Plastic and Reconstructive Surgery : The Future of the Journal and the Field through the 21st Century

HOW WE GOT HERE: A BRIEF HISTORY OF PLASTIC SURGERY When PRS was founded in 1946, Warren Davis, the first editor-in-chief, asked Vilray Blair to comment on what this new journal meant to the field of plastic surgery. “Plastic surgery is one of the oldest surgical specialties,” he wrote. “There is no reason why this journal cannot have a broad field of usefulness to both ‘plastic surgeons’ and men with plastic problems in other branches of surgical practice.”1 This statement was prophetic about the new and bright young specialty and the embryonic PRS! Add in the better half of the population, women, and Blair proved to be quite accurate. As a primer on how we got from Blair’s statement to today, we present a once-each-decade glimpse at the history of the field itself in Table 1, focusing on dominant themes noted in snapshots of this Journal. This capsule of the trends and topics of each time period truly reflects the tremendous growth and progression of plastic surgery, as well as medicine and technology in general. So much has changed in the world at large, the publishing industry, and the Journal itself in the past 70 years that it would be a tall order to compile a thorough listing of the ways in which the Journal itself has grown and changed since its inception. The memorable innovations and evolutions roll off the tongue and were clustered in the late 20th and early 21st centuries: the addition of color figures; increasing cosmetic content; offering Continuing Medical Education and Maintenance of Certification articles and related tests; sectionalizing content by scientific topic; electronic peer review and manuscript submission systems; creating a website to archive, host, and promote Journal content; utilizing that website to disseminate some content freely via special promotions to anyone, anywhere; embracing the tenets of evidence-based medicine; publishing videos and other digital content; harnessing social media to promote scientific content; open access publishing. But much has remained the same as well: general scope of content, the foundation of rigid peer review, printed publication, and commitment to patient care, education, and safety. In our vision of the future, the founding principles of the Journal will remain in place. In honor of the 70th anniversary of PRS, we will today muse on what PRS—and in some small way, the world—may look like upon its 80th anniversary.

C an you believe it is the 70th anniversary of Plastic and Reconstructive Surgery? This is a remarkable opportunity to reflect upon the history and future of our field and our Journal.

HOW WE GOT HERE: A BRIEF HISTORY OF PLASTIC SURGERY
When PRS was founded in 1946, Warren Davis, the first editor-in-chief, asked Vilray Blair to comment on what this new journal meant to the field of plastic surgery. "Plastic surgery is one of the oldest surgical specialties," he wrote. "There is no reason why this journal cannot have a broad field of usefulness to both 'plastic surgeons' and men with plastic problems in other branches of surgical practice." 1 This statement was prophetic about the new and bright young specialty and the embryonic PRS! Add in the better half of the population, women, and Blair proved to be quite accurate.
As a primer on how we got from Blair's statement to today, we present a once-each-decade glimpse at the history of the field itself in Table 1, focusing on dominant themes noted in snapshots of this Journal. This capsule of the trends and topics of each time period truly reflects the tremendous growth and progression of plastic surgery, as well as medicine and technology in general.
So much has changed in the world at large, the publishing industry, and the Journal itself in the past 70 years that it would be a tall order to compile a thorough listing of the ways in which the Journal itself has grown and changed since its inception. The memorable innovations and evolutions roll off the tongue and were clustered in the late 20th and early 21st centuries: the addition of color figures; increasing cosmetic content; offering Continuing Medical Education and Maintenance of Certification articles and related tests; sectionalizing content by scientific topic; electronic peer review and manuscript submission systems; creating a website to archive, host, and promote Journal content; utilizing that website to disseminate some content freely via special promotions to anyone, anywhere; embracing the tenets of evidence-based medicine; publishing videos and other digital content; harnessing social media to promote scientific content; open access publishing.
But much has remained the same as well: general scope of content, the foundation of rigid peer review, printed publication, and commitment to patient care, education, and safety. In our vision of the future, the founding principles of the Journal will remain in place.
In honor of the 70th anniversary of PRS, we will today muse on what PRS-and in some small way, the world-may look like upon its 80th anniversary. Plastic and Reconstructive Surgery • July 2016 to gather enough material to make an issue, and then publish it.
The advent of digital journal publishing has changed the conversation for issue-versus articlebased publishing as well. The demand may or may not be demonstrated from the readers, but we have certainly seen a big push for faster acceptance-topublication times from the authors of these papers. In an issue-based world, where cultivating of the monthly issue involves gathering, queuing, and staging, the time to publication can be delayed.
In an article-based publication world, an article can be published in the order in which it is accepted. Not only do digital journals allow for this to be possible (the costs of printing and distributing each article as it comes would be cost prohibitive, to say the least), but digital journals allow this to be done as fast as possible. Many major journal publishers embarked upon shifting processes to allow for this type of publishing earlier this decade. 2 We surmise that by the end of another decade, most major journals-Plastic and Reconstructive Surgery included-will be publishing content in an "article-based" fashion, that "operates by publishing articles as final and citable without waiting until a journal issue is complete … [it] assigns final citation data on an article-by-article basis, decoupled from the compilation of the journal issue itself." 2 But in this not-too-distant, not-unlikely future, what is the role of a printed PRS?

