Plastic and Reconstructive Surgery • October 2014 interesting to investigate whether applicants with few first-author publications differ in eventual career trajectory from those with multiple publications with less involvement. However, given our retrospective survey methodology, these data would likely have been subject to additional recall bias; future studies will be needed to address this question through accurate means, but until that time, we are left with anecdotal evidence and speculation. Lastly, Mr. Al Omran questions whether a difference exists between traditional M.D. graduates and those with dual degrees. The tendency for graduates with combined M.D./Ph.D. degrees to gravitate toward research-oriented careers has been demonstrated in other fields5; however, our study was inadequately powered to detect any significant impact of this variable on our conclusions. Ultimately, selecting a career after graduation can be a difficult decision for plastic surgeons and is influenced by many factors, both internal and external. The process of prioritizing activities in medical school and choosing the residency with the “right fit” can be challenging. Residency programs have evolved over the past decades with the introduction and adoption of the integrated training model, and have continued to change; the integrated program today is not the same as the integrated program 20 years ago. Location, affiliated hospitals, specific strengths and weaknesses, research opportunities, faculty, and fellow residents are all factors that should be considered. DOI: 10.1097/PRS.0000000000000540
Michael R. DeLong, M.D. Duncan B. Hughes, M.D. Bryan D. Choi, M.D., Ph.D. Michael R. Zenn, M.D. Division of Plastic and Reconstructive Surgery Department of Surgery Duke University Medical Center Durham, N.C. Correspondence to Dr. Zenn Division of Plastic and Reconstructive Surgery Department of Surgery Duke University Medical Center Trent Drive, DUMC 3358 Durham, N.C. 27710 [email protected]
disclosure The authors have no financial interest to declare in relation to the content of this communication. references 1. DeLong MR, Hughes DB, Tandon VJ, Choi BD, Zenn MR. Factors influencing fellowship selection, career trajectory, and academic productivity among plastic surgeons. Plast Reconstr Surg. 2014;133:730–736. 2. Greives MR, Losee JE. Discussion: Factors influencing fellowship selection, career trajectory, and academic productivity
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among plastic surgeons. Plast Reconstr Surg. 2014;133: 737–739. 3. Roostaeian J, Fan KL, Sorice S, et al. Evaluation of plastic surgery training programs: Integrated/combined versus independent. Plast Reconstr Surg. 2012;130: 157e–167e. 4. Herrera FA, Chang EI, Suliman A, Tseng CY, Bradley JP. Recent trends in resident career choices after plastic surgery training. Ann Plast Surg. 2013;70:694–697. 5. Choi BD, DeLong MR, DeLong DM, Friedman AH, Sampson JH. Impact of PhD training on scholarship in a neurosurgical career. J Neurosurg. 2014;120:730–735.
Randomized Controlled Trial Comparing HealthRelated Quality of Life in Patients Undergoing Vertical Scar versus Inverted T-Shaped Reduction Mammaplasty Sir: thank Dr. Swanson for his critique of our article.1,2 I emphasize that our study population is derived from a publicly funded health care system. The main outcome was the clinical effectiveness, i.e. quality-of-life improvement, of the two breast reduction techniques. The cosmetic outcome was not under consideration. This was made clear in the article. Below, I address his specific methodologic concerns. First, it is possible that many patients who undergo breast reductions are interested in aesthetic outcomes as much as the quality of life. Combining both self-pay and publically funded patients would have confounded the quality-of-life findings and the subsequent costeffectiveness analysis. Second, Dr. Swanson questioned whether equipoise existed in our trial. Equipoise is a precondition for performing a randomized controlled trial. Performing a randomized controlled trial is not appropriate if there is clear-cut evidence that one technique is superior. At the inception of our study, there was truly ambivalence that one technique was better than the other as indicated by two surveys of plastic surgeons in North America3,4; therefore, equipoise was met. Third, his concern about randomization, its proximity to surgery, and exclusion of self-pay patients has no merit. We stand by our randomization method, performed a half hour preoperatively. No patient was coerced to join the trial.1 Fourth, on the issue of generalizability, readers of our article were challenged to read it and decide for themselves whether our study findings apply to their patients. From Dr. Swanson’s critique, it appears that his practice is cosmetic, and as we excluded self-pay patients, the findings may not apply to his patients. Fifth, our choice of a randomized controlled trial design over an observational study design was based on the predominance of the evidence that supports the randomized controlled trial as the superior study design for minimizing bias. It is true that there are inherent difficulties in the implementation of a surgical randomized controlled trial.5 This no reason not to
