The 100 Most-disruptive Articles in Plastic and Reconstructive Surgery and Sub-specialties (1954–2014) (2024)

Abstract

INTRODUCTION

The field of plastic and reconstructive surgery has significantly evolved over the past several decades. The innovation that is part and parcel to the DNA of our specialty has driven constant progress in both clinical and basic science research. Research publications are an important aspect of academic productivity and can also influence professional accomplishments such as promotion, tenure, and respect of peers.¹ Many different metrics have been utilized to quantify the impact of publications. Both historically and currently, the most commonly-utilized metric remains citation count.^2,3 However, citation count has notable limitations and problems that prevent it from optimally identifying impactful work; for example, not all citations are positive and equal and it is a purely quantitative metric. In addition, older publications will inherently accumulate more citations over time than newer publications, skewing the true significance of citation count.

In response to the shortcomings of traditional measures of research impact, bibliometricians have developed new metrics to better capture the influence and impact of publications.⁴ One such metric is the “disruption index,” which seeks to measure the degree to which an article disrupts its field and induces a paradigm shift by “introducing something new that eclipses attention to previous work upon which it has built.”^5,6 In other words, a disruptive article displaces the literature that it cited. Disruption scores range from −1 to +1, with positive scores (>0) corresponding to disruptive articles and negative (<0) corresponding to developmental articles (1.0 is a maximally disruptive article). Disruptive articles tend to change established principles, whereas developmental studies tend to build upon those existing principles.^5,6

As the volume of research within the field of plastic surgery continues to explode, quantifying the impact of various publications is critical to identify shifting paradigms and prioritize research and funding. Previous studies have identified impactful publications in plastic surgery using metrics such as citation count^7,8 or the Altmetric score recently seen in Plastic and Reconstructive Surgery.^9,10 Although recently applied to both surgery¹¹ and urology,¹² no studies have applied the disruption score (DS) metric to the plastic and reconstructive (and subspecialty) literature. The purpose of this study was to identify the most-disruptive publications, compare the disruption metric to citation count, and to quantify the most-disruptive journals in plastic and reconstructive surgery.

METHODS

A search of PubMed-indexed literature was performed in March 2020 to identify PubMed Identifiers (PMIDs) of all articles published in Plastic and Reconstructive Surgery (PRS), Annals of Plastic Surgery, British Journal of Plastic Surgery (currently Journal of Plastic, Reconstructive & Aesthetic Surgery), Journal of Oral and Maxillofacial Surgery, Journal of Craniomaxillofacial Surgery, Journal of Craniofacial Surgery Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery, Clinics in Plastic Surgery, Journal of Hand Surgery (American), Journal of Hand Surgery (European/British), Journal of Reconstructive Microsurgery, JAMA Facial Plastic Surgery, Aesthetic Surgery Journal, and Aesthetic Plastic Surgery. The PMIDs were then merged with a validated database of DSs (https://lingfeiwu.github.io/smallTeams/) for all articles indexed in PubMed published between 1954 and 2014.⁵

The DS for a focal article is the ratio of 2 numbers⁵ and is represented by the equation DS = (A−B)/(C+D). The numerator is the number of future publications that cited the focal article without also citing any of its references (A) minus the number of future publications that cited the focal article and at least one of its references (B). The denominator is the total number of times the focal article was cited (C) plus the number of future publications that cited at least one of the references of the focal article, but not the focal article itself (D).⁵ To illustrate the calculation of a figurative study’s DS, we present here a sample calculation. Assuming this study was later cited a total of 50 times, and that 40 of these citations did not also cite one of the citations of the index article but 10 studies did, the numerator would be 40−10 = 30. Assuming then that 30 future studies cited at least one of the references of the focal study but not the focal study itself, the denominator would be 50 + 30 = 80, resulting in a DS of 30/80 = 0.375.

After calculating the DS and identifying the most-disruptive articles, we then utilized the publicly available iCite tool (https://icite.od.nih.gov/)¹³ developed by National Institute of Health to obtain the number of times each article was cited. We ranked the articles in order of DS and selected out the top 100 for inclusion in this study. We also ranked all articles published by the included journals in the time period studied by the number of citations and selected out the top 100. A kernel density plot of all literature indexed in PubMed (1954–2014) was generated to characterize the distribution of DSs in the entire PubMed universe. We limited the study period up to the year 2014 for 2 reasons: first, a period of several years after publication date is needed to allow for future studies to cite a focal article and to calculate a DS, and second, the time period 1954–2014 were the years that were available in the publicly-available database utilized.⁵ Statistical analysis was performed utilizing R Statistical Software (version 4.0.0, Auckland, New Zealand). Figures and plots were created using the ggplot2 package available in R.¹⁴

