Role of Editor, Reviewer, and Author in Plastic Surgery

Abstract

Twelve stories were collected which were written from the perspective of an editor and reviewer.

8.1 The Need for a Reviewer to Play Devil’s Advocate

It has been over a year and a half since the Archives of Plastic Surgery (APS) was listed in PubMed Central. As an ethics editor, I have encountered cases of “salami slicing,” “imalas,” and duplicate publication, as well as plagiarism. However, I cannot be certain that there is no plagiarism in the issues already published because I have not reviewed all of them.

Although there are several sites that check the similarity of papers [1], these search engines cannot detect “intelligently modified plagiarism” [2]. Thereafter the reviewer (referee) should read manuscripts in detail, look up the citations of the original paper, and identify missing papers that must also be cited.

The movie The Devil’s Advocate (1997), in which Keanu Reeves and Al Pacino star as lawyers, comes to mind. The film’s title is a reference to the commonly used phrase “devil’s advocate.” A devil’s advocate is a person who expresses a contentious opinion in order to provoke debate or test the strength of the opposing arguments [3].

This terminology originated in the Roman Catholic Church tradition [4]: During the beatification or canonization process, the Church authorities appointed a lawyer to be the Promoter of the Faith (Latin: promotor fidei), popularly known as the devil’s advocate (Latin: advocatus diaboli), to argue against the canonization of a candidate based on the candidate’s character or other evidence at hand (Another advocate was appointed to argue in favor of the candidate.) [5].

Likewise, in the APS review process, an editor sends a manuscript to three reviewers,

and they fill out several checklists, make comments to the author as well as to the editor, and each make a recommendation (accept as is, accept with minor revisions, major revisions, or rejection). In the case where two or more reviewers accept the manuscript, the editor usually accepts it for publication. In the case where two or more reviewers reject the manuscript, the editor usually rejects it.

I would like to propose that the editor choose at least one reviewer from the reviewer pool to play the role of “devil’s referee.” Like the devil’s advocate in Catholicism examines how accurate the inquiry is, a devil’s referee could examine the originality of the manuscript. He or she should take a skeptical view of the manuscript, looking for holes in the results of the experiment, insisting that the paper contain etwas neues (something new).

In the Catholic tradition, once a person becomes ‘Blessed’ or the ‘Saint’ through the beatification or canonization process, he or she is recognized for having an exceptional degree of holiness, sanctity, and virtue. Similarly, after publication, a manuscript becomes an ‘article’ and is cited in the research databases (PubMed, Scopus, etc.). In both cases, it is the consistent rigor of examination that lends value to the final status.

If unhappy cases of withdrawal after publication occur, the author is to blame. However, the editor and reviewers also hold some responsibility for preventing such cases in advance, to the best of their ability to detect irregularities. Creating a “devil’s referee” role among the reviewers would strengthen the ethical publication standards of APS by ensuring that at least one person always evaluates each paper from a skeptical perspective.

8.2 A Periodical Article Reviewer as Gottfried: The Uncle of Jean-Christophe

You want to make beautiful songs, so as to be a great man; and you want to be a great man, so as to make beautiful songs. You are like a dog chasing its own tail—Romain Rolland

Several months ago, I submitted a paper for publication, entitled “Two parallel papers for the pectoralis major myocutaneous flap for head and neck reconstruction.” Many weeks later, I received a decision letter: major revision with no guarantee of acceptance.

The decision letter contained a list of previous studies I missed in my review and their significance. The reviewer’s comments concluded as follows: “So, rather than reject I am going to ask you to rewrite. Have a focus that you really want to transfer to the readers and let us know of the value of bringing this back after 100 years.”

The decision letter reminded me of a novel I read years ago: Jean-Christophe, written by Romain Rolland and translated into English by Gilbert Cannan [6]. The author depicted the life of a genius German composer, Jean-Christophe Krafft, a fictionalized version of Beethoven.

In his early life, Jean was influenced much by his uncle, Gottfried, as illustrated in the following quotes from the novel’s characters.

Young Jean composed music and submitted it to his uncle. After listening to young Jean’s compositions quietly, Gottfried questioned his nephew about why he needed to add more songs to the world’s repertoire.

Uncle: “Why make them? There are enough [songs] for everything.”

Nephew: “To be a great man!”

Uncle: “You want be a great man?”

Nephew: “Yes.”

Uncle: “What for?”

Nephew: “To make beautiful songs!”

Uncle: “You want to make beautiful songs, so as to be a great man; and you want to be a great man, so as to make beautiful songs. You are like a dog chasing its own tail.”

Jean wanted to show his uncle what an artist he was and showed him his compositions.

“Why did you write them?”

“I don’t know. I wanted to write something pretty,” the young nephew replied.

“There you are! You wrote for the sake of writing. You wrote because you wanted to be a great musician, and to be admired. You have been proud…. Music must be modest and sincere—or else, what is it? Impious, a blasphemy of the Lord, who has given us song to tell the honest truth.” And later, “It is well enough written, but it says nothing…. You see, my boy, everything that you write in the house is not music. Music in a house is like sunshine in a room. Music is to be found outside where you breathe God’s dear fresh air (Fig. 8.1).”

