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

PURPOSE: Aesthetic surgery is a highly visual field relying on photography to inform outcomes. While there has been increasing focus on race and equity in medicine, the effect that this has had on racial representation in the aesthetic plastic surgery literature is unclear. The purpose of this study was to evaluate the representation of racial skin tone in the aesthetic plastic surgery literature over the last two decades.
METHODS: Articles from the Aesthetic Surgery Journal (ASJ) were reviewed for four calendar years (1996, 2000, 2010, and 2016). All images and graphics depicting human figures with visible skin were categorized as white or non-white based on skin tone using the Fitzpatrick scale as a guide with input from observable phenotypes following previously published methods. The country of origin for each article was noted for analysis. The average number of white and non-white images and graphics per article were compared using the Student's t-test. Univariate regression analysis was used to compare the average number of white and non-white images and graphics over time; multivariate analysis was performed to control for the effect of time and international articles on the publication of non-white images.
RESULTS: A total of 2042 images and 282 graphics were analyzed. 1608 (78.7% of images representing white subjects while 434 (21.2%) were non-white. Over time, the percentage of non-white images increased from 5.4% in 1996 to 25.8% in 2010 and remained stable between 2010 and 2016 (25.1%). In contrast, the vast majority of graphics were of white subjects (98.2%) compared to non-white subjects (1.8%). The majority of non-white images came from international sources, with 281 (42.5%) international photos containing non-white subjects compared to 148 (10.8%) American images. Multivariate analysis revealed a statistically significant shift from white images to non-white images in international papers over time while American papers show an increased publication of white images during the same period.
CONCLUSION: This is the first study to examine the racial diversity of images in the aesthetic plastic surgery literature, which serves as a guide for trainees and clinicians in the field. Although the overall representation of non-white skin tone in the Aesthetic Surgery Journal currently approximates the racial distribution of the United States and American Society of Aesthetic Plastic Surgery statistics, there is statistically significant underrepresentation of non-white images found in papers published from the United States, which has persisted over time. In contrast, there is no statistically significant difference in the rate of inclusion of white and non-white subjects in international papers. There have been multiple studies demonstrating an underrepresentation of racial minorities in medical education and literature, which contributes to inequities in healthcare. Plastic surgery researchers in the United States need to be inclusive in the images presented in publications. Authors and journal editors should be mindful of implicit racial bias and strive to better represent the patient populations we care for in our literature.


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