Underrepresentation of Racial Minorities in Breast Surgery Literature: A Call for Increased Diversity and Inclusion.

OBJECTIVE In this study, the extent of racial diversity in images of breast-related plastic surgery published literature was investigated to better understand disparities that exist in breast surgery. BACKGROUND The lack of racial diversity in images of skin color in surgery literature can perpetuate implicit bias and stereotypes. Implicit bias can affect the way patients are evaluated, diagnosed, and treated. The visual aspects of plastic surgery make a lack of diversity in imagery especially impactful on patient care and outcomes. METHODS Published medical images and graphics depicting human skin were analyzed across four major plastic surgery journals. Up to four years were chosen a priori to evaluate from each journal and represented the initial year of color image publication, the year of study initiation (2016), and representative years for a given decade (2000 and 2010). Images and graphics were tabulated, rated by Fitzpatrick scale and categorized into "white" or "non-white". Data were evaluated with pair-wise and linear regression statistics. RESULTS Of the 2774 images and 353 graphics that met inclusion criteria, only 184 (8.18%) images and 9 graphics (6.34%) depicted non-white skin. Temporal analysis showed that there is an increased diversity of images published since 2010 with 0% of images being non-white prior to and 7.3%-10.3% after 2010. International and multi-national authors tended to publish more non-white images. CONCLUSIONS There is insufficient racial diversity visually represented in the breast-related plastic surgery literature with a small degree of progress made towards more equitable imagery over time. Increasing awareness of image content, and the need for equitable visual representation may allow for improved racial diversity in surgical literature.