Fig. 8.1

Jean-Christophe and his uncle Gottfried are breathing fresh air in the sunshine. Available at: https://www.google.co.kr/search?q=jean-christophe+romain+rolland&biw=738&bih=364&source=lnms&tbm=isch&sa=X&ved=0ahUKEwiz66fFtYLQAhUCTLwKHfvDA8EQ_AUIBigB#imgrc=5V_5ibY2oG0LjM%3A. Assessed October 30, 2016

In the paper, I submitted that was sent back for revisions, I just compared two papers about the pectoralis major myocutaneous flap by Aryan (1979) and Baek (1979). Like the young Jean, I just wanted to write something interesting by comparing similar papers published in the same year (1979).

However, after the reviewer’s sharp critique, I took up the reviewer’s challenge to revise my paper extensively. Instead of consulting only the limited selection of references in the usual databases, I located some references that were outside of PubMed, like Gottfried’s exhortation to his nephew to compose outside in God’s fresh air; in fact, I added 12 new references. Finding and obtaining Aymard’s 1957 paper in the Lancet and Conley’s in Surgery (1954) meant drawing out my revision time to a couple of months. I changed the paper’s title, completely rewrote the text, included 3 figures with permission, and prepared 1 chronological diagram. In the end, the revised version was published as a review paper [7].

After completing the publication process, I contemplated the role of the reviewer in the academic journal. The reviewer’s responsibilities include protecting the integrity of a specialty, the reputation of the journal, and the welfare of human and animal subjects, as well as treating the author’s manuscript with respect, fairness, and impartiality [8]. Sometimes a devil’s advocate is needed, who takes a skeptical view of the manuscript, looking for the weaknesses in the paper and investigating whether the paper has etwas neues (something new) or not [9].

Once I achieved my revisions and produced a much better paper and a more worthwhile contribution to the literature, I was truly grateful to the reviewer who shows me the direction for my revision. Like Uncle Gottfried inspired young Jean-Christophe, we need “mentor–reviewers” who point out the stupidity of “a dog chasing its own tail” (writing for the sake of writing) and enlighten less experienced authors by “inducing focus” that they “really want to transfer to readers.”

8.3 Good Surgical Illustrations

When you look at an image and get the message immediately, then it works.—Cassio Lynm

As a subscriber, when I receive the table of contents of a new issue of the Journal of Craniofacial Surgery, I usually look through the titles. When I find an intriguing title, I read the abstract. When I receive a letter asking me to review a manuscript, I also read the attached abstract, and then I must decide whether to agree to review the manuscript. In both cases, if the abstract is interesting, I download the full text as a PDF file. After opening the full text, the first thing I do is scroll to the bottom of the manuscript, until I find the figures, illustrations, and their legends.

When reviewing a paper, if I can get the message immediately when I look at an illustration, the probability is very high that I will write a favorable evaluation. Looking at the illustrations helps me understand the core content that the author intends to communicate. As such, I agree with the saying “An illustration is worth a thousand words.” However, not all illustrations are created equal; some are very good, some are confusing.

As a historical example, Vesalius’s De Humani Coporis Fabrica (1543) contained exquisite woodcut illustrations based anatomic dissections. Gray’s Anatomy (1858) contains the drawings of Henry Vandyke Carter. Nicolas Jacob’s spectacular hand-colored lithographs in Bourgery’s Traité complet de l’anatomie de l’homme comprenant la médecine operatoire (1866–1871) are anatomically correct and reflect a combination of direct laboratory observations and illustrative research (Fig. 8.2). Max Brödel (1870–1941) created illustrations for famous surgeons (Harvey Cushing, William Halstead, and Howard Kelly). I studied using the CIBA atlases drawn by Dr. Frank Netter (1906–1991),and still have them.

Fig. 8.2

Illustration of nasal reconstruction using forehead flap drawn by Nicolas Jacob. Reproduced from “Traité complet de l’anatomie de l’homme comprenant la médecine operatoire (1866–1871)” Vol. 7, Plate 14, Fig. 8.1

I thought about the virtues that good surgical illustrations should have:

• 1. They should be anatomically correct with precise proportions and should include prominent anatomical landmarks to enable easy orientation.

• 2. They should eliminate visual distractions; the goal should be to emphasize the key message and leave out the unnecessary parts.

• 3. They should show the structures behind the scene since viewpoints that the human naked eye could not achieve in the operative field are unrealistic.

• 4. They should simplify the key structures by using unrealistic colors to ensure that they do not blend into the background.

Surgeons are clients of medical illustrators. Surgeons are scientists and illustrators are artists. Therefore, there might be a gap between a client and an illustrator. Science pursues the state of art, and art seeks the state of science. If we “mind the gap,” we can find the intersection of these 2 sets.

To receive a good illustration, clients should give the illustrator their intended ideas—that is, what they really want to show to the reader. Surgeons should provide the illustrator with quick sketches, sound information for all relevant points, and references that might be helpful.

Good communication between surgeons and illustrators will lead to reader-friendly illustrations—that is, to good illustrations.

8.4 Appropriate Roles for the Subscriber, Publisher, Editor, Author, and Reviewer in the Archives of Plastic Surgery

8.4.1 Introduction

Science is strengthened not by research alone but by publication of original research articles in international scientific journals that are read by a global scientific community. The publication process involves author-editor interaction, for which both get credit once the article gets published-the author directly, the editor indirectly [10]. Authors submit a manuscript to the editor, who decides to accept or reject it. The editor then sends the manuscript to the reviewers for their opinion. Aside from the author, editor, and reviewer, publishers and subscribers play their role in scientific journals as well. These five stakeholders are all essential to a journal’s success.

