The motivation behind the study is rooted in a long-documented inequity in global science. Authors from low- and middle-income countries and from regions where English is not the primary language face systemic disadvantages when preparing manuscripts for international journals. Previous studies cited by the team have shown that geographic bias shapes peer reviewer selection, that English-language dominance disadvantages researchers in places like Colombia, and that historically excluded groups continue to encounter barriers in the peer review process. Rejection and resubmission cycles impose real costs on early-career researchers everywhere, but the burden falls hardest on those without access to experienced mentors or institutional support.

The Duke-led team set out to test whether an accessible AI tool could help level that playing field. They designed a controlled comparison of three progressively refined AI approaches, all reachable through an ordinary ChatGPT account, meaning no specialized software, no programming expertise, and no additional cost beyond a standard subscription. The first tool was a baseline deployment of GPT-5 with no special configuration. The second was a Custom GPT augmented with a knowledge base of peer review guidance. The third and most sophisticated version layered on iterative optimization: enhanced system instructions developed through meta-prompting, a technique in which the model itself is used to help draft and refine the instructions given to it, combined with journal-specific guidelines drawn from the field of plastic surgery.

To evaluate these tools rigorously, the researchers assembled sixty manuscript evaluations covering fifteen plastic surgery articles, deliberately spread across five clinical studies, five clinical trials, and five review articles. Each AI-generated evaluation was compared against human peer reviews obtained from journals that practice open peer review, where reviewer reports are published alongside the paper. Two blinded raters then scored every evaluation—human and machine alike—using the Review Quality Instrument, a validated assessment tool developed in 1999 that measures review quality on a scale with a maximum score of 40. The raters did not know which reviews came from humans and which came from AI.

The results were striking. The iteratively optimized Custom GPT, Tool 3, achieved a mean Review Quality Instrument score of 28.5 with a standard deviation of 3.8, significantly higher than every other review type in the study. Human peer reviews averaged 25.2 plus or minus 4.9, the knowledge-base Custom GPT averaged 24.3 plus or minus 5.0, and the baseline GPT-5 averaged 24.0 plus or minus 1.8. The differences were statistically significant at p less than 0.001. In other words, the carefully engineered AI tool did not merely match human reviewers—it outperformed them on average, while the unoptimized baseline model sat slightly below human performance.

Digging into the subcomponents of review quality revealed where the optimized tool excelled most. Using Kendall’s W, a statistical measure of effect size for non-parametric comparisons, the team found that Tool 3 showed its largest advantages in methodological assessment, evidence provision, and interpretation evaluation, with effect sizes of 0.69, 0.59, and 0.63 respectively. These are precisely the dimensions that separate a superficial review from a genuinely useful one: whether the reviewer critically appraises the study design, whether claims are backed by specific evidence from the manuscript, and whether the reviewer interprets the findings in context rather than offering generic praise or criticism.

Equally notable was the tool’s consistency. Across the three manuscript types—clinical studies, clinical trials, and reviews—the optimized AI’s scores ranged only from 28.0 to 29.1, a narrow band suggesting stable performance regardless of article genre. Human reviews, by contrast, showed considerably greater variability, with mean scores ranging from 22.1 to 27.0 across manuscript types. That variability mirrors a well-known reality of peer review: quality depends heavily on the individual reviewer, their time constraints, and their familiarity with the subject matter. A tool that delivers reliably structured feedback could smooth out some of that randomness for authors seeking pre-submission guidance.

The study builds on a growing body of work examining whether large language models can provide useful feedback on research papers. Earlier analyses, including a large-scale empirical study published in NEJM AI, found that models like GPT-4 could identify weaknesses in papers that human reviewers sometimes missed, though concerns about hallucinated criticisms and superficiality persisted. Subsequent studies in hand surgery and transplantation research have compared AI-generated and human peer reviews with mixed results. What distinguishes the new work is its focus on accessibility and optimization: rather than asking whether AI can review manuscripts in the abstract, the team asked how much better a freely accessible tool can become through systematic instruction refinement and domain-specific knowledge integration.

The implications for global surgical research are considerable. A researcher in a resource-limited setting could, in principle, paste a draft manuscript into the optimized tool and receive structured, actionable feedback on methodology, evidence, and interpretation—feedback that might otherwise require a mentor at a well-funded institution. The authors emphasize that the tool requires no technical expertise and no additional cost, which addresses two of the most common barriers to AI implementation in healthcare identified in prior literature: control and cost. Because the tool is designed for pre-submission refinement rather than replacing journal peer review, it also sidesteps some of the thornier ethical questions about AI’s role in editorial decision-making, though the broader debate about generative AI in scientific publishing remains unresolved, as a 2024 Lancet commentary highlighted.

Cautions remain. The study evaluated reviews of plastic surgery manuscripts scored by two raters using a single validated instrument, and the human comparison reviews came from open peer review journals, which may not represent the full spectrum of review quality across all journals. The Review Quality Instrument measures the construct of a review report, not the ultimate accuracy of an AI’s scientific judgments, and large language models can still produce confident errors. The authors report no external funding and no conflicts of interest, and they have made their evaluation scores available in supplementary materials for scrutiny. Still, the central result stands as a provocative data point: with thoughtful meta-prompting and domain knowledge, a tool anyone can access from a standard ChatGPT account produced manuscript evaluations that blinded raters judged better than those written by human experts. For the millions of researchers excluded from the informal networks of academic mentorship, that could be a genuinely democratizing development.

Subject of Research: Development and evaluation of an accessible AI-powered tool for manuscript peer review in plastic surgery research

Article Title: Development and assessment of an accessible AI-powered tool for manuscript evaluation through iterative optimization in plastic surgery research

Article References: Goyal, R., Liang, J., Kulkarni, M. S., Nguyen, P., Gillipelli, S., & Patel, A. (2026). Development and assessment of an accessible AI-powered tool for manuscript evaluation through iterative optimization in plastic surgery research. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 188. https://doi.org/10.1007/s44186-026-00599-z

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00599-z

Keywords: artificial intelligence, large language models, ChatGPT, peer review, manuscript evaluation, plastic surgery, global surgery, meta-prompting, Review Quality Instrument, research equity, low- and middle-income countries, scientific publishing

The thoracodorsal artery perforator flap was first described in the 1990s as a way of harvesting skin and fat from the back without taking the underlying latissimus dorsi muscle, the powerful muscle that drives movements such as pulling and climbing. Traditional muscle-containing flaps from the same region provide robust tissue but leave patients with functional deficits, unsightly bulk, and higher rates of donor-site complications such as seroma and infection. Perforator flaps sidestep much of that problem by isolating the tiny blood vessels, the perforators, that pierce through the muscle to supply the overlying skin, allowing the muscle itself to be spared while the skin paddle remains reliably perfused.

What has been missing, the Vietnamese team argues, is a systematic way of adapting the flap to the specific anatomy and function of each wound rather than forcing every defect to fit a standard design. Their answer is a four-part customization framework built around individualized perforator selection, extended pedicle dissection, tailored flap geometry, and primary flap thinning. In a retrospective case series spanning 2009 to 2011 at Saint Paul Hospital, three women with complex soft-tissue defects of the anterior chest wall, breast, or proximal upper extremity were treated under this framework, and each case illustrates a different technical variation of the same underlying platform.

Preoperative planning began with handheld Doppler ultrasonography. Using an 8-MHz probe, the surgeons mapped perforators arising from the descending and transverse branches of the thoracodorsal artery, the two main vascular highways that feed the skin of the back. This simple bedside mapping step allowed the team to choose which perforator would serve as the vascular lifeline of each flap before a single incision was made. During surgery, performed with the patient in the lateral decubitus position, the flap was elevated in the suprafascial plane and the chosen perforator was then dissected free through the latissimus dorsi muscle, a technically demanding maneuver given the anatomical variability of these vessels.

The first patient, a 32-year-old woman, had lived for 19 years with an unstable, painful presternal scar that had broken down after radiotherapy and multiple surgeries for hypertrophic scars. The surgeons designed an elliptical 7 by 14 centimeter flap based on a perforator from the descending branch and extended the intramuscular dissection to create a 14-centimeter pedicle. Combined with an eccentric position of the perforator within the skin paddle, this produced an effective reach of roughly 24 centimeters from the pedicle origin to the distal tip of the flap, enough to tunnel the tissue under the skin of the chest and cover the farthest portion of the sternal defect without tension, using a rotation arc of nearly 100 degrees. At 35 months of follow-up the flap had survived completely, the chest contour was restored, the pain had resolved, and the scar had not broken down again.

