Underrepresentation of Racial Minorities in Breast Surgery Literature: A Call for Increased Diversity and Inclusion.

OBJECTIVE: In this study, the extent of racial diversity in images of breast-related plastic surgery published literature was investigated to better understand disparities that exist in breast surgery. BACKGROUND: The lack of racial diversity in images of skin color in surgery literature can perpetuate implicit bias and stereotypes. Implicit bias can affect the way patients are evaluated, diagnosed, and treated. The visual aspects of plastic surgery make a lack of diversity in imagery especially impactful on patient care and outcomes. METHODS: Published medical images and graphics depicting human skin were analyzed across 4 major plastic surgery journals. Up to 4 years were chosen a priori to evaluate from each journal and represented the initial year of color image publication, the year of study initiation (2016), and representative years for a given decade (2000 and 2010). Images and graphics were tabulated, rated by Fitzpatrick scale and categorized into "White" or "non-White." Data were evaluated with pair-wise and linear regression statistics. RESULTS: Of the 2774 images and 353 graphics that met inclusion criteria, only 184 (8.18%) images and 9 graphics (6.34%) depicted non-White skin. Temporal analysis showed that there is an increased diversity of images published since 2010 with 0% of images being non-White before and 7.3% to 10.3% after 2010. International and multi-national authors tended to publish more non-White images. CONCLUSIONS: There is insufficient racial diversity visually represented in the breast-related plastic surgery literature with a small degree of progress made towards more equitable imagery over time. Increasing awareness of image content, and the need for equitable visual representation may allow for improved racial diversity in surgical literature.

A Picture of Modern Medicine: Race and Visual Representation in Medical Literature.

BACKGROUND: There has been a recent focus on the impact of race on health equity, which has revealed unsettling results. Multiple studies have shown that the underrepresentation of minorities in medical education such as course slides, pre-clinical lecture material, case studies, and textbooks impedes racial equity in the practice of medicine. AIM OF STUDY: In this study, we aimed to survey the landscape of published imaging in modern medicine to understand the degree of racial diversity represented in current biomedical literature. METHODS: We performed a photogrammetric analysis of medical images from the New England Journal of Medicine representing various medical fields and geographic regions to examine implicit biases with regards to human skin color. RESULTS: Overall, 18% of images depicted non-white skin tone but there was considerable heterogeneity in the percentage of non-white medical images published from different geographic regions and specialties (ranging from 0% to 67%). CONCLUSIONS: Unfortunately, these results suggest that there is an underlying implicit racial bias in published images from medical literature with an underrepresentation of minorities compared to the general population, which could also contribute to inequities in health care. It is critical that health care providers, educators, and trainees promote cultural competency and work to understand the multifaceted influence of race and culture on the daily experience of patients in the modern healthcare system. We hope this study will encourage authors to critically evaluate their medical images for implicit bias so that documented photography in scientific literature may better reflect the populations we serve.

Lateral Pectoralis Major Muscle Flap for Axillary Defect Obliteration.

This article describes the use of a lateral pectoralis major muscle flap for preemptive obliteration of axillary defects in breast cancer patients having reconstructive surgery. The muscle flap is based on a consistent lateral branch of the pectoral component of the thoracoacromial system. The flap is useful to improve axillary contour after sentinel lymph node biopsy or axillary lymph node dissection, and to cover lymphovenous anastomoses.

Patient Representation in Medical Literature: Are We Appropriately Depicting Diversity?

BACKGROUND: Racial disparities exist in the accessibility, delivery, and quality of healthcare. Clinical images are central to plastic surgery, but choice of images in the literature is susceptible to implicit biases. The objective of this study was to determine if published images reflect the racial demographic of patients. METHODS: A search for color photographs and rendered graphics depicting human skin was completed in 6 plastic surgery journals and the New England Journal of Medicine Images in Clinical Medicine for each decade between 1992 and 2017. For each article, images were categorized as white or nonwhite based on Fitzpatrick Scale (1-3 versus 4-6). Additionally, the authors' geographic region was documented. Proportional data and average number of nonwhite images per article were compared. Regression analyses were performed to assess the correlation of time and geographic region on nonwhite images. RESULTS: In total, 24,209 color photographs and 1,671 color graphics were analyzed. In plastic surgery journals, 22% of photographs were nonwhite and the average number of photographs per article with white skin was 5.4 compared with 1.6 with nonwhite skin (P < 0.0001). There was a significant increase in nonwhite photographs over time (r = 0.086, P < 0.001) and association of nonwhite photographs with international authors (r = 0.12, P < 0.001). CONCLUSIONS: Roughly 60%-70% of the world population and 30% of US cosmetic patients are nonwhite. Images in plastic surgery literature reflect neither racial demographics by global region nor the patient population seeking surgery. To advance equitable care, images should better represent the racial composition of the populations served.

Comparison of Outcomes in Immediate Implant-Based Breast Reconstruction Versus Mastectomy Alone.

OBJECTIVES: Immediate implant-based techniques are common practice in post-mastectomy breast reconstruction. Previous studies have shown an increased complication rate in the setting of immediate versus delayed, MD reconstruction. We aimed to quantify any additional risk in complications when implant-based immediate breast reconstruction (IBR) is performed versus mastectomy alone. MATERIALS AND METHODS: We retrospectively reviewed all IBR cases and all mastectomies without reconstruction from 2007 to 2011. Patient characteristics, operative details, and complication rates were reviewed and analyzed. RESULTS: IBR was performed in 315 consecutive women; mastectomy alone was performed in 401 women. Patients undergoing mastectomy alone were more often older, diabetic, and more frequently underwent neoadjuvant chemotherapy or radiation. Overall complications were higher in the IBR group, most commonly reoperation and delayed wound healing. In a multivariate analysis, IBR, increasing age, body mass index, history of radiation therapy, smoking, and nipple-sparing mastectomy were independently associated with increased risk of complications. However, IBR was only independently associated with increased risk of major complications such as reoperation or readmission for intravenous antibiotics, not minor complications. CONCLUSION: Patients selected for IBR are inherently different than those undergoing mastectomy alone. After adjusting for these differences, the increased risk of complications seen in IBR is moderately increased over the risk of complications in mastectomy alone. The observed increased risk of major complications after IBR is largely due to the aggressive management of complications in the setting of a prosthetic implant. IBR is a safe reconstructive strategy with only a slightly increased risk over mastectomy alone.

OBJECTIFS: Les techniques de reconstruction mammaire immédiate par implant sont courantes après une mastectomie. Des études antérieures ont démontré un taux de complication plus élevé après une reconstruction immédiate qu'après une reconstruction tardive. Les auteurs ont cherché à quantifier le risque supplémentaire de complications après une reconstruction mammaire immédiate (RMI) par rapport à une mastectomie effectuée seule. MATÉRIEL ET MÉTHODOLOGIE: Les auteurs ont procédé à une analyse rétrospective de toutes les RMI et de toutes les mastectomies sans reconstruction effectuées entre 2007 et 2011. Ils ont étudié et analysé les caractéristiques de patientes, les détails des opérations et le taux de complications. RÉSULTATS: Selon l'analyse, 315 femmes consécutives ont subi une RMI et 401 femmes, une mastectomie seule. Les patientes qui avaient subi une mastectomie seule étaient souvent plus âgées, diabétiques et soumises à une chimiothérapie néoadjuvante ou à une radiothérapie. Les complications globales étaient plus élevées dans le groupe ayant subi une RMI, surtout à cause d'une réopération et d'une guérison plus lente des plaies. D'après une analyse multivariée, la RMI, le vieillissement, l'indice de masse corporelle, des antécédents de radiothérapiele tabagisme et une mastectomie épargnant le mamelon présentaient une corrélation indépendante avec un risque accru de complications. La RMI présentait seulement une corrélation indépendante avec un risque accru de complications majeures comme une réopération ou une réhospitalisation visant à administrer des antibiotiques par voie intraveineuse, et non de complications mineures. CONCLUSION: Les patientes sélectionnées pour la RMI sont foncièrement différentes de celles qui subissent une mastectomie seule. Après rajustement pour tenir compte de ces différences, le risque de complications observé après une RMI est légèrement plus élevé que celui qui s'associe à une mastectomie seule. Le risque accru de complications majeures observé après une RMI est largement attribuable à la prise en charge énergique des complications après un implant prothétique. La RMI est une stratégie de reconstruction sécuritaire dont le risque est seulement un peu plus élevé que la mastectomie seule.

Comparison of vertical and oblique rectus abdominis myocutaneous flaps for pelvic, perineal, and groin reconstruction.

BACKGROUND: Wound complications after perineal and groin obliterative procedures are a significant cause of morbidity, particularly following chemoradiation therapy. Vertical and, increasingly, oblique rectus abdominis myocutaneous flaps have been used to fill potential dead space and bring healthy, vascularized tissue into the defect. The authors compared the complications and outcomes of patients undergoing perineal or groin reconstruction with vertical or oblique rectus abdominis myocutaneous flaps. They hypothesized that the oblique flap offers outcomes similar to those of the vertical flap, without an increased risk of complications. METHODS: All patients who underwent immediate reconstruction of perineal, pelvic, or groin defects using vertical (n=49) or oblique rectus abdominis myocutaneous (n=22) flaps over the past 10 years at the University of Washington Medical Center were reviewed retrospectively. Patient, disease, and obliterative procedure characteristics and donor- and recipient-site complications were compared. Statistical analysis was performed using the t test for continuous variables and Fisher's exact test for categorical variables. RESULTS: There were no statistically significant differences in major or minor donor- or recipient-site complication rates, need for augmented fascial closure, need for additional flaps, flap loss, readmission, or reoperation rate between the two groups. CONCLUSIONS: Immediate reconstruction of perineal or groin defects with oblique rectus abdominis myocutaneous flaps results in complication rates similar to those with reconstruction using with vertical flaps. Oblique flap reconstruction is a reasonable and safe alternative, providing several distinct advantages over the vertical flap, including greater arc of rotation, thinner skin paddle, less bulk, and limited fascial harvest. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Cortical morphology of visual creativity.

BACKGROUND AND OBJECTIVE: The volume of cortical tissue devoted to a function often influences the quality of a person's ability to perform that function. Up to now only white matter correlates of creativity have been reported, and we wanted to learn if the creative visuospatial performance on the figural Torrance Test of Creative Thinking (TTCT) is associated with measurements of cerebral gray matter volume in the regions of the brain that are thought to be important in divergent reasoning and visuospatial processing. METHODS: Eighteen healthy college educated men (mean age=40.78; 15 right-handers) were recruited (via advertisement) as participants. High-resolution MRI scans were acquired on a 1.5T MRI scanner. Voxel-based morphometry regression analyses of TTCT to cortical volume were restrained within the anatomic regions identified. RESULTS: One significant positive focus of association with TTCT emerged within the right parietal lobe gray matter (MNI coordinates: 44, -24, 63; 276 voxels). CONCLUSIONS: Based on theories of parietal lobe function and the requirements of the TTCT, the area observed may be related due to its dominant role in global aspects of attention and visuospatial processing including the capacity for manipulating spatial representations.