It has been about 2 and a half years since the first issue of the Archives of Plastic Surgery (APS) appeared, and so it is worth taking stock of these five stakeholder roles, how they are playing out in APS, and what responsibility each stakeholder might have to participate more effectively. Thus, in this paper, I, firstly, briefly summarize the role and aims of each journal stakeholder. Secondly, I consider the current status of each APS participant. Finally, for each type of stakeholder, I propose an appropriate role and suggested future direction.

8.4.2 Subscribers (Readers)

Subscribers pay the journal to access new information. They may usually take what is written in a published paper at face value. However, the research experience and clinical expertise of the author do not guarantee validity and relevant recommendations. Uncritical acceptance of information by subscribers potentiates the dissemination of misinformation [11].

My fear is that APS readers do not read each issue carefully and critically because of the relatively small number of submissions of letters to the editor offering opinions, addenda, or critiques of published papers. Letters to the editor should be welcomed by all APS stakeholders for their insight into and relevant critiques of published papers. Both the authors and subscribers should take responsibility for their roles in producing clinical and scientific knowledge, and this partnership can improve patient care [11].

8.4.3 Publishers

A publisher is a kind of businessperson who sells knowledge to a limited number of subscribers, including libraries. The publisher is motivated to increase the number of subscribers and sometimes to improve the publication quality.

The publisher and editor both have considerable power to shape the content and form of the final publication. It is important that a system of checks and balances is maintained, such that the publisher cannot have undue influence on journal content because it is the editor-in-chief who brings clinical and technical knowledge to the table without a profit motivation. One way to accomplish this is to ensure that the editor-in-chief has a sufficient length of tenure and that the incoming editor-in-chief is already familiar with the practicalities of journal publication by serving in the associate editor role or another key role in the editorial board. Currently, APS is working toward this goal by maintaining the same editor-in-chief and associate editor for the third year.

Publishers have other responsibilities in the journal ecosystem. They should develop new products that will both help scientists in their work and enable publishing to remain a viable economic business model so that publication companies can continue to prosper in the future [12]. The publisher must also trust the editor and allocate appropriate levels of financial support to build journal quality on an ongoing basis.

8.4.4 Editors

The editors select manuscripts suitable for publication while rejecting unsuitable manuscripts. Most journals use peer review to raise the quality of published content. However, since the process of peer review can be prone to biases toward ideas that affirm the prior convictions of reviewers and against innovation and radical new ideas, a system of editorial review should also be established [13]. In both systems, the editor is responsible to and communicates with the readers, the publisher, as well as the authors and reviewers.

Editors are central stakeholders in a number of ways, having responsibilities to and simultaneously depending on all of the other journal participants. For the readers to easily locate papers of interest, the editor must attempt to get the journal listed in as many databases as possible. At the same time, the editor depends on authors to submit quality papers of interest to readers. The editor welcomes papers that have originality and that may be likely to be cited in other papers. A key goal of the editor is to have the articles in his or her journal cited by other authors, thereby increasing the journal’s impact factor. The editor also wants papers from other journals to cite his or her own journal, which can also increase the impact factor.

The editor also has a responsibility to increase the author pool through personal and professional connections. Section editors share this responsibility. The editor may also find it helpful to designate a “devil’s referee,” a sort of devil’s advocate who is responsible for examining the originality of a manuscript. The “devil’s referee” should take a skeptical view of the manuscript, looking for holes in the methods and results of the experiment and insisting that the paper contain etwas neues (something new) [9].

The editor of a new journal may face a limited author pool since a journal is not well-recognized internationally. The present editor-in-chief of APS has successfully listed APS in PubMed, PubMed Central, and Scopus but not yet in Science Citation Index (SCI). He is in his third year, with one more year of his term remaining. It is not certain he can continue after 2014, given the time commitment and budget limitations. The other stakeholders must rally around the editor-in-chief to ensure that he has the proper resources.

8.4.5 Authors

The authors’ primary goal is to have their paper read by many readers and cited by other authors. Authors should carefully read the aim and scope section of the journal before selecting a journal for manuscript submission. Authors want their manuscript to be accepted to a journal listed in high-profile databases and one with a high-impact factor. The higher the impact factor is, the greater possibility of the article being cited.

Since APS is not listed in SCI, it seems likely that Korean authors at university hospitals do not choose APS as their first journal for submission. As an ethics editor over the past 2 years, I have encountered cases of “salami slicing,” “imalas,” and duplicate publication, as well as plagiarism. In addition, a few thoughtless authors have made strong protests to the editors when their manuscripts were rejected.

Authors have an important responsibility of submitting manuscripts with scientific integrity. They must be aware that they continue to be responsible for their article’s contents even long after publication. It is recommended that in cases in which a paper has been rejected by APS, especially when legitimate problems have been identified with the manuscript, the authors not argue with the editor but revise their manuscript and find another journal to which to submit their paper.

8.4.6 Reviewers

The peer review system is an important component of modern scientific publishing, and it is a great help to editors in deciding whether or not a submitted manuscript is suitable for publication. The manuscript reviewer is a key player in the manuscript processing system and journal publication process. The reviewer’s responsibilities include protecting the integrity of a specialty, the reputation of the journal, and the welfare of human and animal subjects, as well as treating the author’s manuscript with respect, fairness, and impartiality [8].

In APS, the quality and rigor of the reviewers has not yet been standardized. Some are prone to accept most papers, while others tend to reject more papers. Some recommend too many revisions, while others make too few suggestions. Most of the reviewers do not take sufficient time to seek out similar articles which are not cited (SANC).