The second case pushed the reach of the flap even further. A 62-year-old woman developed a chronic radiation-induced ulcer across the upper pole of her left breast seven years after breast-conserving cancer therapy, with a 6 by 17 centimeter wound set in a field of fibrotic, contracted, poorly vascularized tissue. Here the team departed from the conventional ellipse and designed a racket-shaped flap, in which the dissected descending branch formed the longitudinal axis of the handle while the eccentrically placed skin paddle supplied the distal tissue needed to resurface the entire superior breast defect. Extended intramuscular dissection yielded a 24-centimeter vascular pedicle with an arc of rotation of approximately 130 degrees, permitting tension-free transfer without any microsurgical anastomosis. Two years after surgery the ulcer had not recurred, and the upper breast contour had been satisfactorily restored.

The third case demonstrated the opposite design philosophy: instead of maximizing reach, the goal was maximum mobility for a joint. A 30-year-old woman had severe post-burn scar contracture spanning her left axilla and proximal upper arm, limiting shoulder abduction to just 60 degrees. The surgeons harvested a customized V-shaped flap incorporating perforators from both the transverse and descending branches, with a transverse component of 7 by 16 centimeters and a descending component of 8 by 18 centimeters. Because the axilla demands thin, pliable tissue that will not restrict movement, the flap was primarily thinned from approximately 25 millimeters down to about 5 millimeters, with fat carefully removed under direct vision while preserving the subdermal vascular plexus and a protective cuff around the perforator entry point. The result was a 17-centimeter pedicle with a 90-degree rotation arc, tunneled subcutaneously into the axilla. At six months, the contracture was fully released and active shoulder abduction had improved dramatically to 155 degrees.

The series was not without complications, and the authors are candid about the trade-offs. The third patient developed limited necrosis at the distal tip of her flap, which the team attributes to the combination of aggressive thinning to 5 millimeters, the extended reach of the flap, and the inherently reduced perfusion reserve at the far end of the vascular territory rather than to any single technical error. The problem was managed with simple debridement and direct closure and did not compromise the final outcome. From this experience the authors distill practical safeguards: preserve a soft-tissue cuff around the perforator to reduce vasospasm and venous complications, avoid over-thinning the distal portions of the flap where perfusion is weakest, and ensure the pedicle traverses its tunnel free of tension, kinking, or compression.

Beyond the individual cases, the report situates the TDAP flap within the broader landscape of regional reconstruction. Compared with the conventional latissimus dorsi musculocutaneous flap, the perforator version preserves shoulder strength and avoids the muscle-harvest complications documented in larger series. Compared with intercostal artery perforator flaps, which are often limited by shorter pedicles and restricted mobility, the thoracodorsal system offers pedicle lengths that, with extended intramuscular dissection, can exceed the 8 to 16 centimeters typically reported in anatomical studies. The choice of perforator, the authors emphasize, should be dictated by the reconstructive goal rather than by pedicle length alone: descending branch perforators maximize reach, while transverse branch or dual-perforator configurations better serve flaps that need wider geometry or enhanced perfusion. Notably, despite harvesting large skin paddles, all three donor sites were closed primarily, without skin grafts, thanks to the natural laxity of the lateral thoracic region.

The authors acknowledge the limits of their evidence. With only three retrospective cases, no comparative effectiveness can be assessed, validated patient-reported outcomes were not consistently collected, and intraoperative perfusion was judged by clinical inspection rather than indocyanine green angiography, which might have offered more objective guidance during thinning. The cases are presented as a demonstration of a defect-oriented technical strategy, not as definitive clinical recommendations, and larger cohorts with standardized outcome measures will be needed to validate the approach. Still, the central message is a compelling one: successful perforator flap reconstruction depends less on the flap itself than on how thoughtfully the surgeon customizes perforator selection, pedicle dissection, geometry, and thickness to the biological and mechanical demands of each wound. For patients facing radiation ulcers, burn contractures, and unstable chest scars, that philosophy may mean the difference between a flap that merely covers a defect and one that restores form, function, and freedom of movement.

Subject of Research: Customization of the pedicled thoracodorsal artery perforator flap for chest wall and upper-extremity reconstruction

Article Title: A defect-oriented approach to customizing the pedicled thoracodorsal artery perforator flap for chest wall and upper-extremity reconstruction: a case series

Article References: Nghĩa, P. T., Sơn, T. T., Nam, Đ. P., & Anh, H. T. (2026). A defect-oriented approach to customizing the pedicled thoracodorsal artery perforator flap for chest wall and upper-extremity reconstruction: a case series. BMC Plastic and Reconstructive Surgery, 2(1), Article 28. https://doi.org/10.1186/s44452-026-00041-9

Image Credits: AI Generated

DOI: 10.1186/s44452-026-00041-9

Keywords: thoracodorsal artery perforator flap, pedicled perforator flap, flap customization, chest wall reconstruction, breast reconstruction, upper-extremity reconstruction, flap thinning, perforator selection, radiation ulcer, burn scar contracture, plastic surgery, case series

The study rests on a deceptively simple hypothesis: if ageism, the prejudice and stereotyping directed at people because of their age, fuels a desire to escape the visible markers of aging, then places where ageist attitudes are more widespread should also be places where residents show more interest in cosmetic procedures. Testing that idea at the state level required two things: a reliable measure of ambient ageism for each state, and an equally reliable gauge of how interested each state’s residents are in plastic surgery. McCann turned to large, publicly available datasets to construct both.

Interest in plastic surgery was captured in two complementary ways. The first was Google Trends search data, which reflects how often residents of each state searched for information related to plastic surgery relative to other search activity. Search behavior offers a remarkably candid window into private intentions; people who would never discuss a facelift with a neighbor may still type the query into a search engine at midnight. The second measure was the density of plastic surgeons per capita in each state, an indicator that captures the supply side of the market. Surgeons, after all, tend to establish practices where demand is strong, so a state with more plastic surgeons per resident is plausibly a state with greater appetite for their services. Encouragingly, both measures behaved similarly in the analyses, strengthening confidence that they were tapping the same underlying phenomenon.

The measure of ageism drew on the accumulated evidence of geographical psychology, a field that studies how psychological traits and attitudes cluster across regions. Previous work had already shown that implicit age bias varies meaningfully from state to state and that these variations correlate with state-level health outcomes, including the prevalence of Alzheimer’s disease among older adults. Using state-level indices of ageist attitudes, McCann computed Pearson correlations between ageism and each of the two plastic surgery interest measures. Both correlations came out positive and statistically significant: the more ageist a state, the greater its residents’ interest in plastic surgery and the higher its concentration of plastic surgeons.

Correlation alone, however, is never enough, particularly in state-level research where a handful of demographic variables can masquerade as psychological ones. Wealthier states might both hold less ageist attitudes and afford more cosmetic procedures. States with older populations might be more ageist simply because age groups are in closer proximity, or less ageist because of greater intergenerational contact. To rule out such confounds, McCann employed multiple regression and partial correlation analyses with six statistical controls: state socioeconomic status, the percentage of White residents, the percentage of urban residents, the percentage of female residents, median age, and the obesity rate. The pattern of results survived intact. Even after stripping away the variance attributable to these six characteristics, the association between ageism and plastic surgery interest remained positive and significant for both outcome measures.

The study also attended to two technical threats that can undermine regional analyses of this kind. Multicollinearity, the problem of predictor variables being so tightly intercorrelated that their individual contributions become indistinguishable, showed no evidence of distorting the regression results. Spatial autocorrelation, the tendency of neighboring geographic units to share characteristics in ways that violate the independence assumptions of ordinary statistics, was likewise assessed and not found to be a problem. These diagnostics matter because state-level findings that ignore spatial dependence can dramatically overstate the reliability of an effect. Their absence here lends the central result a solidity that many ecological studies lack.