I
Volume 134, Number 4 • Letters apply it. For a randomized controlled trial to be successful, we need to (1) ask a good clinical question, (2) perform good randomization, (3) recruit a large number of patients, and (4) have an independent assessor. Unfortunately, despite three decades of evidence-based medicine teaching, many plastic surgeons persist in showing before-and-after photographs as the definitive evidence of their work. The second “sin” is failure to collaborate and pool cases (i.e., adequate sample size) to help us find the “truth.” Sixth, our choice of health-related quality-of-life scales was based on a previous observational study6 in which we found these scales to be reliable, valid, and responsive to change. We would have used the BREAST-Q in addition had this been available at the inception of the study. Having rebutted the most serious methodologic concerns, I would tend to agree that the vertical scar reduction is most likely a legitimate technique for self-pay patients as well. The cost-effectiveness analysis (in press) will tell us whether this technique is more (or less) cost-effective compared with the inverted T-shaped technique. DOI: 10.1097/PRS.0000000000000574
Achilleas Thoma, M.D., M.Sc. Division of Plastic Surgery Department of Surgery Department of Clinical Epidemiology and Biostatistics Faculty of Health Sciences Surgical Outcomes Research Center Department of Surgery McMaster University Hamilton, Ontario, Canada
Correspondence to Dr. Thoma 101-206 James Street South Hamilton, Ontario L8P 3A9, Canada [email protected]
disclosure The author has no financial interest to declare in relation to the content of this article. No external funding was received. references 1. Thoma A, Ignacy TA, Duku EK, et al. Randomized controlled trial comparing health-related quality of life in patients undergoing vertical scar versus inverted T-shaped reduction mammaplasty. Plast Reconstr Surg. 2013;132:48e–60e. 2. Swanson E. Letter to the Editor: Thoma et al., Randomized controlled trial comparing health-related quality of life in patients undergoing vertical scar versus inverted T-shaped reduction mammaplasty. Plast Reconstr Surg. 2014;133:59e–60e. 3. Rohrich RJ, Gosman AA, Brown SA, Tonadapu P, Foster B. Current preferences for breast reduction techniques: A survey of board-certified plastic surgeons 2002. Plast Reconstr Surg. 2004;114:1724–1733; discussion 1734. 4. Nelson RA, Colohan SM, Sigurdson LJ, Lalonde DH. Practice profiles in breast reduction: A survey among Canadian plastic surgeons. Can J Plast Surg. 2008;16:157–161. 5. Thoma A, Farrokhyar F, Bhandari M, Tandan V; EvidenceBased Surgery Working Group. Users’ guide to the surgical literature: How to assess a randomized controlled trial in surgery. Can J Surg. 2004;47:200–208. 6. Thoma A, Sprague S, Veltri K, Duku E, Furlong W. Methodology and measurement properties of health-related quality of life instruments: A prospective study of patients undergoing breast reduction surgery. Health Qual Life Outcomes 2005;3:44.
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Michael R. DeLong, M.D. Duncan B. Hughes, M.D. Bryan D. Choi, M.D., Ph.D. Michael R. Zenn, M.D. Division of Plastic and Reconstructive Surgery Department of Surgery Duke University Medical Center Durham, N.C. Correspondence to Dr. Zenn Division of Plastic and Reconstructive Surgery Department of Surgery Duke University Medical Center Trent Drive, DUMC 3358 Durham, N.C. 27710 [email protected]
disclosure The authors have no financial interest to declare in relation to the content of this communication. references 1. DeLong MR, Hughes DB, Tandon VJ, Choi BD, Zenn MR. Factors influencing fellowship selection, career trajectory, and academic productivity among plastic surgeons. Plast Reconstr Surg. 2014;133:730–736. 2. Greives MR, Losee JE. Discussion: Factors influencing fellowship selection, career trajectory, and academic productivity
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among plastic surgeons. Plast Reconstr Surg. 2014;133: 737–739. 3. Roostaeian J, Fan KL, Sorice S, et al. Evaluation of plastic surgery training programs: Integrated/combined versus independent. Plast Reconstr Surg. 2012;130: 157e–167e. 4. Herrera FA, Chang EI, Suliman A, Tseng CY, Bradley JP. Recent trends in resident career choices after plastic surgery training. Ann Plast Surg. 2013;70:694–697. 5. Choi BD, DeLong MR, DeLong DM, Friedman AH, Sampson JH. Impact of PhD training on scholarship in a neurosurgical career. J Neurosurg. 2014;120:730–735.