Print
In the past 30 years there has been a meteoric rise of electronic, digital, and Internet-based technologies. The Editorial Board of the Journal and the American Society of Plastic Surgeons (ASPS) have embraced digital technologies and are often on the forefront of these changes. Our website, PRSJournal.com, IS the Journal of record for PRS. Our app for the iPad was one of the first of its kind. Our articles have crucial components that have to be viewed online or electronically; paper simply cannot present a video. We even launched our own electronic-only journal, PRS Global Open. We at the ASPS and PRS are not Luddites.
Within the past 10 years, we have been presented with several philosophies and strategies which would eliminate a printed version of PRS entirely. It seemed that this was the way the world was heading, but something curious and unpredictable happened: print did not go anywhere. The e-book has not supplanted the printed book itself, as was predicted. "While analysts once predicted that e-books would overtake print by 2015, digital sales have instead slowed sharply … some e-book adopters are returning to print, or becoming hybrid readers." 3 We've seen the same thing in the journals world. Our online and mobile versions are popular and well-used, but the demand for print has not been cannibalized. Anecdotally, we've seen some surprising early adopters to our tech-versions coupled with equally surprising embrace of print. At a recent PRS meeting, we were surprised to learn that an "elder" journal managing committee member (who still has a flip phone, mind you) only reads PRS on his iPad; meanwhile, the two plastic surgery residents in the room (with the latest iPhones in hand) actually preferred the printed edition! Plastic and Reconstructive Surgery in 2026 will still be printed in some form or shape. It will be a smaller edition (a digest, perhaps) with more links to online content and articles, subscribers may be able to opt out entirely, and the very definition of "print" may start to evolve toward the digital as companies like Sony are currently debuting "digital paper." 4 It may be a compendium-style "postpublication" of what was already published online in the previous month or months (as part of an article-based publishing model), but in our best estimate, there will still be a printed component to Plastic and Reconstructive Surgery in 2026.

New Sections (Rise in Content)
One of the most popular structural changes to the Journal itself in the past 70 years was the organization of content based on subject matter, which debuted with the January 2005 issue. The sections were decided based on the broad, diverse, and occasionally "niche" areas of the field of plastic and reconstructive surgery. 5 The sections were Breast, Cosmetic, Experimental, Hand/Peripheral Nerve, Pediatric/Craniofacial, Reconstructive, CME, and Special Topic (although not always presented in this order). The division of our literature, and our field, into these sections represented the current state of the field at the time. Ten years later, these designations still seem to do the trick.
However, I have noticed that as we have grown and evolved, the Special Topics section has grown to be a functional catch-all for topics that don't fit nicely in the other categories. Other topics seem to still fit well in their parent sections, but they could eventually stand alone due to the breadth of the topics. In 2026, will the Journal have any newly defined sections for articles on the following topics? These specific areas of our field may or may not grow to define (or redefine) the Journal in the next decade. In 10 years' time, though, the plastic surgery field will have evolved so much that the literature will reflect and support entirely new sections of monthly peer-reviewed content. The current trend toward less invasive, less aggressive surgical regimens in both cosmetic and reconstructive surgery may be the dominant theme in our specialty by 2026. There will be massive growth in both cosmetic and reconstructive medicine, in addition to more traditional options for cosmetic and reconstructive surgery.