What does the association mean? McCann offers two main interpretations, both framed carefully as speculations rather than conclusions. The first is an aggregation account: the state-level relationship may simply reflect the accumulation of individual-level relationships. If, as a substantial body of laboratory and survey research suggests, people who hold more ageist attitudes or greater aging anxiety are individually more drawn to cosmetic procedures, then states composed of more such individuals should show higher aggregate interest. This interpretation is consistent with prior findings that aging anxiety predicts favorable attitudes toward cosmetic surgery, particularly among middle-aged women, and that fear of aging and fear of death are intertwined in ways that make the pursuit of a youthful appearance psychologically meaningful.

The second interpretation is bolder: the correlation is consistent with a causal link in which ambient ageism, the ageist climate of a community, actively promotes interest in plastic surgery among its residents. Terror management theory provides one theoretical scaffold for this idea. From that perspective, awareness of mortality is buffered by cultural worldviews and symbolic immortality, and the aging body is a potent reminder of death. Anti-aging cosmetic procedures can function as an existential defense, a way of denying the body’s trajectory. A community steeped in ageist stereotypes may amplify this defense, making surgical intervention feel more necessary and more normative. Yet the study’s cross-sectional, correlational design explicitly precludes causal inference. The data were collected for a single year, 2015, and cannot establish whether ageism drives surgery interest, whether surgery-seeking communities develop more ageist climates, or whether both are downstream of some unmeasured cultural factor.

The ecological nature of the analysis also demands caution in a different way. State-level correlations cannot be automatically applied to individuals, a pitfall known since the classic work on ecological correlation in the 1950s. The finding that ageist states have more plastic surgery interest does not mean that every ageist individual wants a nose job, nor that every surgery patient is prejudiced against older people. What it does suggest is that psychological climates, the shared attitudinal atmospheres of places, are associated with consequential patterns of behavior and market activity. This aligns with a growing literature in geographical psychology showing that personality traits, implicit biases, and social attitudes are not randomly distributed across the map but cluster in stable, predictable patterns that relate to health, politics, and economics.

The practical implications are hard to ignore. The American Society of Plastic Surgeons reports millions of cosmetic procedures performed annually, and international surveys confirm that aesthetic surgery is a vast and growing global industry. If ageist climates contribute to that demand, then the stakes of ageism extend beyond the well-documented harms to older adults themselves, including worse health outcomes and increased mortality risk documented in prior research. Ageism, this study implies, may also be written onto younger bodies in the form of Botox, fillers, and facelifts, as people internalize the message that aging is something to be fought. The author notes that this is the first study to empirically demonstrate the association between ambient ageism in a geographic area and residents’ interest in plastic surgery, and the data are openly available for other researchers to scrutinize and extend. Future work with longitudinal designs, individual-level data, and measures that track both attitudes and procedures over time will be needed to determine whether the arrow of influence points from prejudice to the operating table, from the operating table back to prejudice, or in both directions at once. For now, the study stands as a striking reminder that our attitudes toward aging may be inscribed not only in policy and healthcare but in the very geography of the beauty industry.

Subject of Research: The association between state-level ageism and interest in plastic surgery across the contiguous United States

Article Title: U.S. state levels of ageism and interest in plastic surgery

Article References: McCann, S. J. H. (2026). U.S. state levels of ageism and interest in plastic surgery. Current Psychology, 45(18), Article 1521. https://doi.org/10.1007/s12144-026-10025-8

Image Credits: AI Generated

DOI: 10.1007/s12144-026-10025-8

Keywords: ageism, plastic surgery, cosmetic surgery, aging anxiety, geographical psychology, Google Trends, age stereotypes, U.S. states, Current Psychology, state-level analysis, terror management theory, ecological correlation

The study, published in Global Surgical Education, the Journal of the Association for Surgical Education, was led by Joey Liang and colleagues at Duke University School of Medicine, together with senior author Ash Patel of Duke’s Division of Plastic, Maxillofacial, and Oral Surgery. The team set out to answer a deceptively simple question: do the learning objectives attached to continuing medical education sessions at a national plastic surgery meeting actually meet the guidelines promoted by the Accreditation Council for Continuing Medical Education, the body that accredits CME in the United States? To find out, they systematically audited the objectives from two consecutive years of the conference.

Learning objectives are the short, verb-driven statements that appear at the start of a lecture or session, promising what attendees will be able to do afterward. Educational researchers consider them far more than administrative boilerplate. Well-crafted objectives contextualize an educational activity, set clear expectations for the learning task, and focus both educator and learner on the intended outcome. Poorly written objectives, by contrast, leave learners guessing about what they are supposed to gain, and they make it nearly impossible to assess whether the session worked. In the CME context, where the ultimate goal is to change clinical behavior and improve patient outcomes, vague objectives may be one reason that traditional conference-style education has struggled to demonstrate lasting impact on physician practice.

The Duke team analyzed learning objectives from CME programming sessions at Plastic Surgery The Meeting in both 2023 and 2024. Sessions with missing or incomplete objectives were excluded from the analysis. The final dataset included 193 CME sessions, yielding a total of 510 individual learning objectives. Each objective was scored against two of the most widely used frameworks in health professions education: the SMART framework, which asks whether a goal is Specific, Measurable, Attainable, Relevant, and Time-Bound, and Bloom’s Taxonomy, the classic six-level hierarchy of cognitive learning that runs from remembering and understanding up through applying, analyzing, evaluating, and creating.

The results revealed a striking split. On the positive side, the objectives were generally Attainable, Relevant, and Time-Bound, meaning that session organizers were setting realistic goals tied to the content being taught within a defined timeframe. But the picture darkened considerably on the two criteria that matter most for accountability. Only 54.5 percent of objectives were judged Specific, meaning nearly half described learning goals too loosely to guide either teaching or assessment. Worse still, just 20.4 percent of objectives were Measurable, meaning that for roughly four out of every five objectives, there was no way to tell whether the promised learning had actually occurred. An objective that cannot be measured, education researchers argue, is functionally an aspiration rather than a plan.

Bloom’s Taxonomy told a similar story of low cognitive ambition. The mean Bloom’s level across all 510 objectives was just 2.02 out of a possible 6. The objectives clustered heavily at the bottom two rungs of the hierarchy: 37.3 percent targeted the Remember level, the simple recall of facts, and 40.0 percent targeted the Understand level, a step up but still far from the higher-order thinking that practicing surgeons might need to integrate new evidence into complex operative decisions. Only a small minority of objectives asked learners to apply, analyze, evaluate, or create. For an audience of experienced clinicians facing sophisticated reconstructive and aesthetic challenges, the researchers suggest, such low-level objectives may undersell both the learners and the material.

One of the study’s most technically interesting findings concerned discordant verbs. In Bloom’s framework, each cognitive level is associated with characteristic action verbs: an objective at the Remember level might use verbs like list or identify, while an Apply-level objective might use demonstrate or implement. When a writer pairs a verb from one level with a learning goal that actually belongs to another, the objective becomes internally contradictory. The researchers found that 92 objectives, or 18.0 percent of the total, used such discordant verbs. The most common mismatch, accounting for 32 of those 92 cases, was the use of verbs from the Understand category for learning goals that actually sat at the Remember level. In other words, sessions frequently promised understanding while only demanding recall, a subtle but consequential mismatch for anyone trying to gauge what a lecture will deliver.

The quality of objectives was not uniform across the conference. When the researchers compared program tracks, the different thematic streams of the meeting, they found statistically significant differences in the distribution of Bloom’s Taxonomy levels, with p values below 0.001, as well as in the proportion of Specific objectives and Measurable objectives, with p values of 0.001 or lower and 0.004 respectively. This variation suggests that the problem is not a single institutional failing but a diffuse one: some tracks consistently produce better objectives than others, and there is no shared standard being applied across the meeting’s programming. The authors argue that to enable effective implementation into clinical practice, CME activities in plastic surgery should include well-written objectives that align with the complexity and purpose of each activity, with verbs matched to their intended learning levels and outcomes that are specific and measurable.

The findings land within a broader and often sobering literature on CME effectiveness. Decades of research, including influential syntheses published in JAMA and the CHEST evidence-based guidelines, have found that passive, lecture-heavy formats like traditional conferences tend to produce modest changes in physician knowledge and even smaller changes in actual practice behavior. Educational theorists from Malcolm Knowles onward have argued that adult learners, particularly experienced professionals, learn best when objectives are explicit, self-directed, and oriented toward problems they will face in practice. Meanwhile, studies of accredited continuing professional development activities in other fields have found that the majority do not even target clinical behavior change. Poorly written objectives both reflect and reinforce that gap: if a session never commits to a measurable outcome, no one can be blamed when none occurs.

What makes this study notable is its scale and its specificity. Rather than surveying attitudes, the Duke team audited the actual written objectives from 193 sessions across two years of a major national meeting, applying standardized frameworks that are taught in every medical education curriculum. The practical implications are straightforward. Meeting organizers could require objectives to pass a SMART and Bloom’s screen before sessions are accredited; presenters could receive brief training in verb selection and objective writing; and accreditors could make measurability a hard criterion rather than a soft expectation. For the surgeons who sacrifice operating time and pay registration fees to attend, the message is equally clear: the value of a conference hour depends heavily on whether the session promised something concrete in the first place. As CME systems worldwide face pressure to demonstrate real-world impact, this audit of plastic surgery’s largest meeting offers a candid, quantifiable starting point for reform.

Subject of Research: Quality of learning objectives in continuing medical education programming at a national plastic surgery meeting

Article Title: Analysis of learning objective quality in national plastic surgery meeting continuing medical education programming sessions

Article References: Liang, J., Pillai, T., Yapuncich, G., Mohamed, L., Hibshman, N., & Patel, A. (2026). Analysis of learning objective quality in national plastic surgery meeting continuing medical education programming sessions. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 136. https://doi.org/10.1007/s44186-026-00540-4

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00540-4

Keywords: continuing medical education, plastic surgery, learning objectives, Bloom's Taxonomy, SMART framework, medical education, ACCME, surgical education, professional development, Duke University, conference programming, clinical practice change

The historical arc described in the editorial is striking. Reconstructive surgery in its recognizable modern form largely emerged on the battlefields of the twentieth century, where military surgeons confronted injuries of a severity and volume rarely seen in civilian practice. The demands of trench warfare in the First World War drove the development of systematic techniques for facial reconstruction, skin grafting, and the management of complex wounds, and those wartime innovations seeded the civilian specialties that followed. Over the past hundred years, the editorial notes, numerous subspecialties and branches have emerged from that foundation, some widely known and others operating in relative obscurity, but all organized around a deeply personalized approach to treating the patient.

That diversification is one of the field’s defining technical characteristics. Today the umbrella of plastic and reconstructive surgery covers procedures as different in execution as they are in purpose. At one end sit aesthetic operations such as complex facelift procedures, where the surgical goal is refinement of appearance and the technical demands center on precision dissection, preservation of vascular supply, and predictable healing. At the other end sit oncological operations, including robot-assisted tumor resection, where robotic platforms offer magnified three-dimensional visualization and instruments with articulation beyond the capability of the human wrist, allowing surgeons to work within narrow anatomical corridors while planning immediate reconstruction of the resulting defects. Between these poles lie microsurgical free tissue transfer, craniofacial reconstruction, hand surgery, burn care, lymphatic surgery, and body contouring after massive weight loss, each with its own literature, complication profiles, and technical standards.

What unites them, according to the editorial, is a shared set of goals: to improve patient quality of life through surgical excellence, to minimize complications, and to apply innovative techniques and technologies on the basis of evidence rather than fashion. That formulation matters because the field has often been caricatured as driven by cosmetic demand, when in fact its core identity is reconstructive. The same principles of tissue handling, perfusion assessment, and wound management that govern a cosmetic procedure govern the reconstruction of a mandible after cancer resection or the closure of a complex abdominal wall defect. The editorial’s emphasis on evidence-driven innovation reflects a broader movement within surgery to subject even long-standing techniques to rigorous outcomes analysis.

The new journal’s editorial stance is explicitly inclusive. It states that it will welcome research that is scientifically valid and methodologically correct, regardless of how large or small the advance. This is a deliberate departure from the traditional model in which high-profile journals prioritize novelty, accepting landmark trials and rejecting incremental studies that nonetheless contain valuable data. The argument for inclusivity rests on the mathematics of evidence. Large-scale analyses, including systematic reviews and meta-analyses, depend on the aggregation of many individual findings, and the rare complications, unusual anatomical presentations, and negative results that never reach print are precisely the data points that clinical registries and pooled analyses need most.

The editorial develops this idea through an evocative analogy: a virtual conference in which researchers share findings and engage in discussion year-round, allowing others to view a single clinical scenario from tens or even hundreds of different perspectives. Such a platform, the editorial suggests, could educate better than any textbook and generate post-hoc data of extraordinary volume. The underlying concept is familiar from other domains of medicine, where multi-institutional collaborations have revealed patterns invisible to any single center. Surgical specialties have historically lagged in this respect, partly because operative technique varies so widely between surgeons and traditions, and partly because the specialty’s global distribution means that valuable experience is scattered across institutions with vastly different resources and publication access.

Removing barriers to that participation is central to the journal’s stated mission. The editorial commits to welcoming researchers without discrimination based on novelty, location, culture, financial capacity, or surgical tradition. Open access publishing plays a practical role here: when articles are freely readable from anywhere in the world, surgeons in settings without expensive journal subscriptions can both contribute to and draw upon the shared evidence base. The editorial argues that the next stage of progress in plastic and reconstructive surgery requires a worldwide approach, in which the community gathers data and findings collectively to enable the next impactful discovery. In an era when research is easily and openly accessible from anywhere, the journal positions itself as a platform for the accumulation of evidence and knowledge rather than a gatekeeper of prestige.

The scope of the new journal is correspondingly broad. It aims to accommodate all research historically tied to plastic and reconstructive surgery as well as new and developing areas directly related to the field. The subjects associated with the launch article hint at that breadth, spanning bone remodeling and targeted bone remodeling, regenerative medicine and tissue engineering, and surgical orthopedics, alongside core plastic surgery and reconstructive surgery topics. They also include a highly contemporary clinical challenge: complications in body contouring surgery after massive weight loss, an area that has grown dramatically as the population of patients undergoing bariatric procedures and, more recently, GLP-1 receptor agonist therapy has expanded, leaving a rising number of patients with excess tissue and distinct wound-healing risks.

The intersection with regenerative medicine and tissue engineering points to where much of the field’s technical future lies. Reconstructive surgeons have long depended on transferring the patient’s own tissue, and laboratory-grown alternatives, engineered scaffolds, and biologics that modulate healing promise to extend what reconstruction can achieve when native tissue is unavailable or insufficient. Similarly, the linkage with bone remodeling reflects the growing overlap between plastic surgery and skeletal reconstruction, where understanding of how bone responds to mechanical and biological cues informs everything from craniofacial advancement to the integration of implants. These adjacent disciplines are no longer peripheral; the editorial’s framing treats them as integral to the field’s identity.

For a specialty that began with improvised repairs under battlefield conditions, the trajectory described in the editorial is a measure of how far surgical medicine has come, and of how much of its progress now depends on infrastructure beyond the operating room. The launch of a dedicated, open access, inclusively edited journal is presented not as an end in itself but as a bet that the field’s next century of advances will be built on shared, pooled, globally contributed data rather than on isolated centers of excellence. Whether that bet pays off will depend on the community the journal attracts, but the premise is clear: the diversity that made plastic and reconstructive surgery unique is now the very reason it needs a common platform on which to record, compare, and learn from everything its practitioners do.

Subject of Research: The expansion of plastic and reconstructive surgery and the role of open access, multidisciplinary evidence sharing in the field

Article Title: Plastic and reconstructive surgery: a rapidly expanding field

Article References: Sinelnikov, M. Y. (2025). Plastic and reconstructive surgery: a rapidly expanding field. BMC Plastic and Reconstructive Surgery, 1(1), Article 1. https://doi.org/10.1186/s44452-025-00004-6

Image Credits: AI Generated

DOI: 10.1186/s44452-025-00004-6

Keywords: plastic surgery, reconstructive surgery, open access publishing, robot-assisted surgery, microsurgery, regenerative medicine, tissue engineering, bone remodeling, body contouring, evidence-based surgery, craniofacial reconstruction, global data sharing

The research team, led by Emma Hansson with Catrin Wessman and Anna Paganini, recruited 276 women who were referred for breast reduction within Sweden’s publicly financed health care system. All participants met the Swedish national guidelines for the procedure, which specify criteria such as a body mass index under 30 and a minimum breast volume of more than 800 millilitres per breast, adjusted upward for higher BMI ranges. Each woman completed the HADS questionnaire before surgery, and a subset of 52 patients filled it in a second time two weeks later to test how stable the scores were over time. Another 52 patients completed the questionnaire again twelve months after their operation, allowing the researchers to see whether the instrument could detect the change in psychological symptoms that surgery is expected to produce.