In APS, the standardization of reviewers is needed through training in reviewers’ workshops. In my case, when I have a manuscript to review, I hold a journal review club (JRC) session to gather the opinions of colleagues in my department. SANC is usually uncovered during a JRC.

In APS, reviewers are welcome to write a discussion on the article which they reviewed. This is a short response making public the kind of feedback that reviewers typically provide the authors during the review process. A quality discussion is of benefit not only to the authors but also to readers, who can discover different perspectives on the research presented, and particularly newer scholars, who are still learning to read critically.

8.4.7 Conclusions

The responsibilities mentioned here are only a few of those required of each stakeholder in the APS journal publication process. However, they are representative of the many other responsibilities that form the role of each participant in the journal publication ecosystem, all of which depend on and reinforce each other. All of the stakeholders should take pride in meeting their obligations to the scholarly community, because these seemingly mundane tasks all contribute to spreading clinical knowledge that raises the quality of care for our patients.

8.5 The Editor’s Role as a Harriet Shaw Weaver

Two weeks ago I visited Dublin, Ireland, where the summer meeting of the Anatomical Society was held. A literary walk was included in the conference program, and it began just after the poster session. About 50 participants attended in two groups. It started at a famous pub on Duke Street, and an actor guided each group. In the pub, we were guided to a small private hall where I found a picture of James Joyce and a framed letter he had written (Fig. 8.3).

Fig. 8.3

Photograph of James Joyce and his letter to Harriet Shaw Weaver. Taken at “The Duke” in Dublin Weaver was the magazine editor and arranged the publication of Joyce’s book

The actor told us that the letter was written to a magazine editor, Harriet Shaw Weaver, and when Joyce could not find anyone to publish his major work, Ulysses, Weaver set up the Egoist Press for this purpose at her own expense. It is thought that without the editor’s help, the great novel would never have been published, and thereafter Joyce would not have become a world-famous writer.

On my way home, I thought about how much the reviewer’s recommendations to a journal editor should be taken into account. Should the editor rely upon a reviewer’s opinion or does he have the right to accept or reject the paper against the reviewer’s recommendation? Should he play the role of one who ‘plucks a pearl from the mud’ as Weaver did?

A recent paper shows that journal editors tend to place considerable weight on reviewers’ recommendations. If all reviewers recommended not rejecting an article, editors still rejected the manuscript 20% of the time. If all reviewers recommended rejection, the editors rejected the piece 88% of the time. Further, if the reviewers were divided, the editors rejected the manuscript 70% of the time (P = 0.001) [14]. It is noteworthy that if all of the reviewers recommended rejection, the editors still accepted the paper 12% of the time.

The publication process involves author-editor interaction for which both get credit once the article gets published-the author directly, the editor indirectly [10]. However, the process of peer review can be prone to biases toward ideas that affirm the prior convictions of reviewers and against innovation and radical new ideas [13].

In the reviewing process, peer reviewers should avoid intellectual suppression due to the Matthew effect and Heider’s assimilation-contrast theory. The Matthew effect is the phenomenon in which “the rich get richer and the poor get poorer.” In the case of academic publication, it means that manuscripts of famous researchers have a greater chance of being published even if they are inadequate, while unknown authors’ work may be required to meet a higher standard or even rejected simply due to lack of an established reputation [15]. Heider proposed the distinction between two types of affective reactions in relation to the emotional expressions of others. He argued that we experience concordant affective reactions to the ideas of persons who belong to our in-groups and discordant affective reactions to those with whom we do not identify [16].

The role of editors is to comprehend the degree of concordance of reviewers and determine whether to accept or reject an author’s work on its own merits. Sometimes they should be a “devil’s referee” [9], and sometimes they should be a Harriet Shaw Weaver.

At the pub, two actors performed a portion of “Waiting for Godot” by Samuel Beckett. Two characters, Vladimir and Estragon, waited endlessly and in vain for the arrival of someone named Godot. Godo’s absence has led to many different interpretations. For me, as an author, after submitting a manuscript to a journal, the decision letter can be a figurative “Godot” that I feel I am waiting for endlessly. Until that letter finally arrives, I wonder whether the editor will truly be my advocate.

Editors should remain sympathetic to the fact that authors who have submitted a manuscript to a journal are waiting for a letter that begins “I am pleased to inform you that…” While enforcing strong standards of rigor and ethics, the best editors will be on the lookout for unconventional ideas that should be published. It is such ideas that will move science and clinical practice forward the most.

8.6 Importance of Narratives in Scientific Discussion

Paul said “As soon as I shall be beheaded, true men shall take away my body; mark ye well the place, and come thither tomorrow, and ye shall find by my sepulcher two men, Luke and Titus, praying. To whom when ye shall tell for what cause I have sent you to them, they shall baptize you and make you heirs of the kingdom of heaven.”—Golden Legend (1260)

I recently enjoyed a movie entitled Paul, Apostle of Christ (2018), directed by Andrew Hyatt. The plot is thought to be based on Golden Legend (1260), written by Blessed Jacobus de Varagine (1230 to 1299), rather than the New Testament.

After the Great Fire of Rome (ad 64), Emperor Nero persecuted Christians. Their most prominent leader, Paul (James Faulkner), was arrested, tried, and condemned to death, and awaited execution in a prison. Luke (Jim Caviezel) took a risk by visiting Paul in his cell at the jail. There, Luke wrote down a narrative of the conversions they performed and their missionary travels together, which would become the “Acts of the Apostles” (Fig. 8.4). This narrative eventually offered encouragement to Christians who were facing possible martyrdom.