Randomized Controlled Trial Comparing HealthRelated Quality of Life in Patients Undergoing Vertical Scar versus Inverted T-Shaped Reduction Mammaplasty Sir: thank Dr. Swanson for his critique of our article.1,2 I emphasize that our study population is derived from a publicly funded health care system. The main outcome was the clinical effectiveness, i.e. quality-of-life improvement, of the two breast reduction techniques. The cosmetic outcome was not under consideration. This was made clear in the article. Below, I address his specific methodologic concerns. First, it is possible that many patients who undergo breast reductions are interested in aesthetic outcomes as much as the quality of life. Combining both self-pay and publically funded patients would have confounded the quality-of-life findings and the subsequent costeffectiveness analysis. Second, Dr. Swanson questioned whether equipoise existed in our trial. Equipoise is a precondition for performing a randomized controlled trial. Performing a randomized controlled trial is not appropriate if there is clear-cut evidence that one technique is superior. At the inception of our study, there was truly ambivalence that one technique was better than the other as indicated by two surveys of plastic surgeons in North America3,4; therefore, equipoise was met. Third, his concern about randomization, its proximity to surgery, and exclusion of self-pay patients has no merit. We stand by our randomization method, performed a half hour preoperatively. No patient was coerced to join the trial.1 Fourth, on the issue of generalizability, readers of our article were challenged to read it and decide for themselves whether our study findings apply to their patients. From Dr. Swanson’s critique, it appears that his practice is cosmetic, and as we excluded self-pay patients, the findings may not apply to his patients. Fifth, our choice of a randomized controlled trial design over an observational study design was based on the predominance of the evidence that supports the randomized controlled trial as the superior study design for minimizing bias. It is true that there are inherent difficulties in the implementation of a surgical randomized controlled trial.5 This no reason not to
I
Volume 134, Number 4 • Letters apply it. For a randomized controlled trial to be successful, we need to (1) ask a good clinical question, (2) perform good randomization, (3) recruit a large number of patients, and (4) have an independent assessor. Unfortunately, despite three decades of evidence-based medicine teaching, many plastic surgeons persist in showing before-and-after photographs as the definitive evidence of their work. The second “sin” is failure to collaborate and pool cases (i.e., adequate sample size) to help us find the “truth.” Sixth, our choice of health-related quality-of-life scales was based on a previous observational study6 in which we found these scales to be reliable, valid, and responsive to change. We would have used the BREAST-Q in addition had this been available at the inception of the study. Having rebutted the most serious methodologic concerns, I would tend to agree that the vertical scar reduction is most likely a legitimate technique for self-pay patients as well. The cost-effectiveness analysis (in press) will tell us whether this technique is more (or less) cost-effective compared with the inverted T-shaped technique. DOI: 10.1097/PRS.0000000000000574
Achilleas Thoma, M.D., M.Sc. Division of Plastic Surgery Department of Surgery Department of Clinical Epidemiology and Biostatistics Faculty of Health Sciences Surgical Outcomes Research Center Department of Surgery McMaster University Hamilton, Ontario, Canada
Correspondence to Dr. Thoma 101-206 James Street South Hamilton, Ontario L8P 3A9, Canada [email protected]
disclosure The author has no financial interest to declare in relation to the content of this article. No external funding was received. references 1. Thoma A, Ignacy TA, Duku EK, et al. Randomized controlled trial comparing health-related quality of life in patients undergoing vertical scar versus inverted T-shaped reduction mammaplasty. Plast Reconstr Surg. 2013;132:48e–60e. 2. Swanson E. Letter to the Editor: Thoma et al., Randomized controlled trial comparing health-related quality of life in patients undergoing vertical scar versus inverted T-shaped reduction mammaplasty. Plast Reconstr Surg. 2014;133:59e–60e. 3. Rohrich RJ, Gosman AA, Brown SA, Tonadapu P, Foster B. Current preferences for breast reduction techniques: A survey of board-certified plastic surgeons 2002. Plast Reconstr Surg. 2004;114:1724–1733; discussion 1734. 4. Nelson RA, Colohan SM, Sigurdson LJ, Lalonde DH. Practice profiles in breast reduction: A survey among Canadian plastic surgeons. Can J Plast Surg. 2008;16:157–161. 5. Thoma A, Farrokhyar F, Bhandari M, Tandan V; EvidenceBased Surgery Working Group. Users’ guide to the surgical literature: How to assess a randomized controlled trial in surgery. Can J Surg. 2004;47:200–208. 6. Thoma A, Sprague S, Veltri K, Duku E, Furlong W. Methodology and measurement properties of health-related quality of life instruments: A prospective study of patients undergoing breast reduction surgery. Health Qual Life Outcomes 2005;3:44.
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