Open Science
In the environment where stressors-including increasing subscription prices, spike in the number of journals published, changing communication and expectation patterns, and the likecurrently tax the journals publishing system, it has been noted that the field of medicine has been more acutely feeling the "squeeze" than other fields. 6 People want access to medical research information more universally and-arguablyneed it even more in the developing world. Some believe that the direction medical publishing may take from this crossroads will be toward something called "open science." The open science movement sees a future where the publication of peerreviewed, academic journal content more openly meets the needs for the economy and society at large, including "science becoming more responsive to societal needs; greater openness that could improve trust in science; economic benefits accruing from increased rates of innovations …; [and] new services and productivity gains arising from the use of 'big data' techniques and text and data mining." 7 So, how will PRS look in a future where these noble goals and aspirations are more actively met by publishers and potentially mandated by funding bodies? Some of the proposed solutions may not affect the functionality of the end product but would still be substantive: speeding up publication and reforming the peer review system. Other changes may be more visible: perhaps all available data that went into a study will have to be "published" openly along with the article or posted to a large repository; perhaps there will be new databases built to house and make publicly available all protocols, recruitment data, changes, complications, and more for all clinical trials; perhaps a published paper's peer reviews will be made available for the readers. And perhaps some of the changes would not be in the journals or data world at all but in the tenure requirements for academic institutions. 6 The Plastic and Reconstructive Surgery of the future may be part of a global movement toward more open science, in which the public at large may have full access to the articles, the research, and more.

Postpublication Peer Review
One of the hallmarks of the Web 2.0 movement of the past 15 years has been social commenting and ranking, turning the flow of information into a two-way stream. Any online shopper knows that the customer comments and ratings are a good way to find out more about the quality of the product being considered. Some comments should be taken with a grain of salt or ignored altogether, and some results could be augmented due to artificial filters and paid options. But the "wisdom of the crowds"-especially when untampered with-seems to be a good thing. Look at RottenTomatoes.com, Amazon.com, and Wikipedia, for example. Many publishing insiders point toward applying this Internet-enabled, aggregated, public product review toward academic publishing in the form of postpublication peer review. In this process, "all readers, not just the reviewers selected by the editor, are able to review and comment on the paper, and even to rate it on a numerical scale following publication." 7 PLOS ONE has enabled postpublication peer review on its articles already, though fewer than 10 percent of the articles have received any sort of commentary. 7 Though researchers and academics may not be early adopters for this platform, one can still foresee some benefits for it: transparent, broad, interactive discussion. However, one need only look at the vitriol in the comments section of the latest YouTube video or news story to foresee the potentially negative aspects. That said, active moderation and lack of anonymity may be logistical ways to mitigate any sort of abuse.

Plastic and Reconstructive Surgery • July 2016
In 10 years' time, PRS may be employing postpublication peer review as an adjunct to traditional peer review, but not as a replacement. Although the wisdom of the crowds is very useful when deciding what movie to see or what product to buy, the safety of our patients and education of our readers will still depend on an unbiased, critical, and rigid peer review to serve as gatekeeper. The so-called "publish then filter" model would be dangerous, especially for medical journals. We cannot publish all articles and wait for the wisdom of the crowds to separate the good science from the bad.

Academic Social Media
Any look into the journals of the future would not be complete without a look into the future of the "Letter to the Editor." The basic "transaction" of scholarly discovery has been the presentation of ideas, followed by documented question and answer, since the advent of the scholarly journal in 1665. The time may have come, however, that the actual "discourse" portion of scholarly publishing may no longer be worth having in the pages (or e-pages) of the Journal itself. It's not that the discourse of letters and replies would not be welcomed, but that the current drawbacks of journal publishing may for once and for all make the journal platform an inadequate place to have such a conversation "on the record." Recently, we asked a social media commenter to submit their concerns as a letter to the Editor. The conversation went a little something like this (paraphrased): PRS: "Thank you for your comments and concerns. Please consider writing our thoughts up as a letter to the Editor and submitting it to the Journal." Reader: "A letter to the Editor? WTH? What is this … 1985?" Ultimately, a robust conversation was had on Twitter about the issue in the article, and a letter to the editor was submitted and published along with a reply from the original authors. Nevertheless, the reader's initial point was very well received. Is there a role for the traditional "Letters to the Editor" section in today's world, where social media and commenting functionalities allow for realtime discussions with authors, thought leaders, and the rest of the Internet? Could such an existing mechanism be fitted to meet our scholarly needs (and remove any knee-jerk commentary, for which the Internet is so (in)famous) by 2026? Certainly so.
Would our readership want to see the Letters section go the way of the dinosaur? Or is the time delay to official publication not a barrier to significant, scholarly, on-the-record "Letters to the Editor"?

