Missing Shades: An Analysis of Perceived Skin Pigmentation in Scar-Related Images Within the American Society of Plastic Surgeons (ASPS) Resident Education Curriculum

IntroductionScars may result from surgical procedures, trauma, burns, and other cutaneous injuries.Scar outcomes vary according to wound characteristics, anatomical location, genetic susceptibility, and skin pigmentation.Some studies report a higher burden of hypertrophic and keloid scarring in populations with more deeply pigmented skin.In plastic and reconstructive surgery, operative success includes safety, function, durability, patient-reported outcomes, and aesthetic acceptability.We assessed the distribution of perceived skin pigmentation of scar-related images within the American Society of Plastic Surgeons (ASPS) Residency Education Curriculum (REC). MethodsWe reviewed all REC images depicting human scars, including those featuring scar formation, post-operative healing, or surgical planning related to scar management.Non-human subjects and unrelated (non-scar) content were excluded.Each image was independently assessed by four of seven trained reviewers using visual reference derived from the Fitzpatrick categories.Images with substantial reviewer disagreement were reassessed after standardized retraining.We measured interrater reliability using Krippendorff's alpha; image diversity was analyzed by educational module, scar management category, type of image, and course material. ResultsOf 1,327 color images included in the pigmentation analysis, n = 1,288 (97.1%) were assigned to Fitzpatrick Types I-IV and n = 39 (2.9%) to Types V-VI.After retraining and reassessment, Krippendorff's alpha was 0.808, indicating strong interrater agreement.Skin tone Types V-VI were absent from gender affirmation and aesthetic surgery and infrequently represented across the remaining six modules (Breast, Head and Neck, Fundamentals of Surgery, Upper Extremity, Trunk, and Lower Extremity).Clinical case scenarios showed the highest representation for skin tone Types V-VI (13.8%, 4/29), while slide presentations (1.5%, 7/464) and supplemental articles (0%, 0/6) showed the least. ConclusionsHighly pigmented skin tones are infrequently represented in the ASPS REC scar-related images, underscoring the need for more representative educational content.These findings may help prioritize the development of more visually inclusive educational materials.