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Analysis Of Racial Disparities In Breast Plastic Surgery Literature
Daniel Y. Cho, MD, PhD1, Cameron J. Kneib, MD1, Danielle L. Sobol, MD1, Christopher S. Crowe, MD1, Afaaf Shakir, MD2, Megan Lane, MD3, Jacob Burns, MD4, Jonathan P. Massie, MD5, Shane D. Morrison, MD, MS1, Janice Sabin, PhD, MSW1, Janelle D. Sousa, MD1.
1University of Washington, Seattle, WA, USA, 2University of Chicago, Chicago, IL, USA, 3University of Michigan, Ann Arbor, MI, USA, 4University of California Davis, Sacramento, CA, USA, 5Northwestern University, Chicago, IL, USA.

PURPOSE: Breast surgery comprises a significant portion of plastic surgery. Given the high volume of breast surgery procedures, it is a significant area of investigation in plastic surgery literature. The aim of this study was to use established photogrammetric analysis techniques to evaluate the visual representation of racial diversity in the published breast surgery literature and to understand how it compares to the general and plastic surgery patient population.
METHODS: Leading journals in the field of plastic surgery were selected for analysis including Annals of Plastic Surgery (APS), Aesthetic Surgery Journal (ASJ), Journal of Plastic, Reconstructive, and Aesthetic Surgery (JPRAS), and Plastic and Reconstructive Surgery (PRS). All articles published during the full first calendar year in which photographs and graphics were published in color of each journal as well as 2000, 2010, and 2016 were selected for inclusion. Each image and graphic was visually analyzed using the Fitzpatrick scale as a guide with input from observable phenotypes following previously established methods. The average number of white and non-white images and graphics per article were calculated and pairwise comparisons were made using a two-tailed unpaired Studentís t-test.
RESULTS: A total of 913 published articles with 2774 images and 353 graphics met inclusion criteria based on publication date and subject matter of breast surgery. There were 391 (42.83%) articles that included figures depicting human skin of which only 35 (3.72%) articles contained images of non-white subjects; 2065 (91.82%) images were of white skin while 184 (8.18%) images were of non-white skin. There were 5 articles (0.55%) which contained graphics and a total of 9 graphics with nonwhite skin (6.34%) compared to 133 graphics with white skin (93.66%). Temporal analysis revealed that there has been a slight increase in diversity over time from 0% of articles including non-white images before 2010 to 7.3%-10.3% after 2010 across all the journals included in this study. A similar trend was seen with graphics, which revealed 5.6% and 12.2% non-white graphics in 2010 and 2016, respectively. Analysis by average number of images and graphics per article confirmed statistically significant under representation of non-white skin across all journals (p < 0.001).
CONCLUSION: This study is the first known investigation of racial diversity and inclusion in breast imagery. It clearly demonstrates the insufficient racial diversity visually represented in the breast-related plastic surgery literature across multiple journals. There has been a small degree of progress made towards more equitable imagery over time, but the degree of racial representation does not approach the US or plastic surgery patient population. Additionally, breast surgery has significantly less representation than the general plastic surgery and aesthetic surgery literature. Increasing awareness of image content, implicit bias, and the need for equitable visual representation may allow for improved racial diversity in the plastic surgery literature. As plastic surgeons, we can lead this effort and ensure that our trainees are not only technically but also culturally competent and that all our patients feel welcome and well represented by our specialty.


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