Introduction

Writing a case report is fundamental in plastic surgical education to share novel clinical observations, rare complications, and innovative surgical solutions encountered during residency.1 Thus, paving the way for studies of higher levels of evidence. Case report sharing enables surgeons to exchange insights, methodologies and outcomes, promoting knowledge-sharing of solutions to challenging and/or rare clinical cases.2 The SCARE statement offers consensus-based guidelines for structured surgical case reporting, providing educational and methodological guidance to surgery residents3 and aid successful peer-reviewing to maintain scientific rigor and ethical standards.4,5 Writing a clear, concise, and impactful case report is a crucial skill for early-career surgeons.5,6 Unfortunately, the complexities of medical writing are often not fully addressed in postgraduate training,7,8 leading young surgeons to struggle in producing high-quality manuscripts suitable for peer-reviewed journals.9 This study evaluates submitted plastic-surgery case reports to identify specialty-specific areas for improvement and to determine qualitative characteristics most appreciated by specialists.

Methods

A descriptive mixed methods study was conducted on the evaluations of plastic surgical case reporting submitted by plastic surgeons in training. The cases were submitted through the online plastic surgery learning platform PlastSurgeon.com from 2023 to 2025. Submitted cases were prescreened by an internal panel of five surgeons, two holding PhD-degrees, to filter the best presented cases to the specialist panel. The specialist panel comprised 23 international plastic surgery specialists from Denmark, Germany, Sweden and Switzerland, including professors, associate professors, senior consultants and chief surgeons from University Hospitals in Denmark. The study was conducted as an educational study and did not meet the requirements for institutional board review. Patient consent was obtained for all patients enrolled in the case competition for publication. The consent was obtained by PlastSurgeon in compliance with the Danish Data Protection Regulation.

The specialist panel reviewed the case submissions and scored the cases based on six key parameters (1-10 scale): 1. Quality of photos; 2. Quality of text; 3. Clinical solution to the case; 4. Reproducibility of the case when following the procedure step-by-step; 5. Quality of references, pearls and pitfalls; 6. Overall presentation/mediation of the case (double weighted 2-20 scale). Table 1 shows the case assessment scales for each parameter.

Table 1.Parameters and scoring of the cases
Quality of photos/videos Assessment scale
1. Blurry and unusable
2. Poor quality and difficult to interpret
3. Somewhat unclear but usable
4. Fair quality with some room for improvement
5. Good quality with minor issues
6. Very good quality with few minor imperfections
7. Excellent quality with no major issues
8. Exceptional quality with exceptional detail and clarity
9. Near-perfect quality with exceptional detail, clarity, and color accuracy
10. Perfect quality with flawless detail, clarity, and color accuracy
Quality of written text
1. Poorly written with many errors and difficult to follow
2. Poor quality and confusing to interpret
3. Somewhat unclear but understandable
4. Fair quality with room for improvement
5. Good quality with minor issues
6. Very good quality with few minor imperfections
7. Excellent quality with no major issues
8. Exceptional quality with exceptional clarity and organization
9. Near-perfect quality with exceptional clarity, organization, and detail
10. Perfect quality with flawless clarity, organization, and detail
Final solution of the case
1. Inadequate and incorrect solution
2. Poor quality and not well-reasoned
3. Somewhat incomplete or unclear solution
4. Fair solution with some room for improvement
5. Good solution with minor issues
6. Very good solution with few minor imperfections
7. Excellent solution with no major issues
8. Exceptional solution with exceptional reasoning and thoroughness
9. Near-perfect solution with exceptional reasoning, thoroughness, and creativity
10. Perfect solution with flawless reasoning, thoroughness, and creativity
Reproducibility of the case following images step-by-step
1. Impossible to reproduce with many errors
2. Difficult to reproduce and unclear steps
3. Somewhat unclear steps, but reproducible
4. Fairly clear steps, but room for improvement
5. Clear steps with minor issues
6. Very clear steps with few minor imperfections
7. Excellent clarity with no major issues
8. Exceptional clarity with exceptional detail and organization
9. Near-perfect clarity with exceptional detail, organization, and reproducibility
10. Perfect clarity with flawless detail, organization, and reproducibility
Quality of references, pearls and pitfalls
1. No references or pearls/pitfalls provided
2. Poor quality references and few pearls or pitfalls
3. Incomplete or unclear references, with few pearls or pitfalls
4. Fair quality with room for improvement in references, pearls, and pitfalls
5. Good quality with minor issues in references, pearls, and pitfalls
6. Very good quality with few minor imperfections in references, pearls, and pitfalls
7. Excellent quality with no major issues in references, pearls, and pitfalls
8. Exceptional quality with exceptional references, pearls, and pitfalls, providing valuable insights
9. Near-perfect quality with exceptional references, pearls, pitfalls, and creativity, with valuable insights and unique perspectives
10. Perfect quality with flawless references, pearls, pitfalls, and creativity, providing significant value and important contributions to the field.
Overall presentation of the case (Counts double)
2. Poorly presented with many errors and difficult to follow
4. Poor quality and confusing to interpret
6. Somewhat unclear but understandable presentation
8. Fair quality with room for improvement in presentation
10. Good quality with minor issues in presentation
12. Very good quality with few minor imperfections in presentation
14. Excellent quality with no major issues in presentation
16. Exceptional quality with exceptional clarity, organization, and delivery
18. Near-perfect quality with exceptional clarity, organization, delivery, and creativity
20. Perfect quality with flawless clarity, organization, delivery, and creativity, engaging the audience and leaving a lasting impression