Fig. 8.4

St. Luke writing down the conversations of St. Paul, which became the “Acts of the Apostles” by Hye Won Hu, M.F.A. (1986–)

If Luke did not record these conversations on parchment or if his followers did not copy the text (“Acts of the Apostles”), the New Testament would have 26 books instead of 27, and we could never know about the ministry and activities of the apostles after Christ’s resurrection.

At international conferences, so many new ideas are presented. We can take a picture of the posters presented, but at oral presentations, taking pictures is strictly prohibited. In abstract book for free papers, some authors kindly provide the content precisely within the word limit (usually 250 words). However, the abstracts of some panel discussions or invited lectures usually contain only an introduction to the presentation. They are not usually very kind in sharing their “secrets,” rather than “knowledge” about the topic.

Following the presentation, the discussions are usually opened to the floor, and these discussions generally involve good questions, comments, and answers. At that moment, we understand the point of the discussion and how various opinions converge. After the session, however, we cannot remember all of our insights. Even if we jot down some notes to capture the ideas, they are fleeting because our memory is treacherous.

If the scientific committee could provide a full video or transcript of the discussions, and the presentations, this would encourage registered participants to perform their activities more diligently, as in the operating room. The ability to rewind and repeatedly watch crucial parts of the presentation could make it more likely for audience members to write a letter to the editor when the material is published in a journal. Such innovations would be very valuable to the progress of knowledge in the field of plastic surgery.

8.7 Sine Qua Non Conditions for Research

Research is creating new knowledge.—Neil Armstrong

Research has been defined as a “creative work undertaken on a systematic basis in order to increase the stock of knowledge, including knowledge of humans, culture and society, and the use of this stock of knowledge to devise new applications [17].”

In the field of plastic surgery, research is carried out by many surgeons. Several residency training programs require that residents take time away from their clinical activities to focus solely on research, but the amount of time as well as the format of this research time vary considerably. Levi and Longaker insisted dedicated nonclinical research time at least a year would greatly benefit in the training of plastic surgeons [18]. He proposed several types of research for resident training: basic science, translational, outcomes, education, innovation/entrepreneurship, and public health/public policy.

Among them, translational research is increasing in plastic surgery field. Translational research implements a “bench-to-bedside,” from laboratory experiments through clinical trials to point-of-care patient applications, model.

Ten qualities have been suggested to be necessary for a good researcher: interest, motivation, inquisitiveness, commitment, sacrifice, excellence, knowledge, recognition, a scholarly approach, and integration [19].

Then what are the prerequisites (sine qua non conditions) for research itself? In a forum, a retired professor (YO Ahn) of preventive medicine suggested that all research should exhibit professionalism, scientific integrity, logicality, autonomy, and ethics. I strongly agree with him and therefore conducted research into each of these conditions.

Professionalism is a pattern of behavior identified with scientific integrity that, in turn, gives certain privileges. Scientists are expected to behave with intellectual honesty and to exhibit excellence in their thought and behavior.

Scientific integrity is the quality of being honest and having strong moral principles. It generally reflects a personal choice to hold oneself to standards of morality and ethics. This includes values such as honesty in research and publishing, avoidance of plagiarism or cheating, and maintenance of academic standards.

Logicality is the condition of being logical, which means being in agreement with the principles of logic. Logic is a method of human thought that involves thinking in a linear, step-by-step manner about how a problem can be solved.

Autonomy refers to voluntary participation and is based on informed consent. An exception from the principle of voluntary consent can be made when research is conducted using published and public information and archived materials. Research concerning official registries and documents that is carried out without the consent of the research subjects is governed by legislation. Research subjects can provide consent orally or in writing, or their behavior can otherwise be interpreted to mean that they have given consent to participate [20].

Research ethics refers to the application of fundamental ethical principles to scientific research, including the design and implementation of research involving human experimentation, animal experimentation, and various aspects of academic scandals, including patients with scientific misconduct. The key ethical standard regulating medical research is the Declaration of Helsinki (1964).

In the bronze door of the Thomas Jefferson Building of the Library of Congress, the figure of “Research” is carved in relief in a panel of a sculpture by Olin Warner (Fig. 8.5). In the allegorical figure of the goddess with her head turned to the right in three-quarters profile, her left arm is holding the torch of knowledge, and her right arm is holding a sprig of laurel. The interpretation of the allegory of “research” may be up to the viewer. I think that the researcher enlightens the world with the torch of knowledge and that the act of research itself is an honor.

Fig. 8.5

Goddess of Research at the Library of Congress Thomas Jefferson Building by Olin Warner (1896). The left hand of the goddess is holding the torch of knowledge and her right hand is holding a sprig of laurel

To obtain the torch and laurel in both hands, professionalism, scientific integrity, logicality, autonomy, and ethics are needed.

8.8 Scientific Integrity and Mr. He′s Jade

When I am carrying out research or writing a scientific paper, I always try not to forget scientific integrity and to make my paper flawless.

The term flawlessness originates from an episode of ancient Chinese history.

In the middle of the eighth century BCE, Bian He of Chu discovered a valuable piece of unworked jade and presented it sequentially to two kings, both of whom considered it be a worthless stone and punished what they perceived as deception by amputating his heel. When the jade was eventually cut and polished to make a ritual bi (jade-disk with a round hole in the center) it was acknowledged to be a priceless treasure, a perfect jade. Thus, Mr. He′s jade became the most famous jade in Chinese history.

