Greek terms plasticus and plastikos, respectively, which describe that which is capable of molding or forming.3 The obvious difference is that physiologic disturbances seen in medical practices result in objectively observable illness, while individuals seeking cosmetic surgery often present with subjectively determined “complaints” that are best treated by surgical interventions crafted on a case-by-case basis.
Aesthetic surgery in particular is unique in that, relative to other disciplines, it treats a disproportionately greater number of patients with underlying psychiatric conditions, including body dysmorphic disorder, narcissistic personality disorder, and histrionic personality disorder.4 Given the supratentorial aspect of patients undergoing cosmetic procedures, the surgeon's desire to meet a patient's need for emotional satisfaction often outweighs many objectively observable criteria. For example, whether breasts are perfectly symmetric or slightly asymmetric, or technically perfect or imperfect overall, seems to matter less than essential patient satisfaction.5 The intended outcome of aesthetic surgery is largely determined by the patient's individual preference, rather than by what would be viewed as an optimal outcome by more objective measures. As such, plastic surgeons performing cosmetic surgery may, in the interest of self-preservation, be disinclined to defer to a surgical approach potentially defined by high-level evidence if a technique that is “tried and true” and results in satisfied patient, is available. Satisfied patients serve as strong positive reinforcement to continue a clinical practice, given the unique (and harsh) economic and medicolegal climates of cosmetic surgery. In addition, many plastic and reconstructive surgeons pride themselves on their mastery of the design aspect of the surgery, not the algorithm. For example, while nipple reconstruction can be performed at the intersection of the midclavicular and inframammary lines, this is only a guide. The nipple–areola complex must truly be designed. In aesthetic surgery, as another example, a face must be “sculpted” when being lifted. Patients come in all shapes and sizes, so individual modification of the face lift procedure is not only practiced by cosmetic surgeons, but required. Even slight under- or overlifting can have devastating consequences as viewed by the patient.
Several reports also raise significant concerns regarding the widespread applicability of EBM in the surgical arena, given the learning curve and technique-dependent outcomes that are associated with the operations—factors which play a less significant role in the care of patients in other medical disciplines. Furthermore, interoperator bias and intersubject modification are unavoidable in surgery, which is another fundamental aspect differentiating surgical practice from that of our medical colleagues.6 Finally, clinical investigations probing the treatment of surgical disease (as opposed to diseases best treated with medical interventions) frequently do not lend themselves to placebo or “sham” surgery given the potential immediate adverse consequences nonintervention can pose to patients' well-being.
In the face of such hurdles, enthusiasm for participation in studies producing high-level evidence, as described by Chang et al, has been dampened. That said, the potential benefits to be gained by patients through the implementation of an evidence-based surgical practice are beginning to show up in the literature. Recently, investigators have attempted to apply standard, validated, and reliable metrics to traditionally subjective findings. For example, the use of three-dimensional laser scanning and three-dimensional photography have been applied to facial plastic surgery and breast surgery.7,8 Using this technology, it will be possible to objectify changes in craniofacial and breast shape rather than relying on subjective appearance alone. As such, three-dimensional geomorphometrics may be one strategy to eliminate confounding variables and elucidate which intrinsic factors are desired in satisfied patients undergoing breast and facial surgery.
Aesthetic surgery has historically not been predicated on high-level evidence reports. Given the rapid expansion of the literature, elucidating sound scientific information from the mass of data that have been published has become exceedingly difficult. The importance of developing skills to critically evaluate the literature and answer questions with efficiency, validity, and applicability to patients cannot be overstated. Furthermore, emphasis must be placed on improving objective and observable medical aspects of cosmetic surgery, such as operative time, postoperative pain, bleeding, edema, and recovery time.9 An additional obstacle to the practice of evidence-based aesthetic surgery is the fact that many accepted procedures predate the emergence of EBM and their persistence is based in the natural inclination of risk-adverse surgeons to continue to do what they know “works” without consideration for what might truly be best for patients. In order for the field of aesthetic surgery to appreciate and assimilate significant advances, surgeons must commit themselves to a concerted effort to conduct investigations that objectively probe surgeon-controlled variables. Most importantly, however, surgeons must be willing to evolve their practice to achieve optimal patient outcomes based upon the data obtained from these studies.
The authors have no disclosures with respect to the contents of this commentary.