Rethinking Evidence-Based Medicine in Plastic and Reconstructive Surgery

Abstract

Sir: Plastic surgery is a problem-solving specialty.1,2 In solving problems, ends are what matter. Similarly, in surgery, outcomes, “the ends” here, determine success and effectiveness of surgical planning and execution, given that surgery is safe with minimal morbidities. Good outcomes are the product of expertise, anatomical understanding, and technological advancements, when consistently reproducible, proven in a series of adequate volume, they can be used to reinforce certain technique/practice. However, how many outcome reports like these are available in the plastic surgery literature, so that a scientific comparison for an evidence-based approach can be provided? Evidence-based medicine is not without weakness3; it is inherently restrained by the quality of evidence in the literature, affected by the timing of proposal of the technique, experience of the operator, instruments used, anatomical understanding, and volume, and the list goes on. As this is the case, one wonders why we keep on using this method to evaluate what we have, and to find out which method works the best. Although it is worthy to review the literature comprehensively to fully understand a procedure(s) with regard to its limitations, morbidity, indications, and potential refinements, such a review cannot and should not be used to judge and compare methods because of the inherent weakness pointed out. Also, if some would still be interested in these studies, perhaps it could be better to avoid allocating substantial funds, time, and manpower to conduct them. Another hard question is if one can produce one meaningful study per month, for instance, should they invest in a comparison study, under the evidence-based medicine umbrella, or in innovating new techniques, refining old ones, and well-reported outcome studies? Why I am concerned? Plastic surgery “defies” anatomical boundaries,4 and surgery is becoming fluid, with so much overlap among specialties. In addition, referrals are not controlled by plastic surgeons. Thus, when our resources are limited, it becomes crucial to focus more on what can ensure the survival of this specialty rather than what makes it sound more scientific. Can we agree that our ability to do things in many ways and identify problems and innovate solutions to them is what shall ensure our survival as plastic surgeons? Was it an evidence-based medicine mentality that brought about kidney transplantation and pioneered perforator flaps, implant-based reconstruction, and other techniques? Just imagine what evidence-based medicine, lacking high-quality evidence, could have done, instead. My message is this: plastic surgery survival depends on innovations and communications; plastic surgeons still need to be innovators, pioneers, creators, visionaries, and communicators, not only scientists. When we investigate the literature, let us do it to answer questions that lay down foundation for groundbreaking ideas. Although outcomes studies are needed, let us have less space for a comparison among techniques such as autologous versus implant-based, or approaches such as open versus closed, manual versus robot, or in between flaps, and so forth. If comparison must be made, let it be among experts, not among a pool of data. Let us ask better, and give more space to identify problems and pioneer solutions for them. DISCLOSURE The author has no financial interest to declare in relation to the content of this article. Nidal F. AL Deek, M.Sc., M.D.Department of Plastic and Reconstructive SurgeryChang Gung Memorial HospitalChang Gung Medical College and Chang Gung University199 Tun-Hwa North RoadTaipei 10591, Taiwan[email protected]