Robert B. Cialdini’s Six Principles of Persuasion is an excellent read for any person in a current leadership role or those who wish to become a leader in their field.1 Among those tenets, the principle of scarcity states that “people want more of what they can have less of.”1 The meaning or practical application of this tenet refers to “highlighting unique benefits and exclusive information.”1 How does this apply to submitting a scientific manuscript? Indeed, scarcity applies to the very inception of a research idea and follows through all the way to the time that a manuscript is published and consumed by its readership. Authors should view their original ideas as scarce and unique, all while designing a sound research framework in which to prove their hypotheses. The principle of scarcity applies to the process of a manuscript submission, revision/rejection, followed by resubmission of a revised manuscript to another journal, or not at all. Through a revision process, authors should work to highlight their work as exclusive information, indeed. Throughout our clinical and academic careers, how many times have we been asked to revise a submitted manuscript or grant or received a rejection? Those who have been in the practice long enough will agree that rarely are articles accepted from initial submission, and academic rejections are a quite common practice. In fact, more than 80 percent of the articles submitted to the top surgical journals, including Plastic and Reconstructive Surgery, are rejected.2,3 The rejection rate increases even further when it comes to journals such as Lancet, JAMA, and Nature, with only 5 to 7 percent of submitted articles being published.4–6 After committing significant amounts of time and hard work to conduct research, authors receiving a rejection from a journal may likely be somewhat disheartened. With rejection come feelings of being upset, angry, frustrated, and discouraged. Some authors would even rather bury that one rejected paper instead of dealing with the reviewers’ comments. However, one should keep in mind that publications in high-quality journals will have an impact not only on their future research but also help colleagues around the world who will read and benefit from their work. A variety of rationalities may emerge: Why was my paper rejected? Are they biased against me due to me? My practice setting? Why are the same authors publishing articles on the same topics? Ultimately, the readers of the journal deserve evidence of high-quality research to update their knowledge and practice. Although the work behind revisions may be quite rigorous and time consuming, remember that revisions can only improve a manuscript and provide prime research to the readers. As our esteemed immediate past editor-in-chief of this Journal has said more than once, no one has had more articles rejected than him, even as prolific as he has been in his career! Despite a common practice of manuscript rejections, currently there is a paucity of literature on guidance for how to submit revisions. In this article, we will discuss “dos and dont’s” when revising a manuscript, reasons for the rejection, and tips on how to respond to reviewers’ comments. WHY DO PAPERS GET REJECTED? Why are papers sent back for revision or outright rejected in the first place? There are many reasons; however, in the majority of cases, it really comes down to the studies with minimal or no impact. Completing the project when the answer is apparent has no scientific value. For instance, if conducting a study to compare whether operating in a clinic will cost less money than in the main operating room, the outcome is somewhat obvious and does not provide new information. Before starting a project, it is important to ask the “so what?” or “who cares?” questions and whether the question will advance knowledge in the field. Another reason for outright rejection from a journal is a statistical reason. Studies with statistical fatal errors, such as inadequate power, low sample size, or incomplete data with haphazard statistical analyses and results, will inevitably be rejected. Conducting a valid study with appropriate statistical methods is imperative. For example, before starting the study, it is worthwhile to perform a power calculation to determine the sample size needed for statistically significant effect.2,7,8 Poor language with spelling and grammatical mistakes is another reason for rejection. If the authors are not fastidious about the art of the language and delivery, how can the editors and reviewers of journals trust that the authors paid attention to the science and research they have completed. Henry Gee, senior editor of Nature, once wrote that some of the clearest manuscripts received are often from the authors whose first language is not English. His explanation is that nonnative speakers have been taught English the old-fashioned way with formal grammar teaching. He also highlights how frustrating it is to read manuscripts written in a dreadful manner: “It produces a general frustration akin to that felt by the boxer who, while still gloved, tries to peel a banana.”9 When writing a manuscript, oftentimes we focus on the hypothesis and statistical analysis of the study, neglecting the importance of the writing itself. Communicating with readers in a clear, plain, and succinct way by building structured paragraphs