The choice of HADS was deliberate and scientifically motivated. Many familiar depression measures, including the Beck Depression Inventory and the Hamilton rating scales, were originally developed for psychiatric populations. Women seeking breast reduction, by contrast, typically do not have primary psychiatric disorders; their distress is linked to a somatic condition. HADS was designed precisely for medically ill patients. Its fourteen items, split evenly between an anxiety subscale and a depression subscale, deliberately exclude symptoms that could be confused with physical illness, such as fatigue and dizziness, and it omits items on suicidal ideation. Each item is scored on a four-point scale, giving subscale scores from 0 to 21, where 0 to 7 suggests no significant symptoms, 8 to 10 indicates possible cases, and above 10 suggests probable cases. Despite its validation for breast cancer reconstruction, HADS had never been validated for benign breast conditions such as macromastia, a distinction the authors argued warrants separate testing.

The technical heart of the study was a battery of psychometric analyses reported according to the COSMIN checklist, an international standard for studies of patient-reported outcome measures. Confirmatory factor analysis was used to test whether the questionnaire’s underlying structure held up in this specific population. The researchers compared the classic two-factor model, with separate anxiety and depression factors, against a three-factor model that adds a dimension of negative affectivity, reflecting the theoretical overlap between anxiety and depression. Both models showed satisfactory or near-acceptable fit across standard indices, including the comparative fit index, the nonnormal fit index, the root mean square error of approximation and the standardised root mean squared residual. All factor loadings were statistically significant and above 0.30. Because both structures fit comparably well, the team judged the models using the Akaike information criterion and, weighing clinical usefulness and comparability with prior research, proceeded with the original two-factor structure.

The reliability results were reassuring. Internal consistency, measured by Cronbach’s alpha, came out at 0.85 for the anxiety subscale and 0.87 for the depression subscale, comfortably within the accepted range of 0.70 to 0.95 and short of the level that would suggest redundant items. Every item correlated sufficiently with the total score of its subscale, with corrected item-total correlations ranging from 0.45 to 0.73, all above the recommended threshold of 0.3. Inter-item correlations fell between 0.2 and 0.8 for both subscales, indicating that the questions hang together without duplicating one another. In plain terms, the questionnaire measures what it claims to measure consistently, without wasted or contradictory questions.

Stability over time, known as test-retest reliability, was assessed in the 52 women who repeated the questionnaire after two weeks. The intraclass correlation coefficient was 0.81 for anxiety and 0.75 for depression, values classified as good reliability under widely used benchmarks. Bland-Altman plots showed mean differences between the two time points close to zero, and the limits of agreement stayed within the seven-point margin the researchers had prespecified, corresponding to the clinical cut-off between non-cases and probable cases. This matters because a screening tool that gives wildly different answers on consecutive occasions cannot be trusted to guide individual treatment decisions.

Construct validity was tested by comparing HADS against instruments that should, in theory, produce related results. The depression subscale correlated strongly with the Beck Depression Inventory and the anxiety subscale correlated strongly with the Beck Anxiety Inventory, both at a Spearman coefficient of about 0.7, exactly matching the researchers’ pre-registered hypotheses. The team also compared HADS with the psychosocial well-being domain of the BREAST-Q, the most widely used quality-of-life instrument in breast surgery, which asks about feelings such as self-confidence and happiness with one’s body. Here the correlation was moderate and negative, around minus 0.5, meaning that higher breast-related psychosocial well-being goes hand in hand with fewer symptoms of anxiety and depression. Importantly, the authors note, this moderate relationship shows that the two instruments capture related but distinct constructs, supporting the case for measuring depression and anxiety separately rather than assuming a breast-specific quality-of-life questionnaire covers them adequately.

The questionnaire also proved responsive, meaning it could detect real change over time. Twelve months after surgery, patients reported significantly fewer symptoms on both subscales, with mean decreases of 1.1 points for anxiety and 1.2 points for depression, each statistically significant. No floor or ceiling effects were observed, so the scale retains its ability to distinguish between patients at both the healthy and severely symptomatic ends of the spectrum. Together, these findings paint a picture of an instrument that is valid, reliable and sensitive enough to serve both halves of the clinical workflow: pre-operative evaluation and post-operative outcome assessment.

The authors are candid about the limits of generalisability. Their sample comprised women treated in the Swedish public system, excluding patients with a BMI over 30, a group that is operated on in some countries, particularly the United States, and one in which obesity and comorbidity are known to influence HADS scores. The post-operative sample was relatively small, and cultural factors can affect questionnaire scores, although the authors argue this matters most when creating norm data rather than when validating an instrument for a specific condition. They also caution that because both the two-factor and three-factor structures fit the data acceptably, and because anxiety and depression symptoms clinically overlap, HADS should be used carefully when attempting to differentiate the two conditions in individual patients.

Even with those caveats, the study delivers something the field has lacked: a validated, reliability-tested standard for measuring depression and anxiety in women with breast hypertrophy undergoing reduction. Because different clinics and countries have historically used a patchwork of unvalidated instruments, comparisons between studies and meta-analyses have been difficult, slowing the accumulation of evidence about the psychological benefits of the surgery. A common, psychometrically sound yardstick changes that. It gives clinicians a defensible tool for documenting the emotional indications for surgery and for demonstrating, with patient-reported data, that the operation relieved psychological as well as physical suffering. For a procedure that has often had to justify itself against perceptions of being cosmetic, that standard may prove as consequential as any surgical technique.

Subject of Research: Validation of the Hospital Anxiety and Depression Scale for assessing depression and anxiety symptoms in women undergoing breast reduction surgery

Article Title: Creating a standard for evaluation of symptoms of depression and anxiety in women undergoing reduction mammaplasty: validation and reliability of HADS

Article References: Hansson, E., Wessman, C., & Paganini, A. (2025). Creating a standard for evaluation of symptoms of depression and anxiety in women undergoing reduction mammaplasty: validation and reliability of HADS. BMC Plastic and Reconstructive Surgery, 1(1), Article 2. https://doi.org/10.1186/s44452-025-00001-9

Image Credits: AI Generated

DOI: 10.1186/s44452-025-00001-9

Keywords: breast reduction, breast hypertrophy, HADS, depression, anxiety, patient-reported outcomes, psychometric validation, plastic surgery, macromastia, questionnaire reliability, BREAST-Q, Sweden

The editorial examines several of the most active research fronts where AI is being tested in plastic surgery, and its conclusions are strikingly cautious. The central message is that while AI has already proven useful in non-clinical settings such as communication, accounting, feedback collection, and office management, the technology has not yet accumulated sufficient evidence to justify routine use in clinical practice. That gap between enthusiasm and proof, the author suggests, is where the specialty’s attention should now be focused.

One of the most debated applications is the computerized assessment of aesthetic outcomes. Plastic surgery has long struggled with the subjective nature of judging surgical results, and AI-driven computer vision promises to replace human impression with numbers. A study by Varghaei and colleagues assembled what is likely the largest curated paired pre- and postoperative facial image dataset to date, comprising 7,160 photographs from 1,259 patients. The team introduced a scalable, interpretable computer-vision framework designed to quantify aesthetic outcomes of facial plastic surgery using frontal photographs. On its face, this seems like a decisive step toward objectivity, but the editorial raises a fundamental objection: quantification does not guarantee objectivity.

The problem lies in how these systems learn. Current AI technology is dominated by multimodal large language models trained on human input, and the way humans train these models inevitably shapes the opinions they produce. The editorial coins the term compjective to describe this hybrid state, in which a machine’s judgment is neither fully objective nor entirely subjective. The authors of the facial analysis study themselves acknowledged that facial attractiveness, though inherently subjective, is often associated with geometric regularities such as bilateral symmetry, proportionality, and averageness. That concession raises an uncomfortable question: can computerized assessment of aesthetic outcomes ever truly be objective?