THE JOURNAL IN 2086
As this is our 70th anniversary, we decided to look even deeper into our "crystal ball" to predict some changes for PRS after another 70 years in existence. The following are our top hypotheses.
1. Reconstruction after Cancer. It is our firm hope that by 2086 the scientific community will have won, or at least be winning, the war on cancer. It would be our specialty's fondest pleasure to no longer have to perform any breast reconstructions following cancer. If we can "cure" most cancers, including cancers of the breast, head and neck, and skin, by biogenetics or bioengineering techniques or mechanics, the resultant mastectomies and other postcancer reconstructions would be relics of the past. The Journal's postcancer reconstructive content in breast and reconstruction may be massively diminished in 70 years due to a simple lack of customers, but other areas will grow where plastic surgery continues to lead in the arena of reconstruction. Until the day, however, when the world is cancer-free, plastic surgeons will be there to help patients find a new normal and a new sense of physical self after cancer.
2. The Tactile Journal. We are confident that there will be a printed PRS in 10 years. We are equally confident that there will be some sort of handheld, tactile version of the Journal in 70 years. It may not be "print" or even "paper." Perhaps foldable, mass-produced digital devices will eventually supplant print by the end of the 21st century. That said, it is our firm belief that print will still prove to be an advantageous, efficacious, and customer-preferred technology for some uses, including books and journals.
3. International Journal. With the rising technological and academic prowess of countries such as China 8 and India 9 evident now, we predict that by 2086 the Journal may reflect a broader mix (and maybe even a majority) of academic articles originating from outside North America 4. Open Journal. By 2086, PRS will likely be entirely open and free for all, worldwide. This may be part of the open access movement or the logical conclusion of the open science discussions happening today, or a result of some other force entirely. However it happens, all signs appear that electronic access to medical research and science may not be behind the pay wall in the future.
5. Nanosurgery. The present climate shows microsurgery being refined and perfected and made more and more "micro" with each minor evolution; the plastic surgery literature is already showing results of "supermicrosurgery" focused on blood vessels thinner than 1 mm. 10 Coupled with the field's current advances in wound healing and in vitro research and treatments, it is not remotely "sci-fi" to see nanosurgery being a mainstream tool in daily use in our field. By 2086, plastic and reconstructive surgeons will routinely perform minimally invasive or even completely noninvasive surgeries on small particles.
6. Plastic and Reconstructive Surgery … in Space. NASA is planning on sending humans to an asteroid by 2025 and to Mars by 2039. 11 Plastic surgeons are often found on the frontlines of battles 12 and where they're needed most. Knowing what we currently do about the effects of prolonged exposure to weightlessness, including bone breakdown, muscle atrophy, and fluid shift, 13 it is our belief that plastic and reconstructive surgeons, with centuries of research into reconstruction, human anatomy, nerves and microsurgery, wound healing, and compression, will be on the frontlines in the final frontier of space exploration. The literature, by 2086, will likely include studies on how plastic and reconstructive surgery can aid in reconstructing the damages caused by space travel. 7. A New Beauty Standard. The definition of beauty is subject to individual preferences but can be influenced by trends, and that likely won't be different in 70 years. Recent literature has shown us trends of so-called Westernization of the nose and eyes, 14,15 facial feminization, [16][17][18] and more "natural"-looking results. [19][20][21] Will the rise of India and China create countertrends toward "Easternization"? Facial feminization could be followed by a surge in feminization of other areas, including the neck, hands, and feet, but will it be matched with a rising demand for "masculinization"? How far will consumer demand force the advance of "natural" results in cosmetic procedures? Only time will tell, but one thing is certain: change. Beauty may not be radically different in 2086, but the future of plastic surgery will definitely have to adapt to what changes do come.

CONCLUSIONS
When he predicted 70 years ago that PRS would "have a broad field of usefulness," Blair was right. The field and the Journal have continued to educate, evolve, and push through into new scientific frontiers. For 70 years, Plastic and Reconstructive Surgery has been the one consistently excellent reference for every specialist who uses plastic surgery techniques or works in conjunction with a plastic surgeon: men and women. The Journal has brought readers cutting-edge research and consequential follow-up on the latest techniques for all areas of plastic and reconstructive surgery. Seventy years ago, it's likely that the Journal's founders considered that the Journal's readership would have expanded beyond plastic surgeons and affiliated specialists. More and more, the information published in this Journal is not only of tantamount importance to academic and clinical surgeons but also of specific personal interest to patients and of general interest to the public at large. In the past 70 years, PRS has emerged as the number one source of plastic surgery science and advances for the whole world. With your support as readers, reviewers, and authors, the next 70 years should be equally incredible.
"The best way to predict your future is to create it." -Abraham Lincoln