Assessment tool for the six parameters

All evaluations were submitted by the specialist panel anonymously/blinded through SurveyMonkey.com and collected to a prefabricated Excel sheet to be analyzed.

The mean score and standard deviation for each parameter were calculated. The parameters with the lowest mean scores were identified as areas of greatest weakness and vice versa. Qualitative analyses were conducted for case parameters with high-scoring means in the upper mean quartile (7.5 or above for parameters assessed from 1 to 10 and a mean of 15.0 or above for parameters assessed from 2-20). The first and last author independently screened the methodology of high-scoring parameters and collected the assessments into a prefabricated Excel sheet. High-scoring methodologies were differentiated into categories 1) + indicating the high-scoring methodology was present in one to two cases; 2) ++ indicating the high-scoring methodology was present in three to four cases; 3) +++ indicating the high-scoring methodology was present in five or more cases.

Results

Fifty-one surgical case reports across 4 continents (North America, South America, Europe and Asia) were submitted to the annual case competition during the three-year period. The best 27 cases were included in the study (Table 2) after internal screening, of which eight were from 2023, eight were from 2024, and 11 were from 2025.

Table 2.Included cases 2023-2025
Case Competition Year Case Name
2023 Breast Reduction Utilizing Breast-sharing technique
Reconstruction of extensive circumferential defects of the leg using an ischemic preconditioned bipedicular MS-2-TRAM Free Flap
Extensive scalp reconstruction using a free myocutaneous lattisimus dorsi flap
Malignant Phyllodes Tumor of the Breast
1st dorsal intermetacarpal artery flap (Kite, Holevich, Hilgenfeldt, Foucher flap)
Paramean forehead flap for soft tissue nasal reconstruction
Single-stage treatment of chronic osteomyelitis reconstructed with a free muscle flap
Pushing the Limits of Lower Extremity Reconstruction: Successful use of a free conjoined anterolateral and anteromedial thigh flap in a 66-year-old patient
 
2024 Reconstruction of lower right eyelid using a combined tarsoconjunctival
flap, temporal fascial turn-over flap, transposition flap and full-thickness skin graft
Revolving Door Flap
Closure of larger tip defect by a modified Peng-Flap with extended Nasofrontal dissection
Unconventional Reconstruction of a Complex Genital Defect
The Skaerlund-Stairway approach to reconstruction of upper eyelid defects
Pushing the Limits of Unilateral Autologous Breast Reconstruction
Fleur-de-lis abdominoplasty
Hypothenar hammer syndrome after minor injury to the hand
 
2025 Lower Back reconstruction with free ALT flaps, free radial bridge flap and vein graft
Reconstruction of an extensive foot defect using a combined sensory split latissimus dorsi and serratus anterior muscle flap
Hatchet flap for reconstruction of a defect on the anterior chest wall
Fingertip reconstruction by a V-Y flap and eponychial flap in a patient with fingertip amputation
Cervicofacial Flap for Cheek Reconstruction Post Excision of Pigmented Solid Basal Cell Carcinoma
Adipofascial Turnover Flap for Reconstruction of a Dorsal Finger Defect Following SCC Excision
Closure of a larger defect on the cheek with the versatile bilobed flap
Flower Flap - A Novel Papilla Reconstruction Technique Using Local Flaps and Skin Graft
Pushing Beyond Anatomical Boundaries: Latissimus Dorsi Sliding Flap for Lower Thoracic Wall Reconstruction
Closure of a complex defect after a dog bite wound of the middle third of the face
Utilizing the reverse radial forearm flap for burn wound management of the hypothenar

Best cases to be reviewed by the specialist panel after initial selection based on criterion from table 1 assessed by internal assessment panel.