Independent evidence suggests the answer, for now, is no. A comparative evaluation by Haider and colleagues tested leading multimodal large language models, including ChatGPT-4o, GPT-4, Gemini, and Claude, on their ability to assess aesthetic features through both qualitative and quantitative analysis. The verdict was sobering. Without fine-tuning or integration with specialized computer-vision architectures, none of the models could provide a reliable aesthetic assessment. In practical terms, the general-purpose systems that most people call artificial intelligence today do not have the capacity to replace a surgeon’s trained eye and accumulated experience in evaluating an aesthetic result. The editorial’s assessment is that AI-driven computer vision has not yet proven to be a reliable resource for clinical integration and requires substantial advancement, though it may serve as a supplementary tool for quantifying treatment results in research settings.

A second frontier is continuous monitoring, where the case for machine assistance is arguably stronger. Every surgeon knows the classical signs of inflammation, calor, dolor, rubor, tumor, and functio laesa, and every training surgeon has endured the burden of watching flaps overnight with instructions as vague as calling if the color changes. A monitoring system that never gets drowsy and never loses focus could be a welcome alternative to a tired colleague. Kim and colleagues developed and tested an automated free flap monitoring system based on artificial intelligence, and the results were promising: sensitivity for detecting venous insufficiency reached 97.5 percent, while sensitivity for arterial compromise reached 92.8 percent. These figures suggest that supplemental monitoring and early warning systems could genuinely optimize patient care, but the editorial is careful to note that such technologies have yet to be evaluated in a clinical trial setting.

That trial evidence may not be far off. Several clinical studies are currently underway focusing on AI-assisted monitoring, diagnosis, and detection. Among them are WISDOM, a trial using AI within digital wound monitoring of surgical wounds to prioritize non-healing wounds for urgent review, registered as NCT06475703; AnAsToMoSIs, a study of artificial intelligence approaches to the monitoring of microvascular free-flap inpatients, registered as ISRCTN36476735; SeeWound2, a clinical evaluation of a digital wound-assessment device using AI-based image analysis, registered as NCT07211295; and an AI risk assessment model for complication prevention in plastic surgery, registered as NCT06507384. Most of these studies are observational or device precision studies, which means the field is still in the phase of establishing that the tools work as claimed, not yet proving that they improve outcomes.

Beneath these specific applications lies a deeper set of methodological problems that the editorial identifies as endemic to the literature. Many published AI models derive from single centers or demographically narrow datasets, which severely restricts their applicability to larger and more varied patient communities. When such models are ported to different populations, performance will likely degrade, because those populations do not resemble the original training data. There is little published work on cross-ethnicity fairness audits or performance stratification across different phenotypes, and many studies omit the detailed metadata that would make post-hoc analysis, standardization, or reproducibility possible. Patient-reported outcomes are frequently missing from pilot studies, a flaw the editorial calls major, since a patient’s understanding of a successful outcome may differ substantially from that of a computerized assessment program. Ultimately, the argument goes, AI metrics must map to patient-reported outcomes, to the surgeon’s decision-making, or to demonstrable improvements in care, and current models show signs of both selection bias and aesthetic bias.

There are, however, examples of success that point the way forward. The editorial cites work by Ravi Dhawan and colleagues reviewing FDA-approved AI-utilizing tools in the wider surgical field, which found that the devices that have cleared regulatory hurdles share common features, including necessity and efficiency. Future pioneers of AI technology in plastic and reconstructive surgery, the editorial argues, should weigh the necessity, safety, and reliability of their tools in improving patient outcomes, reducing complications, and ensuring minimum disruption to existing clinical standards and practices. A tool that is merely novel, in other words, is not enough.

To close the gap between promise and proof, the editorial lays out a set of steps for responsible integration. Reporting standards should be mandated, covering everything from methods to metadata, with proper study registration, open access data sharing, and detailed transparency as prerequisites for a reliable tool. Validation should be prospective and pre-registered, ideally multi-center, because retrospective validation is subpar for supporting the effectiveness of a new tool, even one designed only as a supplement. A patient-centered approach should govern development, with patient feedback included in assessing effectiveness and sufficient fairness audits, subgroup analyses, and stratification of performance by age, sex, ethnicity, and skin tone to avoid perpetuating aesthetic biases. Surgeon-AI workflow integration trials should investigate how AI metrics influence surgical planning, patient counseling, shared decision-making, and interrater variability, with clinician feedback loops refining the AI’s decision logic during testing. Finally, regulatory and consent frameworks need attention, since existing bodies such as the FDA and CE marking schemes do not define specific approval pathways for AI technology, and without a standardized approach governing patient consent and data protection, these tools cannot be freely deployed. The editorial’s conclusion is blunt: while the specialty is prepared for AI that optimizes care and improves outcomes, existing research does not yet provide sufficient evidence of safety for clinical integration, and future work must incorporate both patient and surgeon feedback while meeting the same methodological and reporting rigor that has become standard in clinical trials.

Subject of Research: Responsible and evidence-based integration of artificial intelligence into plastic and reconstructive surgery

Article Title: Responsible and safe integration of AI technology into clinical practice: accommodating the inevitable technological change

Article References: Sinelnikov, M. Y. (2025). Responsible and safe integration of AI technology into clinical practice: accommodating the inevitable technological change. BMC Plastic and Reconstructive Surgery, 1(1), Article 6. https://doi.org/10.1186/s44452-025-00006-4

Image Credits: AI Generated

DOI: 10.1186/s44452-025-00006-4

Keywords: artificial intelligence, plastic surgery, reconstructive surgery, computer vision, large language models, free flap monitoring, clinical trials, patient outcomes, FDA regulation, aesthetic assessment, fairness audits, surgical innovation

The study, led by Mohammed Yousof Bakhiet, a surgeon affiliated with Al-Baha University in Saudi Arabia and the University of Kordofan in Sudan, used a structured online questionnaire distributed between June 15 and 20, 2025. Every one of the 14 plastic surgeons working in Sudanese governmental hospitals responded, a 100 percent response rate that itself speaks to the tiny size of the workforce. The respondents had a median age of 48.5 years, and 13 of the 14 were men, a distribution the author attributes to the pre-existing gender imbalance in Sudanese plastic surgery rather than any war-specific effect. Half were consultants and half were specialists who had completed postgraduate training within the previous five years, and half reported more than a decade of surgical experience.

The most striking demographic finding was displacement. Nearly two-thirds of the surgeons — nine of the 14 — had been forced from their homes by the fighting, joining the millions of Sudanese internally displaced since the conflict began. Most plastic surgery units in the country were run by a single surgeon, and when those surgeons fled, the units effectively ceased to exist. Before the war, plastic surgery services were concentrated in Khartoum, with smaller regional units in Atbara, Kassala, Port Sudan and Shendi. As fighting engulfed the capital, most Khartoum-based services stopped, and the burden shifted to the already under-resourced peripheral centers. A single plastic surgeon in Elobied, a city under active fighting and siege, now represents the only provider of plastic surgery services in a combat zone in the country.

The survey’s central result is bleak: 86 percent of respondents said the availability of plastic surgery services in their facilities had been severely disrupted or had ceased entirely. Only a small minority reported no impact. Reconstructive work — burn management, complex wound reconstruction, facial trauma repair and limb salvage — was universally affected, with nearly 79 percent of surgeons reporting that all of these procedure categories had been compromised. Half of the respondents said reconstructive operations were often delayed, and another 28 percent said they were always delayed. For patients with war wounds, where soft tissue loss, exposed bone, and damaged vessels and nerves demand advanced reconstructive techniques within tight time windows, such delays translate directly into amputations, disfigurement and death.

Perhaps counterintuitively, the raw numbers of operations did not collapse. Before the war, half of the surgeons reported performing three to six emergency operation lists per month; during the war, 64 percent reported more than six. Elective lists and outpatient clinics showed no statistically significant change before versus during the conflict, with p-values of 0.357 and 0.564 respectively. But the author cautions that these figures mask a profound shift in the character of surgical work. Personal communication with colleagues suggests the operation lists have swung heavily toward emergency and trauma-related procedures, while elective reconstruction and patient follow-up have withered. This pattern — where a surge in trauma volume conceals the erosion of routine surgical services — has been documented in other conflict zones, including Syria, Yemen and Ukraine, and it carries a hidden long-term cost: surgeons who operate only on blast and gunshot injuries for years risk losing the broader technical repertoire that defines their specialty.