and writing well-constructed sentences is the key to successful publication.10,11 Plagiarism is another reason for rejection, as it is a violation of ethics and warrants instant rejection from the journal. Plagiarism may also include self-plagiarism in the form of double submissions or resubmitting prior completed work. Rephrasing and resubmitting the same original data will warrant scrutiny and may incur bans from submitting future manuscripts. Before submitting a manuscript, authors should review a journal’s requirements, as they constitute an essential part of manuscript preparation; following the author’s instructions in terms of format, reference style, and number of figures and tables is essential. If the material in a manuscript is beyond the scope of the journal, it may be rejected without sending it to the reviewers. For instance, psychology-dedicated manuscripts would not be suitable for surgical journals. Poor illustrations with substandard quality, inaccurate formatting, and tables with erroneous lines and context are common reasons for manuscripts being returned for revision. Elegant illustrations and clean photographs are treasured standards of our specialty. We frequently encounter errors not only in the initial submission but also in resubmitted revised manuscripts. Resubmitting the manuscript with incomplete data and justifying a response without supportive evidence will not increase the probability of subsequent acceptance. Aggressive and inflammatory responses, such as “we disagree with reviewers’ comments” or “we respectfully disagree” should be avoided in the revised manuscript submission. How you respond to criticism can impact whether your work will be ultimately published. Respectful responses to reviewers’ comments acknowledge the efforts of the reviewers in spending their discretionary time to make the papers better. HOW TO REVISE REJECTED WORK All of us receive rejection letters, and even some Nobel Prize winners’ innovative ideas originally started out in a rejection pile.12,13 Rejection is disheartening, but remember that a manuscript or grant rejection is not a personal rejection; one should avoid emotional, impulsive, or aggressive response to reviewer’s critiques. Mark McGuinness wrote in his book Resilience: Facing Down Rejection and Criticism on the Road to Success that if you are serious about making your dream a reality, at some point you will expose yourself to rejection and criticism.14 He mentions that developing resilience, the ability to bounce back from failure, disappointment, and hostility, is crucial in achieving your goals. As he noted in his book, “Just because you or your work were not the right fit in any particular situation, it does not mean you are fundamentally incapable of achieving your ambition.”14 Thus, it may be prudent to read the reviewers’ comments and put them aside for a few days. Pause and think, remain constructive and polite regardless of how disappointed or frustrated you may be. Decide whether the revised manuscript should be resubmitted to the same journal or submitted to a new one. Do not bury your rejected paper; instead, use all the valuable feedback you have received to improve your work. Personally, one of the authors (S.J.L.) frequently tells his research team members that every paper has a home, and you just have to find the right one. If you decide to resubmit your work to the same journal, return the revised manuscript within the period allotted for submission. One may strengthen one’s manuscript by doing more analysis, but be aware that in some cases, collecting and analyzing data may take longer than anticipated; if further analysis is not possible, acknowledge the limitation in the manuscript. Do not postpone revising your work. Also, if substantial change is unfeasible, such as collection of the new data, include your rationale in your cover letter and response. When we read responses in the revised manuscripts, we frequently find it surprising how disorganized some responses are written. Respect the reviewers’ time and your own time by providing a detailed response to each comment underneath in an itemized fashion and putting the changes in the response letter. Do not make the reviewer search for the comments and revisions, and be specific about where exactly in the manuscript changes are made. Reviewers are busy people; strive to make their lives easier by stating each critique and respond appropriately. A terse response such as “see page 5 line 1” will not be well received. Journal requirements may require edits in a different color font (most commonly, red text). A returned response asking for a manuscript revision is a great opportunity! Do not waste this chance to improve your manuscript further to achieve an acceptance. The review process for Plastic and Reconstructive Surgery, by taxing a broad array of experienced reviewers, produces impactful scientific manuscripts for the global plastic surgery readership. Reviewers who routinely use inflammatory, derogatory, critiques and unprofessional language will not be invited in this process. Avoid sentences such as “Agree, see page XX, line XX for your comment,” but instead explain what changes you have made. Your explanation in the response should acknowledge the reviewers’ comments and is an opportunity to explain your viewpoint. A response should include changes to the text of