The mean overall scores were as follows for the six parameters: 6.78 (SD=0.81) for quality of photos and videos; 6.63 (SD=0.55) for quality of written text; 7.30 (SD=0.86) for final solution of the case; 6.84 (SD=0.71) for reproducibility of the case following step-by-step; 6.56 (SD=0.62) for quality of references, pearls, and pitfalls; and 13.42 (SD=1.37) for overall presentation of the case. The mean score across the six parameters is displayed in table 3.

Table 3.Scoring overview of parameters reported by the specialist panel
Parameters
Mean (SD)		 Quality of photos/videos Quality of written text Final solution of the case Reproducibility of the case following step-by-step Quality of references, pearls and pitfalls Overall presentation of the case (Counts double)
2023 6.92 (1.01) 6.74 (0.54) 7.80 (1.00) 6.93 (0.85) 6.70 (0.71) 13.52 (1.54)
2024 6.65 (0.70) 6.57 (0.55) 7.13 (0.66) 6.70 (0.64) 6.21 (0.54) 13.28 (1.32)
2025 6.76 (0.70) 6.61 (0.56) 7.06 (0.71) 6.88 (0.63) 6.71 (0.49) 13.45 (1.25)

SD=Standard deviation

Twenty-nine times a case parameter scored a mean of 7.5 or above. The scores were distributed as following: five within quality of photos/videos; three within quality of written text; 10 within final solution of the case; six within reproducibility of the case following step-by-step; one within quality of references, pearls and pitfalls. Four cases had a mean score above 15 within overall presentation of the case.

The qualitative evaluation of cases with a mean score above 7.5 is displayed in table 4 as a measure of high-quality case reporting.

Table 4.Number of cases with a mean score above 7.5 regarding distinct assessment parameters
Parameter Recommendation level Recommendation
Quality of photos/videos
Five cases met the assessment criteria		 +++
++
++
++
+		 High resolution
Pre-operative surgical drawings
Multiple angles and surgical steps
Perioperative markings of anatomical structures
Diagnostic imaging
Quality of written text
Three cases met the assessment criteria		 ++
++
++		 Error-free grammar and precise wording
Reproducible surgery following description step-by-step
Structured written presentation
Final solution of the case
Ten cases met the assessment criteria		 +++
+++
++		 Well described rationale for choice of surgery
Combining two or more techniques/methods to solve complicated surgical challenges (innovative solution).
Well described preoperative considerations of surgical alternatives
Reproducibility of the case following step-by-step
Six cases met the assessment criteria		 ++
++		 Well-described preoperative, perioperative and postoperative considerations for following step-by-step
Explanatory images and/or surgical drawings/illustrations
Quality of references, pearls and pitfalls
One case met the assessment criteria		 + Detailed description of pearls and pitfalls including a number of references to appropriate literature/publications.
Overall presentation of the case (Counts double)
Four cases met the assessment criteria		 ++
++
++		 Three or more other parameters above a mean of 7.5
Scoring high in quality of text is the main contributor for overall presentation of the case.
Explanatory high-resolution, high-quality images and illustrations

+ indication the high-scoring methodology was present in one to two cases; ++ indication the high-scoring methodology was present in three to four cases; +++ indicate the high-scoring methodology was present in five or more cases.

Discussion

This study assessed specialist plastic surgeons’ evaluation of case reports submitted by young surgeons over a three-year period.