RESULTS

A kernel plot for the DSs of the 12,742,382 PubMed-indexed articles (1954–2014) across all specialties is shown in Figure ​Figure1.1. For our analysis, a total of n = 53,507 articles were identified, n = 15,759 in PRS, n = 6,276 in Annals of Plastic Surgery, n = 5467 in British Journal of Plastic Surgery (currently Journal of Plastic, Reconstructive & Aesthetic Surgery), n = 7843 in Journal of Oral and Maxillofacial Surgery, n = 1770 in Journal of Craniomaxillofacial Surgery, n = 3496 in Journal of Craniofacial Surgery, n = 1937 in Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery, n = 1104 in Clinics in Plastic Surgery, n = 3691 in Journal of Hand Surgery (American), n = 2463 in Journal of Hand Surgery (European/British), n = 406 in Aesthetic Surgery Journal, n = 450 in JAMA Facial Plastic Surgery, n = 1225 in Journal of Reconstructive Microsurgery, and n = 1620 in Aesthetic Plastic Surgery. The 100 most-disruptive articles in plastic and reconstructive surgery and sub-specialties are presented in Table ​Table1.1. For comparison, the top 100 most-cited articles in these journals is presented in Table ​Table2.2. The top five including nine of the top 10 most-disruptive articles were published in PRS. Additionally 21 of the top 30, and 64 of the total list of 100 appeared in the same journal. The second-most articles on the list appeared in British Journal of Plastic Surgery (currently Journal of Plastic, Reconstructive & Aesthetic Surgery) (n = 15), third-most in Journal of Oral and Maxillofacial Surgery (n = 7), fourth-most in Annals of Plastic Surgery (n = 6), followed by Journal of Hand Surgery (American) (n = 3), Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery (n = 2), Journal of Hand Surgery (European/British) (n = 1), Clinics in Plastic Surgery (n = 1), and Journal of Craniomaxillofacial Surgery (n = 1) (Table ​(Table3).3). There were no articles from either Journal of Reconstructive Microsurgery,Journal of Craniofacial Surgery, JAMA Facial Plastic Surgery, Aesthetic Plastic Surgery or Aesthetic Surgery Journal in the top 100. The top 100 most-disruptive publications in these journals were more disruptive than 99.8% of all PubMed articles. Citation counts of the 100 most-disruptive articles ranged from 1 to 502 (mean = 44.9 citations). The correlation coefficient linking DSs and citation counts was 0.01 and 0.11 among all articles, and the 100 most-disruptive articles, respectively.

Figure ​Figure22 displays a scatterplot of DSs by citation count for all plastic surgery articles, and Figure ​Figure33 displays a kernel density plot of DSs by journal. Mean DSs by journal are presented in Table ​Table4.4. The highest mean DS was in Clinics in Plastic Surgery and PRS. The average PRS, Annals of Plastic Surgery, British Journal of Plastic Surgery (currently Journal of Plastic, Reconstructive & Aesthetic Surgery), Journal of Oral and Maxillofacial Surgery, Journal of Craniomaxillofacial Surgery, Journal of Craniofacial Surgery, Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery, Clinics in Plastic Surgery, Journal of Hand Surgery (American), Journal of Hand Surgery (European/British), Aesthetic Surgery Journal, JAMA Facial Plastic Surgery, Journal of Reconstructive Microsurgery, and Aesthetic Plastic Surgery article was more disruptive than 81%, 33%, 42%, 22%, 36%, 38%, 77%, 88%, 10%, 12%, 38%, 26%, 34%, and 23% of all PubMed articles, respectively.

Figure ​Figure44 displays publication year histogram for the top 100 most-disruptive articles. The most common decade represented was the 1980s (n = 31), and the least common was 2000s (n = 9). The mean DS for the 1960s, 1970s, 1980s, 1990s, and the 2000s was 0.59, 0.55, 0.53, 0.55, and 0.55, respectively. With respect to study types, there are notable differences between the focus of the most-disruptive and the most-cited articles. The most common study types in the most-disruptive list were methodological studies (n = 32), case reports/series (n = 31), and reviews (n = 19), whereas for the most-cited list, they were case reports/series (n = 33), reviews (n = 17), and novel surgical techniques (n = 9).