The logistical failures underpinning this erosion were consistent across respondents. Limited access to surgical equipment and disruption of supply chains for medications and disposables were each cited by 86 percent of surgeons as major challenges. Close behind, 71 percent pointed to the lack of intensive care or post-operative capacity — a critical gap for patients undergoing complex reconstructions, who often require prolonged ventilatory support and flap monitoring in the hours after surgery. Shortages of qualified plastic surgeons and inadequate anesthesia support, each reported by 57 percent, rounded out the list. These findings mirror earlier reports from Sudan, including a 2024 study that found more than half of surgical practitioners in conflict zones had ceased practice entirely, and analyses showing that only about one-third of hospitals in war-affected areas continue to function at all.

The human resource picture may be the most consequential for Sudan’s recovery. Twelve of the 14 surgeons — 86 percent — reported a severe impact on the availability and retention of trained staff. Continuing medical education was rarely available for 64 percent of respondents and only occasionally available for the rest; just 7 percent reported regular access. The author links this academic isolation to a documented decline in training quality, citing a separate study of Sudanese surgical residents that found widespread concern about reduced case volumes and learning opportunities in operating theaters. The risk is a compounding brain drain: as training pipelines dry up, the next generation of reconstructive surgeons never materializes, and the country’s capacity to treat war injuries — and, eventually, the enormous backlog of untreated deformity and disability — shrinks further.

Institutional support, which in most humanitarian crises cushions health systems against exactly this kind of shock, was largely absent. Half of the respondents’ hospitals received no external support for surgical services at all, and only 29 percent reported receiving any. The author contrasts this isolation with other conflict settings, where international partnerships with non-governmental organizations have helped sustain at least essential medical services, and suggests that insecurity, access difficulties and competing organizational priorities have left Sudan’s surgical services outside the reach of the global humanitarian response. The result is a health system running on local goodwill and improvisation, with surgeons continuing to operate despite unpaid salaries, personal displacement and physical danger.

When asked what they needed most urgently, the surgeons’ answers formed a stark roadmap. Medical equipment and supplies topped the list at 43 percent, followed by trained plastic surgeons and personnel at 36 percent. Education and training programs and health system logistics each drew 21 percent, and funding 7 percent. The emphasis on training, even amid active combat, reflects a professional conviction that sustainable care requires continuous development — that a surgeon who cannot learn cannot long remain effective. The author acknowledges the study’s limitations: a sample of 14, self-reported data vulnerable to recall bias, restriction to governmental hospitals, and the use of categorical ranges for case volumes, which limited statistical analysis. But with only 14 plastic surgeons in the entire country, the sample is effectively the population, and the picture it paints is unlikely to be distorted by small numbers.

What emerges from this survey is a case study in how war hollows out a surgical specialty from the inside — not through a single dramatic event, but through the slow attrition of supplies, staff, training and institutional support. Plastic surgery occupies a peculiar position in wartime medicine: it is simultaneously a frontline necessity for the complex wounds that modern violence inflicts and a long-horizon discipline whose value is measured in function restored and lives rebuilt over years. Sudan’s 14 wartime plastic surgeons are holding that dual mandate together under siege conditions. The survey’s message to the international community is unambiguous: without urgent deliveries of equipment, supplies and trained personnel, the specialty that Sudan’s wounded most need may simply not survive the war that created the need.

Subject of Research: The impact of armed conflict on plastic surgery services and surgical workforce in Sudan

Article Title: Survey of challenges faced by plastic surgery services during the current Sudan conflict

Article References: Bakhiet, M. Y. (2025). Survey of challenges faced by plastic surgery services during the current Sudan conflict. BMC Plastic and Reconstructive Surgery, 1(1), Article 8. https://doi.org/10.1186/s44452-025-00008-2

Image Credits: AI Generated

DOI: 10.1186/s44452-025-00008-2

Keywords: Sudan conflict, plastic surgery, reconstructive surgery, war injuries, health system collapse, humanitarian crisis, surgical workforce, trauma surgery, displacement, supply chain disruption, medical education, global surgery

The scope of the series, as outlined in the editorial, is deliberately broad. It will welcome research articles examining the foundation and evolution of plastic and reconstructive surgery, including studies of the contributions of individual surgeons and patients, the historical development of surgical techniques and instrumentation, and even the field’s reflections in art and literature. That breadth reflects a central claim of the editorial: every procedure, condition, surgical algorithm and instrument in the specialty carries its own story, and those stories collectively explain how modern practice came to look the way it does.

The historical arc the editorial sketches stretches back further than most readers might expect. It opens with ancient Sanskrit texts describing Sushruta’s procedure for nasal reconstruction, a reference to one of the earliest documented operations in which tissue was deliberately transferred to repair a defect of the face. Nasal reconstruction holds a special place in the origin story of the specialty because the nose, prominently exposed and vulnerable to injury, was among the most socially and functionally devastating losses a person could suffer. Techniques for rebuilding it developed across centuries and cultures, long before the term plastic surgery existed, and the editorial treats this ancient lineage as the starting point of a continuous tradition of innovation that runs unbroken to the present day.

From that ancient beginning, the editorial traces a path to the other end of the technological spectrum: modern robot-assisted surgery. The contrast is striking, but the authors’ point is that the two are connected by more than chronology. The principles that govern reconstruction today, such as careful wound closure, respect for tissue planes and the strategic transfer of tissue from one part of the body to another, were established through accumulated experience rather than invented overnight. Knowledge of this history, the editorial argues, is an important resource for understanding and respecting the sacrifices and contributions of the surgeons and patients whose experiences defined the techniques, principles and standards that define practice today.

A central and sobering theme of the editorial is the role of war. For the most part, the modern techniques used in plastic surgery took root in field army hospitals and were first performed by military surgeons, who were tasked with wound closures of varying complexity, extremity reattachments, burn treatments and other consequences of armed conflict. The scale and complexity of injury seen in the First and Second World Wars necessitated rapid surgical innovation, producing novel techniques in wound closure, reconstruction and microsurgery. Battlefield conditions, in this telling, functioned as an brutal forcing function: mass casualties with unprecedented combinations of injuries demanded solutions that civilian practice had never been required to develop at speed.

The editorial names a remarkable roster of contributors from the first half of the twentieth century, a period when the specialty crystallized into a distinct discipline. Among those listed are Sir Harold Gillies, Sir Robert Jones, Henry Pickerill, Hippolyte Morestin, Erich Lexer, Jaques Joseph, Otto Lanz, Johannes Esser, Vladimir Petrovich Filatov, Archibald McIndoe, Luke Voyno-Yasenetsky, Vincenz Czerny and Suzanne Noël. The list spans multiple countries and national traditions, underscoring that the birth of modern plastic surgery was an international enterprise rather than the achievement of a single school. Several of these names remain familiar to surgeons today through eponymous flaps, instruments and techniques that are still taught in training programs around the world.

What distinguishes this editorial from a conventional celebration of surgical pioneers is its insistence on remembering the other half of the partnership: the patients. It is equally important, the authors write, to remember the soldiers and civilians whose injuries compelled the marvelous surgical progress from which patients continue to benefit today. Their suffering and sacrifice are often overshadowed by the focus on the surgeon or the technique, but their experiences are a reminder that the history of surgery carries a tremendous human cost that must never be forgotten. This reframing is significant for how the series is likely to approach its subject. Rather than treating historical patients as passive material upon which progress was made, the editorial positions them as contributors whose injuries, endurance and outcomes shaped the establishment and evolution of surgical practice.

The announcement also arrives at a meaningful moment for the journal itself. BMC Plastic and Reconstructive Surgery is a new open access title, and the history series appears in its first volume, as article number nine. Launching a focus series on the field’s origins in a journal’s inaugural year is a deliberate statement of editorial identity: the journal is positioning historical scholarship not as a peripheral curiosity but as a core strand of the specialty’s literature. The open access model matters here too, since making historical research freely available allows surgeons, students, historians and the public to engage with the field’s past without paywall barriers.

For working surgeons, the editorial suggests that historical knowledge has practical value beyond commemoration. Understanding why a particular flap design, fixation method or reconstructive algorithm emerged, and under what constraints it was first tested, can deepen technical judgment and clarify which elements of current practice are fundamental principles and which are contingent solutions to problems that may no longer exist in the same form. For patients, the history is a reminder that every contemporary standard of care, from burn reconstruction to microsurgical reattachment, was earned through the experiences of people who underwent surgery in eras without modern anesthesia, antibiotics or imaging.