In the fourth century BCE, in the Warring States period, the state of Zhao acquired this jade. At this time, Qin was the most powerful state. One day, emissaries from King Zhao-Xiang of Qin (325–251 BCE) came to the Zhao court and offered 15 cities in exchange for the sacred Heshibi jade disk. The King of Zhao did not trust the King of Qin because he had been untrustworthy historically.

Lin Xiangru volunteered to go to the Qin court with Mr. He′s jade. At the Qin court, the King of Qin passed Mr. He′s jade among his ministers and concubines, making no mention of the promised 15 cities. Lin thought that the King of Qin did not intend to keep his word. Therefore, he tricked the King of Qin by claiming that there was a tiny “flaw” in the jade, and when the King of Qin returned the jade to him so that he could point out the flaw, Lin threatened to smash both the jade and his head (i.e., to commit suicide himself) against a pillar if the King of Qin tried to take it back by force (Fig. 8.6). The King of Qin, unwilling to see the jade ruined, agreed. That night, still not trusting the King of Qin, Lin ordered his henchman to take the jade back to Zhao in secret (returning the jade intact to the State of Zhao) [21].

Fig. 8.6

Lin Xiangru threatens to smash both the jade and his head (i.e., to commit suicide himself) against a pillar if King Zhao-Xiang of Qin tries to take the jade back by force. Illustration by Hye Won Hu

As my teacher (Prof. Key June Seong, anatomist, 1926–1988) emphasized the importance of “flawlessness” when I was preparing my master’s thesis, I think that scientific papers need scientific integrity.

Scientific integrity is the quality of being honest and having strong moral principles. It generally reflects a personal choice to hold oneself to standards of morality and ethics. This includes values such as honesty in research and publishing, avoidance of plagiarism or cheating, and maintenance of academic standards [22].

Since I strive for my papers to be flawless, I published a poem entitled “Scientific integrity [23].”

Tigers leave hides when they die,

I will bet on my proud name.

The messenger offered the famed jasper to the king,

and yet he nearly lost his neck by treachery.

In my papers, I will write truth and nothing but truth.

With the spirit of losing life at the cross,

I would place myself across the creek,

and become a stone bridge.

Now when I write a paper, I rub my heels with my fingers and reflect on the meaning of flawlessness.

8.9 My Scalpel Stops Here

If you can’t stand the heat, get out of the kitchen.—Harry Truman

Recently, I participated in an annual conference held by the hospital where I was trained. The theme of the conference was “Advances in Facial Plastic Surgery,” and the last session focused on revision rhinoplasty.

A presenter introduced his personal principle for revision rhinoplasty, in which the capsule is removed completely, followed by release and a septal extension graft. The most important point he made related to the attitude underlying this surgical technique: “It stops here.” This meant that this operation should be the last one for the patient’s nose.

This phrase reminded me of Harry Truman’s farewell address in 1953. “The President—whoever he is—has to decide. He can’t pass the buck to anybody. No one else can do the deciding for him. That’s his job.” This metaphorical expression, “passing the buck,” is derived from the game of poker.

In the middle of the nineteenth century, the integrity of players was unreliable. Because the dealer has the greatest opportunity to cheat, players would take turns in the dealer role. To avoid arguments about whose turn it was, the person who was next would be given a marker, commonly a knife. The marker became known as a “buck,” because the handles of many knives were made from buck (stag) at that time (Fig. 8.7).

Fig. 8.7

A buck knife for designating the person who will be the next dealer

Like President Truman, surgeons must choose the surgical plan based on his or her own decision. The surgeon must take the patient’s history, perform a physical examination, and then sleep on the choice of the best option for the patient. If the patient is dissatisfied with the result, he or she will complain and perhaps even sue the surgeon who performed the operation. Surgeons must keep in mind the principle, “My scalpel stops here.”

At that conference, I also gave a presentation, entitled “Anatomy for blepharoplasty.” After my presentation, the chairperson asked me about the difference between the motor innervation of the lower eyelid that I described in a publication years ago and a new publication by another author. I replied that the difference is due to the dissection method: from the skin or from the periosteum. I added that I had already submitted a letter to the editor on the topic, which has been published. An audience member asked me about the terminology of the layers of the orbital septum. I used the term “levator sheath” because Dr. Whitnall used it one hundred years ago. The audience member was confused because a Japanese ophthalmologist has been creating new terms for existing structures without searching the older literature.

On my way home I thought about the role of authors, especially the corresponding author. According to the International Committee of Medical Journal Editors (ICJME), the corresponding author is the individual who takes primary responsibility for communication with the journal during the manuscript submission, peer review, and publication process. The corresponding author should be available after publication to respond to critiques of the work and cooperate with any requests from the journal for data or additional information should questions about the paper arise after publication [24].

The buck also stops in front of the corresponding author of a manuscript, just like politicians and surgeons. They all have responsibilities that last as long as they breathe and will only perish when they pass away.

8.10 The Ajax Dilemma in Authorship

For if they had been able to see the truth, then mighty Ajax, in anger over the arms, would never have planted in his chest the smooth sword—Ajax, who was the most powerful in battle, except for Achilles, and whom the breath of the unswerving Zephyr conveyed in swift ships, to bring back the wife of golden-haired Menelaus from the city of Ilus.—From Nemean 7, by Pindaros 518–438 BC

When I visited Rome before the coronavirus pandemic, I saw a fragmentary marble statue of a nude male (Fig. 8.8, left) in the Museo Pio-Clementino of the Vatican Museums. Because it was very similar to the torso showing visceral anatomy in the Fabrica of Vesalius (Plate 59, Fig. 8.8, right) [25], I read the text of the exhibition. The torso, which is named the “Belvedere Torso,” is believed to have been made by Apollonios, an Athenian, during the first century BC. According to the Vatican Museum website, “the most favored hypothesis identifies it with Ajax, the son of Telamon, in the act of contemplating his suicide.” The statue later came to be admired by Michelangelo, for which reason it came to be known as the “Torso of Michelangelo” and the “School of Michelangelo.”