DISCUSSION

This is the first study to apply the disruption index to the field of plastic and reconstructive surgery. We present in the current study a list of the top 100 most-disruptive studies appearing in 14 of the most popular journals in plastic surgery (1954–2014). In our analysis, we found that DSs correlated poorly with citation count. This findings underscores that the disruption metric may capture unique characteristics of paradigm-shifting studies that may be overlooked when favoring citation count. This list contains some of the most infamous and practice-altering articles in the history of our specialty.

The most-disruptive article appearing on the list, “Minimally Invasive, Limited Incision Breast Surgery: Passing Fad or Emerging Trend?” was published by Rod J. Rohrich in PRS in 2002.¹⁵ This “Cosmetic Viewpoint” starts by quoting Albert Einstein: “Problems cannot be solved at the same level of awareness that created them” and discusses what were at the time recent trends in minimally invasive breast surgery, breast liposuction, and limited incision mastopexy/breast reduction.

The second-most disruptive article published in 1966 in PRS was “The Ultimate Fate of Freeze Dried Fascia: Experience with its Use in the Correction of Facial Paralysis.”¹⁶ In this report, Snyderman et al discussed their positive experience in 15 patients treated with freeze-dried fascia for facial palsy. To that point, the use of fresh autologous fascia was standard until the authors benefited from the advent of a tissue bank in 1953 at the Memorial Sloan Kettering Cancer Center.

The third-most disruptive article by Ulrich and Meyer “A Suction Curette for Removal of Excessive Local Deposits of Subcutaneous Fat” appeared in PRS in 1978 and was the first documented report on the use of liposuction.¹⁷ This study described the authors’ transition from what was at the point the standard method of removal of localized fat deposits by curette through a small incision in select areas (eg, trochanteric lipodystrophy) to their use of a stainless steel suction curette (devised by Ulrich) to “treat fat deposits elsewhere (eg, stomach, thighs, calves, knees).” This report appeared a few years after Arpad and Giorgio Fischer first started using a blunt suction-assisted cannula to treat fat deposits of the outer thighs.¹⁸

The fourth-most disruptive study is the 1998 study by Schneider, Morykwas, and Argenta “A New and Reliable Method of Securing Skin Grafts to the Difficult Recipient Bed.”¹⁹ This PRS study described their experience with the Vacuum Assisted Closure device (KCI: San Antonio, Tex.) for skin graft to wound bed apposition in place of the traditional tie-over bolster method.

The fifth-most disruptive study is also the fourth-most cited on the list. This 1985 PRS study by Illouz titled “Body Contouring by Lipolysis: A 5-Year Experience with Over 3000 Cases” presented the author’s experience with liposuction body contouring and subsequent surgical correction of the deformity resulting from overlying skin contraction.²⁰

It is also worth noting that the sixth-most disruptive 1967 study by Brunner describing “The Zig-Zag Volar-Digital Incision for Flexor Tendon Surgery” has for over 50 years been the incision-of-choice for flexor tendon and volar digital exposure.²¹ Other notable works appearing in the top 10 include a 1979 large-volume review of palatal fistulae by Abyholm et al (“Palatal Fistulae Following Cleft Palate Surgery” in Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery²²), the first description in 1984 by Sheen of the now ubiquitous spreader graft in rhinoplasty (“Spreader Graft: A Method of reconstructing the Roof of the Middle Nasal Vault Following Rhinoplasty” in PRS²³), McKissock’s 1972 description of his now eponymous breast reduction technique (“Reduction Mammaplasty with a Vertical Dermal Flap” in PRS²⁴), and finally the 1969 Australian study by Snell and Dott advocating for widespread use of plating in mandibular fractures (“Internal Fixation of Certain Fractures of the Mandible by Bone Plating” in PRS²⁵).

The most-cited study (n = 502 citations, 91^st on the list of most-disruptive studies) is the 1989 case report by Koshima et al entitled “Inferior Epigastric Artery Skin Flaps Without Rectus Abdominis Muscle” published in the British Journal of Plastic Surgery (currently Journal of Plastic, Reconstructive & Aesthetic Surgery).²⁶ This now infamous article was the first description of the deep inferior epigastric artery perforator (DIEP) flap, which has since become the gold-standard for autologous free flap breast reconstruction at many centers around the world. The current authors would like to stress that all articles in the top 100 are highly disruptive studies. Although, in theory, the number one article on the list is more disruptive than the fifth, which are both more disruptive than all the studies appearing lower, the list is meant to be viewed as a body rather than as a consecutive ranking. The study by Koshima et al²⁶ is one of the most revolutionary studies in the history of plastic surgery, and because it was identified at the top 100, the current authors believe that this is evidence of the merit of this novel bibliometric. Moreover, although many of the articles appearing in the most-disruptive list also carried high citation counts, many did not (n = 25 articles had <10 citations). This finding is similar to the study by Becerra et al investigating disruption in academic surgery, in which 23 of their top 100 also had <10.¹¹