the manuscript and addressing them in the response letter. Copy and paste revised text or sentences into the response letter if feasible. Poor formatting with no page or line numbers will make it difficult for reviewers to find changes made, and the paper will be returned to you to make those changes. Address each of the reviewers’ comments individually as if they were the only comments and avoid replying with “Please see our response to Reviewer #1’s comment.” Repeating information as necessary by incorporating adjustments in the response you are addressing to each reviewer is allowable (Table 1). Certainly, authors do not have to agree with all the critiques. However, one approach is to choose your words carefully by emphasizing part of the reviewer’s comment you agree with first, followed by the explanation why you chose not to make a change. Provide evidence with citations from the literature and be clear by answering completely to the comment. Politely disagree without being argumentative or frameshift the conversation without coming off as too strong (Table 2). Avoid sentences such as “We disagree with the reviewer…” and instead comment “We agree with the reviewer that.… However, ….” or “We appreciate the reviewers’ insightful suggestion and agree that.… However, …. Nevertheless, we recognize this limitation should be mentioned in the manuscript.” Table 1. - Dos and Don’ts of How to Respond to a Reviewer’s Comments Dos Don’ts • Follow the journal’s guidelines for revision in terms of word count, format, reference style, and number of figures and tables • Submit poor illustrations with substandard quality or tables with erroneous lines and context • Provide response to each comment underneath in an itemized fashion • Respond with emotional overtone, using inflammatory remarks • Start comments by thanking reviewer for the time and effort spent on the review • Thank the reviewers for their comment; however, be careful not to overstate the gratitude in an unctuous way • Response should include changes to the text of the manuscript rather than just addressing them in the response letter • Respond with “Agree, see changes made in the manuscript”; instead discuss your answer in the response letter and changing manuscript text • Address each of the reviewers’ comments individually • Make reviewers search for the changes made • Be specific as to where changes were made to the manuscript (journal may require making edits in a different color font) • If disagreeing with the reviewer, be polite and provide evidence-based information without being argumentative • Answer completely, provide evidence, and be concise in your response Table 2. - Examples of How to Begin a Response to a Reviewer’s Comments General Response Disagreeing with Reviewer Thank the Reviewer • Thank you very much for your valuable comments• Thank you for your important insights• We appreciate the reviewers’ comments• We apologize for the lack of clarity • We agree with the reviewer that …, however, ….• We appreciate the reviewers’ insightful suggestion and agree it would be useful to demonstrate that …; however, such an analysis is beyond the scope of our paper, which…. Nevertheless, we recognize this limitation should be mentioned in the manuscript. • We thank the reviewer for the kind remark If asked for extensive changes, one can suggest writing a subsequent article or a follow-up article. Maintain a positive attitude and be open to criticism—seeing it as an opportunity to improve your work will make responding to reviewers less burdensome. Robert B. Cialdini, professor of psychology and marketing, explains in his book Influence, New and Expanded: The Psychology of Persuasion, that it is typically in our best interest to be consistent.15 However, he also adds: “We fall into the habit of being automatically so, even in situations where it is not the sensible way to be.” He further explains that consistency offers a shortcut: “Once we have made up our minds about an issue, stubborn consistency allows us an appealing luxury: we don’t have to think hard about the issue anymore.”15 If we view this matter from his perspective, a rejected manuscript is automatically a failure, as we are consistent with the idea that rejection is bad. However, if we weigh the pros and cons and view it as an opportunity to improve our work, it will make the whole process of revision a much better experience. Finally, do not forget to thank the reviewers for their comments and time they have dedicated to help you improve your work. However, be careful not to overstate the gratitude in an unctuous way. As with any skill, high-quality manuscripts come with experience and effort. When receiving a rejection, think deeply how to make your research stronger and to mitigate the weaknesses of the manuscript. Always remember that revisions make a manuscript better. As Mark McGuinness defines “feedback” in his book: “It refers to any process that raises your awareness of your performance and helps you improve it.”14 Be polite and respectful when responding to reviewers’ comments and provide a scientific rebuttal to any points you disagree with. Be concise and clear, and respond by providing evidence rather than an emotional, inflammatory reaction to the criticism. Finally, do not forget to make it easy for reviewers to find the changes made. Above all, keep learning and continue writing!