Dermatologic surgery textbooks depict skin of colour in under 9 percent of their clinical images, a new analysis has found. The figure lands in a specialty where surgical outcomes — from flap design and graft take to scar quality and pigmentary complications — track directly with how well trainees have seen varied skin tones before they ever lift a scalpel.

The study counts images, not intentions. That's what makes the under-9-percent figure hard to argue with: someone opened the textbooks, tallied the photographs, and reported what the pages actually show. For a discipline that teaches by visual pattern recognition, the inventory matters more than any syllabus statement on equity.

Why does image representation matter in surgery specifically?

Dermatologic surgery sits at the sharp end of the representation problem. Medical dermatology has accumulated a growing literature on missed or late diagnoses in skin of colour, driven partly by reference images that default to lighter Fitzpatrick types. Surgery adds its own layer: wound healing, keloid and hypertrophic scar risk, post-inflammatory hyperpigmentation at treated sites, and pigmentary changes after lasers or energy-based devices all present differently across skin tones.

A trainee who has seen hundreds of Mohs repairs on lighter skin and only a handful on darker skin is learning odds, not exceptions. The under-9-percent tally quantifies exactly how lopsided those odds are in the textbooks many programs treat as standard references.

How does this fit the broader literature?

The finding doesn't arrive in a vacuum. Earlier analyses have repeatedly flagged image disparities in general dermatology atlases and educational resources, and the pattern has held across formats — print textbooks, online modules and slide decks used in resident teaching. The new contribution is narrowing the count to surgical texts, where the visual gap had been discussed anecdotally but not tallied with the same rigor.

Surgical education arguably depends on images more than most subspecialty teaching. Flap geometry, closure selection and staged repair decisions are taught through photographic case series. If darker skin tones occupy under 9 percent of that visual corpus, the deficit compounds across every chapter a resident works through.

What are the practical consequences for trainees and patients?

The downstream effects cluster in a few concrete places:

• Scar prediction. Keloid formation and pigmentary change after surgery are more common and more visually consequential in darker skin types, yet trainees see fewer examples of both the complications and their successful management.

• Procedure selection. Choices among closure techniques, and expectations patients can be counselled on, depend on seeing outcomes across the full range of skin tones.

• Confidence and referral patterns. Clinicians who feel underprepared operating on skin of colour may defer, refer differently or under-treat, and the patient bears the delay.

None of these consequences is hypothetical for the growing share of patients with skin of colour who now make up a substantial and rising portion of dermatologic demand in many countries.

What would fixing the gap require?

Textbook publishers control the fastest lever. Adding clinical photography across skin tones to future editions — and to the revision cycles of the specific titles counted in the analysis — would move the number directly. Authors and editors commission the images; the study gives them a baseline of under 9 percent to improve on.

Programs don't have to wait for the next edition. Supplementing assigned reading with dedicated atlases of surgery in skin of colour, and building diverse cases into teaching files, closes part of the gap at the institutional level. Conference organizers hold a parallel lever: the case presentations and live-surgery panels that shape practice habits long after residency.

Photography itself is part of the fix. Consistent, well-lit documentation of darker skin tones — where erythema, margins and early wound complications can be subtler to the eye and to the camera — improves both teaching archives and day-to-day clinical records.

What happens next?

The under-9-percent figure now gives educators, publishers and program directors a quantified starting point rather than a general complaint. Whether the next round of major surgical textbook revisions moves that number meaningfully will be the metric to watch — and, if history in adjacent dermatology resources is any guide, it will take deliberate commissioning rather than passive correction.