Discussion

Sir: Thank you to Drs. Glasberg and Song for the discussion1 of “Financial Conflicts of Interest in Plastic Surgery: Background, Potential for Bias, Disclosure, and Transparency.”2 The discussion deserves comment. The discussants offer within a counterargument essentially three points: (1) another explanation for the emergence of key opinion leaders rather than one of bias induced by industry payments; (2) the mutually beneficial relationship of industry and plastic surgery; and (3) a reassurance that although a problem may exist, the American Society of Plastic Surgeons leadership is in “proactive” discussions of the issue. The first is a victim of an incorrect assumption; the second and third succumb to the logic error of begging the question. The other elements of the piece include criticism of the use of my lecture at the 92nd Annual Meeting of the American Association of Plastic Surgeons as a reference not “peer-reviewed.”3 Granted, the lecture was not, but other references, peer-reviewed, were cited that questioned the efficacy and cost of indocyanine green (Spy System; Novadaq Technologies, Inc., Mississauga, Ontario, Canada). First, Drs. Glasberg and Song raised the question of “Dr. Luce potentially introduces bias to sway the readership to assume causation and correlation” and pose another explanation (“safe to entertain the possibility”) that the excellent results published by paid consultants of a corporation that markets a particular device or technology are achieved because such individuals are “excellent and experienced surgeons.” The degree of excellence and experience of paid consultants as surgeons is not the point; bias introduced by financial conflict of interest is the primary issue. The entertained possibility proffered by the discussants does not endure an elemental examination. As already cited in the article, Lopez et al. (the full article is now available in the Journal4) weighed the results of the use of human acellular dermis (acellular dermal matrix) by authors with and without a conflict of interest and determined that the former reported fewer surgical complications. Nevertheless, in breast reconstruction when acellular dermal matrix was not used, the reported complications were similar between those that reported a conflict of interest and those that did not report such a conflict, not an anticipated result if a difference existed in excellence and experience. Also, an assessment5 of the influence of manufacturers on the outcome of a comparison of two different systems of negative-pressure wound therapy determined that the results favored the particular corporation involved, whether by paid consultants or paid research, in 18 of 19 studies, and was not a consequence of excellence or experience. Second, Drs. Glasberg and Song, currently President and Vice President of the American Society of Plastic Surgeons, respectively, provide reassurance to the readers that the leadership of the American Society of Plastic Surgeons has the issue of financial conflict of interest under consideration and will propose measures. A discussion of solutions assumes a priori a problem exists and indeed one does which, after all, was the principal thrust of the article. The readers of the Journal and American Society of Plastic Surgeons members eagerly await the unveiling of those measures, but both can be forgiven of lingering doubts. Although not addressed in the article,1 similar questions to those raised with respect to the Plastic and Reconstructive Surgery Editorial Board could also be directed toward American Society of Plastic Surgeons leadership positions. Should the officers of our principal specialty society have financial conflicts of interest? Third, Drs. Glasberg and Song reiterate the point (established in the Summary of the published article) of the positive aspects of the interaction between industry and the development of new products and techniques. Those developments may spring from industry-sponsored research, funds granted directly to an investigator. Again, the objective is not to sever that mutually advantageous arrangement, but to eliminate the potential for bias, accomplished by an “arms-length” relationship as outlined by others.6 Possibly, the article, the resultant discussion, and these comments will further propel a specialty-wide dialogue into the issue of financial conflicts of interest. DISCLOSURE The author has no financial interest to declare in relation to the content of this communication. Edward A. Luce, M.D. Department of Plastic Surgery University of Tennessee Health Science Center 1068 Cresthaven Memphis, Tenn. 38119 [email protected]

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