Fig. 8.8

The Greek hero Ajax depicted in a sculpture of his torso and in a drawing. Left: “Belvedere Torso” (first century BC, Athenian sculptor Apollonios) in the Museo Pio-Clementino. Right: Plate 59 of “De humani corporis fabrica libri septem” (“On the fabric of the human body in seven books,” 1543) of Andreas Vesalius

In Homer’s Iliad, Ajax was notable for his abundant strength and courage, shown particularly in two fights with Hector. After Achilles is killed by Paris, Ajax and Odysseus are the heroes who fight against the Trojans to retrieve the body and bury it. After the burial, each claims Achilles’ armor, which had been made by the smith-god Hephaestus. A competition is held to determine who deserves the armor. To whom would the king, Agamemnon, give the gorgeous armor? Which soldier is more valuable: Ajax the magnificent, loyal, always in the thick of the fighting, always saving lives, or Odysseus the strategist, the trickster? The king arranges an oratorical contest to decide the issue. Odysseus proves to be more eloquent and, with the aid of Athena, the council gives him the armor. Ajax, the loyal workhorse, loses the contest. Ajax, “unconquered” and furious, becomes crazy and slaughters the Achaeans’ herds of captured livestock, believing them to be his enemies through a trick of Athena. Unable to deal with this dual dishonor, he falls upon his own sword, “conquered by his [own] sorrow”, and commits suicide.

Drawing inspiration from this ancient conflict between Ajax and Odysseus over the armor of Achilles, a book entitled The Ajax Dilemma was written by Paul Woodruff in 2011 [26]. This book deals with one of today’s most pressing moral issues: how to distribute rewards and public recognition without damaging the social fabric. How should we honor those whose behavior and achievement is essential to our overall success? Is it fair or right to lavish rewards on superstars at the expense of the hardworking rank-and-file? How do we distinguish impartial fairness from true justice?

Reading this book, I reflected on coauthor meetings just before submitting a manuscript to a certain journal. Sometimes, everybody is happy in those meetings, but sometimes this is not the case. Of course, we have to verify our authorship during the submission process or just after the submission before the review process starts. This led me to wonder whether we also face the “Ajax dilemma” when determining the authorship of papers.

According to the “Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals,” the International Committee of Medical Journal Editors (ICMJE) [27] recommends that authorship be based on the following four criteria:

• 1. Substantial contributions to the conception or design of the work or the acquisition, analysis, or interpretation of data for the work.

• 2. Drafting the work or revising it critically for important intellectual content.

• 3. Final approval of the version to be published.

• 4. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

This recommendation states that all individuals who meet the first criterion should have the opportunity to participate in the review, drafting, and final approval of the manuscript. It furthermore specifies that the criteria used to determine the order in which authors are listed on the byline may vary and are to be decided collectively by the authors and not by editors.

As the recommendation states, the determination of the order of authors should be decided by the authors as a group. The corresponding author, like the king Agamemnon, can be the chairperson of the coauthors’ meeting. However, it is not always easy to determine who will be the first author—analogous to the question of who is deserving to take Achilles’ armor. Like the Greek army that won the Trojan War, we also are facing the “Ajax dilemma.”

At this moment, we should remember a story from the Talmud, describing three brothers, who, respectively, had a magic telescope, a magic carpet, and a magic apple.

A king had a beautiful, beloved princess, but she was at the verge of death due to an illness. Many doctors prescribed and applied all kinds of medicines, but none worked. Becoming very desperate, the king proclaimed that whoever heals the princess will marry the princess and will eventually become the next king as the reward. Three brothers who lived far away from the palace heard that the princess was ill and discussed how to heal her. Each of these brothers had a magical item: the first brother had a magic telescope that could see anywhere; the second brother had a magic carpet that could fly anywhere; and finally, the third brother had a magic apple that could heal any illness. Therefore, they verified the proclamation with the magic telescope, and then they flew out to the palace on the magic carpet and gave the princess the magic apple. The princess got better immediately. The king could not decide which one to give his daughter to, because they all took part in healing her.

Here is the question: who would you accept as the bridegroom of the princess if you were the king and why? I would suggest accepting the third brother, because he gave up his magic apple, which the princess ate. I believe that we all have the wisdom to give credit for authorship according to the contribution that each researcher makes.

8.11 Archives of Korean Plastic Surgery

While I was in London for 3 months in 2016, I visited the British Association of Plastic, Reconstructive, and Aesthetic Surgeons (BAPRAS) archives located at the Royal College of Surgeons in London.

The palatoplasty method I have been using for almost 30 years (V-Y pushback) was derived from Dr. Kilner via Dr. Calnan, so I wanted to see some relics belonging to Dr. Kilner.

I contacted the Hunterian Museum and made an appointment with the curator. There, I met the honorary archivist Dr. Roger Green and was shown three boxes of Dr. Kilner’s relics: drafts of papers, pictures of the patients he operated on, schemas submitted to journals, and his handwritten notes. While in the room, I wore gloves on my hands to protect the papers. As I read Dr. Kilner’s lecture draft written 68 years ago, I felt as if I was listening to him give the lecture in the lecture room downstairs.

