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Formal decision trees in plastic surgery.

The process of diagnosis and treatment can be seen as a series of decisions in which the probability of one outcome is compared with the probability of another in a series of steps using a set of heuristics derived either from experience or from medical evidence. A decision tree can be defined as the diagrammatic representation of this choice between different options.1 Guidelines and protocols are informal decision trees, but they may not take into account decision-making concepts such as heuristics or bias as explicitly as a formal decision tree. Formalizing the decision-making process reduces potential bias and provides a process that is transparent to both residents and patients. This process has been used successfully in elective hysterectomy selection, to increase the number of patients proceeding to hysterectomy via a vaginal as opposed to an abdominal route, with benefits in terms of improved surgical outcome and reduced costs.2 Since plastic surgery commonly involves complex decisions that take into account not only potential surgical outcomes but also patients’ expectations, there is a clear potential for using decision trees to formalize the process of selection and provision of information for different conditions. The basic concepts used in making a formal decision tree are illustrated in this editorial using the example of reduction mammaplasty.3 There are four main steps to decision analysis: