Levels of Evidence in Plastic Surgery Research: A 10-Year Bibliometric Analysis of 18,889 Publications From 4 Major Journals

Level of evidence in high impact surgical literature: the way forward

Evidence-based medicine stipulates that clinical decision-making should revolve around scientific evidence. The goal of the present study is to evaluate the methodological quality of surgical research recently published in JAMA Surgery, International Journal of Surgery, and British Journal of Surgery, the three surgical journals with the highest impact factor. An electronic search of the PUBMED database was performed to retrieve all articles published in the JAMA Surgery, International Journal of Surgery, and British Journal of Surgery in the year 2022. Three authors independently reviewed all retrieved articles and methodological designs of the publications were analyzed and rated using a modification of the Oxford Centre for Evidence-Based Medicine Levels of Evidence (Oxford Levels of Evidence scale). The initial search identified 1236 articles of which 809 were excluded after title and abstract screening. The remaining 427 underwent full text/methods read, of which 164 did not meet the inclusion/exclusion criteria. A total of 273 studies were included in the analysis. The average level of evidence was 2.5 ± 0.8 across all studies assessed. The majority of study designs were comprised of retrospective cohorts (n = 119), prospective cohorts (n = 47), systematic reviews of non RCTs (n = 39), and RCTs (n = 37). There was no significant difference in the average level of evidence between the top three journals (p = 0.50). Most clinical studies in the highest impact factor surgical journals are of level III evidence, consistent with earlier literature. However, our analysis demonstrates a relatively higher percentage of LOE I and II compared to what was previously published in the literature.

Characterizing Cleft Rhinoplasty Across Skeletal Maturity: A Systematic Review of Terminology and Surgical Techniques

OBJECTIVE

The purpose of this study is to assess cleft rhinoplasty terminology across phases of growth.

DESIGN/SETTING

A systematic review was performed on cleft rhinoplasty publications over 20 years.

INTERVENTIONS

Studies were categorized by age at surgical intervention: infant (<1 year); immature (1 to 14 years); mature (>15 years).

MAIN OUTCOME MEASURES

Collected data included terminology used and surgical techniques.

RESULTS

The 288 studies included demonstrated a wide range of terminology. In the infant group, 51/54 studies used the term "primary." In the immature group, 7/18 studies used the term "primary," 3/18 used "secondary." In the mature group, 2/33 studies used the term "primary," 16/33 used "secondary," 2/33 used "definitive," 5/33 used terms such as "mature," "adult," and "late," and 8/33 did not use terminology.

SURGICAL TECHNIQUE ASSESSMENT DEMONSTRATED

cleft rhinoplasty at infancy used nostril rim or no nasal incision, immature rhinoplasty used closed and open rhinoplasty incisions; and mature rhinoplasty used a majority of open rhinoplasty. Infant and immature cleft rhinoplasty incorporated septal harvest or spur removal in <10% of cases, whereas these procedures were common in mature rhinoplasty. No studies in infants or immature patients used osteotomies or septal grafts, common techniques in mature rhinoplasty.

CONCLUSIONS

Current terminology for cleft rhinoplasty is varied and inconsistently applied across stages of facial development. However, cleft rhinoplasty performed at infancy, childhood, and facial maturity are surgically distinct procedures. The authors recommend the terminology "infant," "immature," and "mature" cleft rhinoplasty to accurately describe this procedure within the context of skeletal growth.

A Review of Authorship Inflation and Multicenter Collaboration Trends in Orthopedic, Medical, and Surgical Journals Over the Last 60 Years

Over the past six decades, authorship numbers in academic publications have increased significantly, a phenomenon known as authorship inflation. This study aims to analyze comparative authorship trends and the influence of multicenter collaborations across major orthopedic, medical, and surgical journals. We reviewed metadata from The New England Journal of Medicine (NEJM), Annals of Surgery (AS), and The Journal of Bone and Joint Surgery (JBJS) from January 1, 1960, to December 31, 2019. The number of authors per publication, the prevalence of multicenter studies, and their correlation were analyzed. Data was visualized using heat maps and box plots, and trends were statistically tested using the Jonckheere-Terpstra, Mann-Kendall, and generalized linear mixed models (GLMMs). A total of 73,062 articles were analyzed, with 1,190 articles identified as originating from multicenter studies. The number of multicenter trials was found to have increased significantly over time (p < 0.001), plateauing in NEJM but continuing to rise in JBJS and AS. There was a significant increase in authorship numbers per publication over time, across all journals (p < 0.0001). There was a significant statistical correlation (p < 0.0001) as indicated by the coefficient of determination (r2), for the association between the proportion of publications with >10 authors and the proportion of multicenter publications across all three journals. Authorship inflation in academic publishing may be attributable to the rise in multicenter collaborations. The rate of increase in authorship was more pronounced in medical and surgical journals compared to orthopedic journals, reflecting differing trends across specialties. These findings highlight the evolving nature of research collaboration and authorship practices in academic publishing.

The Most Cited Publications in Abdominal Wall Reconstruction-A Bibliometric Analysis

BACKGROUND

Abdominal wall reconstruction (AWR) is a treatment option for structural defects of the abdominal wall. The most frequently cited publications related to AWR have not been quantitatively or qualitatively assessed. This bibliometric analysis characterizes and assesses the most frequently cited AWR publications, to identify trends, gaps, and guide future efforts for the international research community.

METHODS

The 100 most cited publications in AWR were identified on Web of Science, across all available journal years (from May 1964 to December 2023). Study details, including the citation count, main content focus, and outcome measures, were extracted and tabulated from each publication. Oxford Centre for Evidence-Based Medicine levels of evidence (LOE) of each study were also assessed.

RESULTS

The 100 most cited publications in AWR were cited by a total of 9674 publications. Citations per publication ranged from 43 to 414 (mean 96.7 ± 52.48). Most publications were LOE 3 (n = 60), representative of the large number of retrospective cohort studies. The number of publications for LOE 5, 4, 3, 2, and 1 was 21, 2, 60, 2, and 12, respectively. The main content focus was surgical technique in 44 publications followed by outcomes in 38 publications. Patient-reported outcome measures were used in 3 publications, and no publications reported validated esthetic outcome measures.

CONCLUSIONS

Overall, 3 was the LOE for most frequently cited AWR publications, with more publications below LOE 3 than above LOE 3. Validated outcome measures and patient-reported outcome measures were infrequently incorporated in the studies evaluated.

Should the Eigenfactor Replace the Impact Factor?: A Bibliometric Study of Plastic, Reconstructive, and Aesthetic Surgery Journals

BACKGROUND

Despite the global acceptance of the impact factor (IF) by researchers and academic institutions as one, criticism has been voiced regarding its effectiveness in evaluating the unbiased impact of a journal. To overcome the limitations and drawbacks of the IF that were presented by the scientific community, they introduced several other citation-based bibliometric indices.

METHODS

All plastic and reconstructive surgery journals were analyzed, and bibliometric indices were extracted from the relevant source. Pearson correlation coefficients were used to determine correlations between the various indices.

RESULTS

All correlations in between the various bibliometric indices were found to be positively and statistically significant, ranging from moderately highly associated for the IF and Eigenfactor (r = 0.632) to very strongly associated (r = 0.962) for the IF and the Article Influence Score.

CONCLUSION

In the field of plastic and reconstructive surgery, the Eigenfactor and its derivative, the Article Influence Score, could potentially serve as better indices than the IF in demonstrating the overall picture. This information is based on the inclusion of a greater number of journals in the calculation and subtraction of self-citations, without compromising their correlation with other indices.The use of Eigenfactor and other additional bibliometrics cooperatively with the IF could provide the most extensive evaluation of a journal's scientific impact.

A Novel and Simplified Parameter for Mandible Angle Asymmetry Evaluation in Chinese Females

AIM

To develop a novel and simplified parameter for mandible angle asymmetry (MAA) evaluation for facial countering surgeries in Chinese females.

MATERIALS AND METHODS

A total of 250 craniofacial computer tomography of healthy Chinese individuals were collected in this retrospective study. Mimics 21.0 was applied for 3-dimensional anthropometry. The Frankfort and Green planes were set as referenced vertical and horizontal planes for measuring the distances to gonions. The differences in both orientations were analyzed to verify the symmetry. Mandible angle asymmetry (∠Go-N-ANS, MAA) which comprehensively represented horizontal and vertical placements was defined qas the novel parameter for asymmetric evaluation and quantitative analysis was conducted to generate referenced materials.

RESULTS

Mandible angle asymmetry was divided into horizontal and vertical asymmetry. No significant differences were found in either horizontal or vertical orientations. The horizontal difference was 3.09±2.52 mm, the reference range was (0.28, 7.54) mm, whereas the±ertical difference was 2.59±2.48 mm, the reference range was (0.12, 6.34) mm. The difference of MAA was 1.74±1.30 degrees, and the reference range was (0.10,4.32）degrees.

CONCLUSION

This study provided a novel parameter for asymmetric evaluation in the mandible angle region through quantitative 3-dimensional anthropometry, arousing plastic surgeons' attention to both aesthetics and symmetry in facial contouring surgery.

[Evidence-based Research in Plastic and Aesthetic Surgery: Cross-sectional Analysis of Research Papers Between 2019 and 2021]

BACKGROUND

In the field of plastic and aesthetic surgery, continuous international publication is seen annually. However, the publication output is not regularly assessed for its level of evidence. In view of the strong publication activity, a regular assessment of the evidence level of the current publication years is reasonable and was the objective of this work.

MATERIAL AND METHODS

We evaluated the Journal of Hand Surgery/JHS (European Volume Journal), the journal Plastic and Reconstructive Surgery/PRS and the journal Handchirurgie, Mikrochirurgie und Plastische Chirurige/HaMiPla from January 2019 to December 2021. The authors' affiliation, the type of publication, the number of patients examined and the level of evidence with existing conflicts of interest were considered.

RESULTS

A total of 1341 publications were evaluated. Of these, 334 original papers were published in JHS, 896 in PRS, and 111 in HaMiPla. The largest share were retrospective papers (53.5%, n=718). The further distribution was as follows: 18% (n=237) clinical prospective papers, 3.4% (n=47) randomised clinical trials (RCT), 12.5% (n=168) experimental papers and 6.5% (n=88) anatomic studies. The distribution of evidence levels of all studies was as follows: Level I: 1.6% (n=21), Level II: 8.7% (n=116), Level III: 20.3% (n=272), Level IV: 25.2% (n=338), Level V: 2.3% (n=31). In 42% (n=563) of the papers, there was no indication of the level of evidence. Most level I evidence was from university hospitals (n=16) in 76.2% (χ²-test 0.619, >0.05, 95% confidence interval).

CONCLUSION

Although RCTs are inappropriate for many surgical questions, well-designed and conducted cohort or case-control studies could improve the evidence base. Many of the current studies tend to be retrospective and do not have a control group. Researchers in the field of plastic surgery should consider using a cohort or case-control design when an RCT is not feasible.

Classification of Alar Dynamic Aesthetic in an Asian Female Population: Experts or Automatic Algorithms?

AIM

To provide referenced classifications of alar dynamic aesthetics from both subjective and objective perspectives for determining proper surgical strategies in alarplasty.

METHODS

A total of 150 healthy Asian female participants were instructed to perform two standardized facial movements including a resting pose and a maximum smile while taking care not to show their teeth. The participants were recorded using a dynamic three-dimensional surface imaging system. Frames depicting the resting position and the alar maximum enlargement during the smile were exported separately for anthropometric analysis and classification. The alar dynamic aesthetic was assessed through measurement of the anthropomorphic changes comparing the resting and maximum smile statuses and then transformed into quantitative analysis through the algorithm [Formula: see text]. Subjective classification and evaluation of the subject cosmetic deficiencies and proposals for therapeutic interventions to improve the subjects' alar dynamic aesthetic were performed by three senior plastic surgeons through visualization of the resting and smiling images. The surgeons were asked to divide and classify the subjects into three groups (Class I, Class II and Class III) according to the surgeons' perceptions of degree of the subjects' deficiencies in alar dynamic aesthetic. The more deficiency there was in the aesthetic, the higher the class that the subject was assigned into. The surgeons were presented with the full set of images of the patients on two separate occasions each three months apart, to assess interobserver reliability. Clustering analysis, which is based on machine learning, was applied for objective classification of the images.

RESULTS

According to the senior plastic surgeon experts' subjective classification, the subjects' alar flaring mobility was judged as follows: Class I (6.78 ± 3.84%), Class II (10.35 ± 4.18%), and Class III (18.68 ± 4.15%), while alar base mobility was judged as Class I (12.71 ± 7.57%), Class II (20.06 ± 10.06%), and Class III (30.86 ± 13.20%). By clustering analysis, alar flaring mobility was determined to be Class I (7.01 ± 3.51%), Class II (11.18 ± 4.76%), and Class III (12.72 ± 5.66%), while alar base mobility was Class I (9.07 ± 4.23%), Class II (21.88 ± 4.25%), and Class III (38.59 ± 7.08%). No statistical significance was found in the distribution and assignment of classes between the two methodologies.

CONCLUSION

Classifications of alar dynamic aesthetics could arouse attention to facial dynamic aesthetics and provide referenced quantitative parameters for plastic surgeons to determine appropriate treatments for alarplasty. For patients with Class I mobility, treatments are not recommended, while minimally invasive treatments can be deemed to be optional for patients with Class II alar mobility to potentially improve alar dynamic aesthetics. For patients with Class III alar mobility, surgical treatments are strongly recommended as options. Combing subjective classification with automated algorithms can provide a novel perspective and improve reliability for facial aesthetic classification analysis.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Authorship trends in the Egyptian orthopedic journal (from 2012 to 2020), as an example of a specialized Egyptian medical journals

Background

Authorship trends in medical journals were studied in many disciplines, mostly in western countries' journals. We aimed at studying the authorship trends in the Egyptian Orthopaedic Journal as an example of a specialized Egyptian medical journal.

Results

A total of 397 articles were eligible for analysis. The mean number of authors per article was 2 ± 1 (range from 1 to 6), 161 (40.6%) articles were single authorship. The degree of the first author was reported in 305 (76.6%), the first author carried an M.D. degree in 302 (99%) articles, and in three (1%), the first author carried a master’s degree. No authors with a bachelor's degree were reported. Forty-two institutions contributed to the publications, 14 (33.3%) international and 28 (66.7%) Egyptian national institutions. In 368 (92.7%) articles, all the authors were from the same institution, and 29 (7.3%) articles were published as a cooperation between different institutions with a mean 1.1 ± 0.3 institution per article. International contribution to the journal was found in 21 (5.3%) articles. The orthopedic department from Cairo university was the most contributing department to the journal publications.

Conclusions

The old trend of single authorship prevails in the journal publications with a notable deficiency in young researchers’ contribution to the journal and low incidence of international contribution and poor national institution cooperation.

Methods for Minimizing Bleeding in Facelift Surgery: An Evidence-based Review

INTRODUCTION

Bleeding and hematoma remain leading causes of postoperative complications and unsatisfactory patient outcomes in facelift surgery. Several methods have been implemented, and continue to be developed, to minimize bleeding in facelift surgery. These methods include perioperative blood pressure management, compression dressings, drains, tissue sealants, wetting solution infiltrate, and tranexamic acid.