The records of plastic surgery go back to at least 500 BC. However, the modern discipline as we know it has its origins in the First World War. The BAPRAS archives were founded in the 1980s by Antony Wallace and are known as the Antony Wallace Archive. The current honorary archivist is Roger Green, who succeeded Brian Morgan, who retired from the post in 2014, having spent 15 years overseeing and expanding the archive. Mr. Morgan followed Phil Sykes and Charles Chapman in this role.

The BAPRAS archive holds a number of photographs, some of which depict staff and treatment procedures from the World War I, although the majority of the items are from plastic surgery personalities from the 1930s and the World War II. The BAPRAS archive has a collection of plastic surgery instruments, for example, that belonged to Professor Joseph, who was the pioneer of cosmetic rhinoplasty. All BAPRAS-archived instruments are available for viewing and can be accessed online (http://surgicat.rcseng.ac.uk/).

On my way back to Korea, I thought about the history of Korean plastic surgery. The Korean Society of Plastic, Reconstructive, and Aesthetic Surgery (KSPRS) was founded in 1966, and the first volume of the Journal of the Korean Society of Plastic and Reconstructive Surgery (Taehan Sŏnghyŏng Oekwa Hakhoe chi) appeared in October 1974 (Fig. 8.9). Starting with Vol. 39 (2012), it was continued as Archives of Plastic Surgery (APS). We marked our 50th anniversary in 2016. The KSPRS has its own office with sample space, and the pioneers of the KSPRS are getting very old; some of them have even passed away.

Fig. 8.9

The first issue of JKSPRS The first issue of the Journal of the Korean Society of Plastic and Reconstructive Surgery (Taehan Sŏnghyŏng Oekwa Hakhoe chi), vol. 1, no. 1, October 1974. Left, cover; right: table of contents. Donated from Dr. Lee Taik Ho (Board No. 9)

It is time to create our archives: the Archives of Korean Plastic Surgery. We should gather all our experiences and knowledge of plastic surgery in the past, including memories of working with or being a patient of the pioneering Korean plastic surgeons. When pioneers retire, the KSPRS should try to persuade them to donate their relics. A room should be dedicated as a space for the archives, and famous instruments and relics should be photographed and exhibited online.

There is an Oriental saying that “Tigers die and leave their skins; people die and leave their names.” We should preserve our ancestors’ relics and the spirits that are inside of them.

8.12 They are Analyzing Us: Our Own Survey is Needed

When I searched for a paper written by a plastic surgeon colleague of mine, I found that it had been cited four times [28]. Interestingly, one of the citations was from a paper that had been published in a journal in the field of management, not in a medical journal [29].

Because the title contained the intriguing words “cosmetic surgery” and “Seoul,” I read the linked article. It was written by researchers in the fields of business and accounting from Malaysia and China, and the journal was published in the United States.

In order to collect market data on women’s willingness to undergo cosmetic surgery in Seoul, the authors interviewed 400 women aged 19–40 years in Seoul using a self-administered questionnaire. These researchers in the fields of business and accounting used the theory of reasoned action, which analyzes factors such as attitudes, subjective norms (celebrities and the media), and psychological attributes (social status and self-esteem) that influence patients’ intention to undergo cosmetic surgery. They found generally positive attitudes toward cosmetic surgery among women living in Seoul, with favorable intentions towards cosmetic surgery, as manifested by the belief among Korean women that undergoing cosmetic surgery is the most effective way to improve their appearance and social status. Their results revealed that celebrities and the media played an important role in influencing women to undergo surgery.

The authors approached this topic from the perspective of marketing and management and suggested that their results provided important information for designing effective strategies to advertise and promote cosmetic surgery. They also discussed psychological attributes, such as self-esteem and social status.

Reading this article, I was surprised that researchers in the field of business and accounting wrote this paper and that they were interested in cosmetic surgery marketing in Seoul. Although there are only about 51 million Koreans living in South Korea and 7.4 million Koreans living outside of the Korean Peninsula, accounting for roughly 1% of the world population [30], the authors were clearly aware that South Korea is ranked third in the world in the number of cosmetic procedures, with 1,156,000 Koreans undergoing such procedures in 2015 [31], and the Korean cosmetic surgery market has a 24% market share of the total world market [32].

I think that the authors of this article regard the Seoul cosmetic surgery market as a wide-open field (blue ocean) for future business initiatives.

The Korean Society of Plastic and Reconstructive Surgeons (KSPRS) has been gathering data from all training hospitals for many years. At any training hospital, we must report daily information on the operations performed and the number of patients in our department. However, I have not seen any articles based on the prospective data collected by our society.

As the authors in the field of business and accounting suggested, additional research is needed to determine patients’ satisfaction with non-core and post-cosmetic surgery services (after-sales services), such as the doctor’s skills and knowledge, the environment of the clinic, and other factors that collectively define the total or augmented product.

The KSPRS has recently been making efforts to internationalize itself as a society [33]. We, as members of the KSPRS, should have a prospective analysis of our market before our possible rivals. We should analyze the market ourselves, instead of letting further surveys be done by marketing managers from countries that compete with us. For this, a survey supported by the Korean Society of Aesthetic Plastic Surgeons of the KSPRS is needed. Remember that our city, Seoul, is the “center of cosmetic surgery.”