The series now open for submissions invites researchers to document and analyze this heritage in detail, whether through studies of individual surgeons and patients, the evolution of specific techniques and instruments, or the field’s portrayal in art and literature. As the editorial makes clear, the history of plastic and reconstructive surgery is extensive, complex and remarkable in its depth, and the journal intends to ensure that this record, with all of its innovation and all of its human cost, is preserved, examined and made freely available to everyone the specialty serves.

Subject of Research: The history and evolution of plastic and reconstructive surgery from ancient times through modern military-driven innovation

Article Title: History of plastic surgery: introducing a BMC Plastic and Reconstructive Surgery focus series

Article References: Sinelnikov, M. Y. (2025). History of plastic surgery: introducing a BMC Plastic and Reconstructive Surgery focus series. BMC Plastic and Reconstructive Surgery, 1(1), Article 9. https://doi.org/10.1186/s44452-025-00009-1

Image Credits: AI Generated

DOI: 10.1186/s44452-025-00009-1

Keywords: plastic surgery, reconstructive surgery, history of medicine, military surgery, Sushruta, Harold Gillies, Archibald McIndoe, microsurgery, world wars, surgical innovation, open access, BMC Plastic and Reconstructive Surgery

The patient’s story began in 2011, when she noticed a small mass in the lower quadrant of her left breast. Like many patients facing a frightening symptom, she initially avoided medical care and tried to treat herself. Over three years the mass grew, became tender and pulled her nipple inward, finally prompting her to seek help. A biopsy confirmed breast cancer, and in 2015 she underwent a modified radical mastectomy with left axillary lymph node dissection at another hospital, followed by adjuvant chemotherapy and radiotherapy to the chest wall and axillary region. Detailed records of that treatment were unavailable to her new care team, a gap that would complicate later decisions.

For nearly a decade she did well. Then, roughly four months before admission, a mass appeared in her left armpit. Two weeks before she reached the hospital, a foul-smelling discharge began leaking from the old surgical incision site, and she had been attempting to sterilize the wound at home with alcohol. On examination she had no diabetes, hypertension or smoking history, but her body mass index was 35, a factor that raises the technical difficulty of any flap operation. The wound itself was ulcerated and infected, a clinical picture the team judged consistent with recurrent disease, so no preoperative biopsy was taken.

Imaging told a more sobering story than the visible wound. A contrast-enhanced chest CT scan revealed multiple enlarged, matted left axillary lymph nodes, the largest measuring 6.6 by 3.7 centimeters, along with soft tissue thickening at the mastectomy bed and in the axilla. It also showed several tiny bilateral lung nodules and, unexpectedly, a destructive bone lesion with soft tissue involvement in the sternum, although the patient felt no symptoms from it. Crucially, the scan showed no narrowing or encasement of the major axillary vessels, which meant the surgeons could proceed without a dedicated angiogram. Orthopedic and cardiothoracic consultants concluded that even if the sternal lesion represented oligometastatic disease, there was no indication for sternal resection or additional surgery.

The operation itself was a study in positioning and technique. Under general anesthesia, the patient was first placed supine while surgeons completely excised the recurrent mass and all infected, ulcerated tissue. The team chose the latissimus dorsi flap, the broad, fan-shaped muscle of the back, for three reasons: its robust and predictable blood supply, its ample tissue volume, and its anatomical proximity to the axilla. The patient was then turned onto her side for flap harvest, returned supine for insertion, and the flap was rotated 180 degrees to cover the defect without twisting its pedicle, the leash of vessels, chiefly the thoracodorsal artery and vein, that keeps the transferred tissue alive. The thoracodorsal pedicle is typically preserved even after axillary lymph node dissection, which is precisely what makes this flap viable in patients who have already had armpit surgery.

The early postoperative course was promising, then tested. The flap initially looked healthy, but within days signs of infection appeared at the drain site, and a small wound dehiscence produced serous discharge. Swabs from the drain fluid and wound edges grew Pseudomonas aeruginosa, a hardy hospital-associated bacterium. The team responded with five days of gentamicin and ciprofloxacin, local wound care and daily dressing changes. The fever resolved, inflammatory markers fell, the infection signs disappeared and the small dehiscence closed completely, with ciprofloxacin continued to finish the course. The flap itself survived fully, which is the single most important benchmark of success in this kind of reconstruction.

Pathology added an unexpected twist. The resected mass proved to be a focal squamous cell carcinoma, positive for p63 immunostaining, that had infiltrated the dermis, subcutaneous fat and skeletal muscle fibers, with areas of epidermal ulceration and necrosis. Hormone receptor testing showed the tumor was negative for estrogen and progesterone receptors and negative for HER2 overexpression, a triple-negative profile that limits options for endocrine or targeted therapy. Because the surgery was explicitly palliative rather than curative, the team decided that re-irradiation and additional adjunctive treatments were not indicated, a decision shaped by the patient’s overall condition and the goals of care.

One month after surgery, a new problem surfaced: tingling and numbness in the ulnar distribution of the left hand, particularly the medial half of the fourth and fifth fingers. The ulnar nerve had not been injured during the operation; the neuropathy was attributed to compression and traction caused by the tension of the flap sitting in a space crowded with the brachial plexus, axillary artery and axillary vein. This is a recognized hazard of axillary reconstruction, where the reconstructive material must coexist with the neurovascular bundle that supplies the entire arm. The condition was managed medically, and the authors note that pressure on any of these structures is an inherent risk whenever tissue is placed into the axilla.

At seven months of follow-up the results were largely encouraging. The wound had healed completely, there was no recurrence or reinfection, and functional and cosmetic outcomes were judged satisfactory. The trade-offs were real but modest: a hypertrophic scar at the donor site on the back, left shoulder abduction roughly 30 degrees short of the right side, and a slight limitation in internal rotation. For a patient whose alternative was an open, infected, recurrent tumor in a previously irradiated field, preserving near-normal shoulder function is a meaningful outcome, since the primary goals of axillary reconstruction are protecting vital neurovascular structures and restoring shoulder mobility.

The case also sits within a broader surgical landscape. Local and regional flaps, including the latissimus dorsi and the thoracodorsal artery perforator flap, are usually the first choice for axillary defects because they bring reliable blood supply and good contour into a difficult region. When local tissues are unavailable, free tissue transfer such as the anterolateral thigh flap becomes an alternative for large defects, using recipient vessels like the thoracoacromial or transverse cervical arteries. The latissimus dorsi flap carries its own known complication profile: seroma formation occurs in roughly 70 percent of cases, surgical site hematoma in about 5 percent, and late hypertrophic scarring in 28 percent of patients, while some women experience mild back muscle weakness affecting overhead lifting. Some authors argue that an asymptomatic seroma should be considered an inevitable side effect rather than a true complication. What this report ultimately demonstrates is that a well-vascularized muscle flap can succeed even in a contaminated, previously radiated axilla, and that careful flap selection combined with multidisciplinary teamwork, spanning plastic surgery, oncology, orthopedics and cardiothoracic consultation, remains the decisive factor in reconstructing recurrent breast cancer.

Subject of Research: Latissimus dorsi flap reconstruction of an axillary defect following excision of recurrent breast cancer ten years after mastectomy

Article Title: Latissimus dorsi flap reconstruction of axillary defect caused by excision of ulcerated and infected mass ten years after mastectomy: a case report

Article References: Alashqar, M., Alashqar, A., Giacaman, Y., Hadya, F., Draidi, R., & Hasan, M. (2025). Latissimus dorsi flap reconstruction of axillary defect caused by excision of ulcerated and infected mass ten years after mastectomy: a case report. BMC Plastic and Reconstructive Surgery, 1(1), Article 11. https://doi.org/10.1186/s44452-025-00011-7

Image Credits: AI Generated

DOI: 10.1186/s44452-025-00011-7

Keywords: breast cancer recurrence, latissimus dorsi flap, axillary reconstruction, mastectomy, reconstructive surgery, flap surgery, ulnar nerve compression, Pseudomonas aeruginosa, radiotherapy, case report, plastic surgery, shoulder mobility