METHODS

An evidence-based review of methods used to minimize bleeding in facelift surgery was conducted using the PubMed database according to PRISMA guidelines. Included studies were evaluated for the effects of implemented methods on bleeding outcomes in facelift surgery. Recommendations for each method evaluated were determined based on the amount, level, and heterogeneity of included studies.

RESULTS

Thirty-six studies were included in the evidence-based review. Effective strategies to reduce the time to hemostasis, postoperative drainage volume, and hematoma rate included perioperative blood pressure management, tissue sealants, and tranexamic acid. While the use of drains or wetting solution infiltrate did not demonstrate to significantly influence bleeding outcome measures, these methods may provide other advantages to facelift surgery. Compression dressings have not demonstrated a significant effect on facelift outcome measures.

CONCLUSIONS

Perioperative medical management of blood pressure, tissue sealants, and tranexamic acid are most effective in facilitating hemostasis and preventing postoperative hematoma in facelift surgery.

Aesthetic Contouring of the Chest wall with Rib Resection

BACKGROUND

In past decades, several invasive and noninvasive aesthetic procedures have been sought as a way to improve body contouring, and one may resort to uncertified and potentially dangerous procedures to achieve that goal. An example of this practice would be the resection of ribs to reduce the waist for aesthetic reasons. The objective was to check scientific evidence on the effectiveness and safety of removal of floating ribs for aesthetic purposes.

METHODS

A systematic review of the literature was carried out in EMBASE/Elsevier, Cochrane, Scopus, Medline, PubMed, BVS, SciELO, OneFile, and Lilacs, throughout the period until June 2020, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Fifty-six articles were found in all databases. After applying the inclusion criteria, by reading the title and abstract of the studies found, only two articles were definitively included. One addressed the possibility of removing the 7th and 8th ribs for improving body contouring in patients with an exaggerated anterior projection of the chest wall, without showing cases or surgical techniques. The other demonstrated procedures of body contouring in transgender by the removal of the 11th and 12th ribs in five of the 22 patients studied, just providing a brief description of the surgical technique used, without details.

CONCLUSIONS

Despite the relevance of the theme and its popularity, there is not enough scientific evidence to support the practice, effectiveness and safety of the resection of ribs for aesthetic purposes.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The 100 Most-cited Articles in Abdominoplasty: A Bibliometric Analysis

Background:

Abdominoplasty is one of the most common aesthetic procedures performed globally. Research in this field is evolving, with recent emphasis on evidence-based surgery optimizing informed consent. This bibliometric analysis aimed to characterize emerging research trends and to assess the methodological quality of the highest impact abdominoplasty research.

Methods:

The 100 most-cited articles in abdominoplasty were identified on Web of Science, across all available journals and years (1950–2019). Study details, including the citation count, main subject, and outcome measures, were extracted from each article by 2 independent reviewers. The level of evidence of each study was also assessed.

Results:

The 100 most-cited articles in abdominoplasty were cited by a total of 2545 articles. Citations per article ranged from 206 to 34 (mean 65). Overall, 50 articles were assessed to be level of evidence 3, which is representative of the large number of cohort studies (n = 59) on the list. Similar numbers achieved levels 2, 4, and 5 (n = 16, 20, and 14), though none reached level 1. The main subject was operative technique in 50 articles, followed by outcomes in 34 articles. Only 7 articles utilized objective cosmetic outcome measures. Patient-reported outcome measures were employed in 25 articles, though only 5 incorporated validated questionnaires.

Conclusions:

The most-cited research in abdominoplasty largely comprised low-to-moderate quality studies, with no article achieving the highest level of evidence. Contemporary high-quality evidence incorporating validated outcome measures is crucial to enhance shared decision-making, particularly in aesthetic procedures.