Background
Scar management is an integral part of postoperative care in plastic surgery. The approach may vary based on skin tone. Hence, comprehensive training on scar prevention and treatment of all Fitzpatrick skin types is important in resident education. Nationwide, plastic surgery residents use the American Society of Plastic Surgeons (ASPS) Resident Education Curriculum as an online resource during their training. A previous study found that this online resource generally does not equitably represent patients of diverse skin tones. The aim of our study was to assess the representation of diverse skin tones in the ASPS Resident Education Curriculum teaching materials specifically on scarring. We hypothesized that the modules focused on scarring do not equitably represent patients of diverse skin tones.

Methods
The ASPS Resident Education Curriculum was reviewed to select teaching modules that mentioned the term “scar” in their learning objectives. Visual aids were then identified in the selected modules. Three independent raters scored these visual aids on the Fitzpatrick scale I-VI. The Fitzpatrick scale ratings were categorized into 3 groups: I-II, III-IV, and V-VI. One-way ANOVA and Tukey’s post-test analysis were performed to compare Fitzpatrick scales I-II versus V-VI. Percent agreement was used to calculate inter-rater reliability among the raters. 

Results
Between September 8-10, 2022, we identified three modules that mentioned “scar” in their learning objectives. These included 21 visual aids: 65% reflected a Fitzpatrick scale of I-II (14±1.53), 29% a scale of III-IV (6±1.73), and 6% a scale of V-VI (1±0.58). There were significantly more visual aids categorized as Fitzpatrick I-II versus Fitzpatrick V-VI (p<0.001). We did not identify a dedicated module on teaching plastic surgery residents scar prevention or treatment. The inter-rater reliability between the three raters was 74.6%.

Conclusion
Our study demonstrates that skin tone representation in scar management teaching materials for plastic surgery residents is skewed towards Fitzpatrick scales I-II, representing the lightest skin tones. Adequate knowledge of scar prevention and treatment of all skin tones is essential given that hypertrophic or keloid scars often occur in individuals of darker skin tones. We recommend creating a dedicated scar management module in the ASPS Resident Education Curriculum containing diverse representation of skin tones.

Diversity in Scar Teaching Materials in the ASPS Resident Education Curriculum

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