Cases with high-scoring images displayed high resolution, pre-operative surgical drawings/illustrations, multiple angles and surgical steps, perioperative markings of anatomical structures and diagnostic imaging. Referring to the SCARE guidelines point 19, it states that images and/or videos must be included where relevant and include pre-, peri- and post intervention. The guidelines further state adequate annotation on images.10 To some extent the SCARE point captures the relevance of visual aids to mediate understanding. We believe that the plastic surgical assessment conducted in this study calls for more in-depth visual case reporting due to the nature of this specialty. Preoperative markings are crucial for in-patient preparation, surgical understanding and mediation of considerations to peers11,12 and it is therefore of essence to include it in plastic surgical case reporting. It is generally observed that cases that lack comprehensive step-by-step visual aid are assessed less successful in mediating the cases. This overlaps with the study’s assessment of reproducibility following the case step-by-step (SCARE point 12c) in which well-described preoperative, perioperative and postoperative considerations, and explanatory images and/or surgical drawings yielded successful assessments. Not surprisingly, the study reports error-free grammar and precise wording were present in high-scoring cases in the category, quality of written texts which has previously been described.13,14 The clinical solution to the case was added to the questionnaire, which corresponds to SCARE point 12b. The study’s qualitative analysis reported well described rationale for choice of surgery, combining two or more techniques/methods to solve complicated surgical challenges (innovative solution) and well described preoperative considerations of surgical alternatives as key drivers for successful case reporting. As each case report in this study was assessed by a panel of 11 or more specialist plastic surgeons, we believe that it is relevant to discuss using two or more existing methods/techniques to solve a challenging clinical problem. It seems highly appreciated by specialists to rely on basic principles when faced with a challenging case by combining such for successful case mediation. In 2024, Grosu-Bularda et al. proposed a problem-solving approach to solve complex tissue defects.15 They describe various reconstructive methods but conclude that complex tissue defects must take various factors into account, including etiology, defect characteristics, restoration of form, function and psychological aspects, patient compliance, the surgeon’s skills, and emerging technology.15 Their study mentions combinations of emerging techniques and technologies; however, it does not mention the principle of combining basic plastic surgical techniques to solve challenging cases. We believe it is a great philosophy to rely on the basics before exploring new and less tried methods. See Figures 1, 2 and 3 for a case example of high-resolution image with drawings, combining surgical techniques to obtain a great and safe reconstructive result of the lower leg.

Et billede, der indeholder tekst, lægeundersøgelse/medicin, Medicinsk udstyr, sundhedsvæsen Automatisk genereret beskrivelse
Figure 1.Detailed description of wound bed size and depth with exposed plate osteosynthesis. Description of debridement and preparation for free flap reconstruction.
Et billede, der indeholder tekst, Fastfood, Kød/hud, mad Automatisk genereret beskrivelse
Figure 2.Reconstruction using combined anterolateral thigh flap and anteromedial thigh flap, with explaining drawings of arteries and veins with microsurgical anastomosis on the lower leg.
Et billede, der indeholder tekst, lægeundersøgelse/medicin Automatisk genereret beskrivelse
Figure 3.Final flap inset and reconstruction of lower leg. The flaps are found viable.

The quality of references, pearls and pitfalls are assessed together in this questionnaire with rationale to all being a measure to evaluate the authors’ ability to reflect on prior art in relation to the case. The study, which described in detail the pearls and pitfalls (SCARE point 13d, 14b-d), including references to appropriate literature, received greater recognition from the Specialists. Analyses of the three parts independently, was unfortunately not possible due to the nature of the questionnaire. The final question concerned the overall presentation of the case. Not surprisingly, cases that had multiple high-scoring categories were evaluated best in overall presentation. The quality of text was evaluated as the best predictor for overall presentation of the case, which highlights the outmost importance of well written and structured case reporting.

Deficiencies in scientific writing are currently an issue and may be due to the lack of standardized scientific training in medicine which makes early-career surgeons unequipped with the skills necessary to effectively communicate their clinical experiences and research findings. Incorporating good practice in case report writing into residency curricula would most likely enhance the quality and impact of scholarly work produced by young surgeons.16,17 This study adds a valuable insight into actionable measures that can improve young doctors’ future surgical case reports.

Limitations

This study is conducted as a retrospective cohort study (Evidence level III).18 The scoring instrument was not validated before implementation and selection bias could occur due to prescreening.

Conclusion

Our study demonstrates the great value of specialist assessment in identifying areas for improvement in plastic surgical case reporting. By addressing low-rating areas and qualifying high-performing papers this aims to improve future plastic surgical case reporting, and we can empower the next generation of plastic surgeons to contribute meaningfully to scientific literature and advance the field of plastic surgery.

Funding

This study received funding from the online educational platform PlastSurgeon.