The most common decade of disruption in the top 100 was the 1980s, with 31 articles at the top 100. Although the World Wars and the following decades certainly were integral in the development of plastic surgery,²⁷ the 1980s saw an explosion of innovation in part due to technological advances in plastic surgery and surgery more generally.²⁸ However, notably, the 1980s had the lowest average DS (0.53), with the 1960s having the highest average DS (0.59) of the decades included in our analysis. The 2000s had the fewest appearances on the list of top 100 with 9 articles, although, as previously discussed, the most-disruptive article was published in 2002 by Rohrich.¹⁵

The list of the most-disruptive articles also contains a broad diversity of topics and study designs. In fact, the broad range of topics was so variable that it precluded analysis. However, data on study design are presented with the most common type of study on the disruptive list— methodological studies (n = 32), whereas that for the most-cited list was case report/series (n = 33). Although case reports/series were also relatively common on the disruptive list (n = 31), there were very few methodological studies appearing in the most-cited list (n = 6). Although one may expect a list of the most paradigm-shifting studies in plastic surgery to feature a long list of high level of evidence randomized controlled trials, our results are similar to the results of other studies, including the Nature study by Wu et al,⁵ which initially investigated the disruption bibliometric. They concluded that small teams disrupt, but large teams develop. In both the most-disruptive and most-cited lists in the current study, a large number of case series and case reports seem to highlight this phenomenon: that these types of studies may report on novel concepts that serve to introduce a topic/finding to the wider surgical community and then serves as a foundation for larger, higher level of evidence studies to investigate novel findings. The current authors would also like to stress that the disruption metric is not synonymous with the dictionary definition of the word disruption, which carries its own connotations and may lead to misinterpretation of this bibliometric. Rather, we recommend the reader to focus on the definition of disruption, as outlined in the Methods section and the equation described. Furthermore, although some highly disruptive studies may change clinical practice, many do not. The mean feature of the disruption index is identifying articles that supplant previous literature on a given topic. Moreover, although some of these studies changed clinical practice, all of the highly-disruptive articles share the characteristic that they shifted paradigms in a given topic, as evidenced by shifting citations from previous literature to the index study after publication.

The DS serves as an alternative and complimentary tool to the citation count, which although simple and pragmatic, may not capture all scopes of innovation for quantifying scholarly impact. With the continued explosion of scientific literature, bibliometric measurements have become increasingly important to analyze and rank academic productivity.²⁹ Academic plastic surgery is an exceedingly competitive field and bibliometric measurements are frequently also used for promotion.³⁰ Although citation count or bibliographic indices derived thereof (h-index and g-index) are often used as a proxy for scholarly impact, these metrics have notable limitations.³ Several recent studies^9,10 have investigated alternative bibliometrics in plastic surgery, including the Altmetric score. Shiah et al compared the Altmetric score with “traditional” citation-based metrics such as the Hirsch index (H-index) and concluded that the Altmetric score has a weak positive correlation with conventional bibliometrics.⁹ Another recent study by Ruan et al investigated the relationship among the Altmetric score, Mendeley reader score, citation count, and downloads in PRS, and described the merits of the Altmetric score but discouraged its use as a stand-alone bibliometric.¹⁰

This study carries several limitations. Our analysis was conducted in 14 plastic and reconstructive surgery journals. Thus, articles published in other plastic surgery journals, or high-impact journals such as general surgery or medicine are excluded. Additionally, DSs and citation counts, like all bibliometrics, change over time as new scientific literature is published, and this analysis provides a snapshot in time of the current bibliometrics. Additionally, older studies are theoretically favored by this metric (as with other metrics) as they have had more time to aggregate citations. The favoring effect is likely counterbalanced by the fact that outdated studies eventually are less likely to be read or cited due to the dramatic changes that surgery is constantly undergoing. Despite these limitations, this study provides an important contribution to the plastic surgery literature by providing a repository of disruptive plastic surgery articles that may have otherwise been overlooked using traditional bibliometric tools. Future work will focus on comparing the disruption index with other alternative metrics such as Altmetric score, H-index, Mendeley reader score, and download counts.

CONCLUSIONS

We present the 100 most-disruptive articles in 14 of the most popular plastic surgery journals published between 1954 and 2014, utilizing a novel bibliometric index. A detailed analysis of these studies, including correlation to citation counts and analysis of publication years, is also presented. To our knowledge, this is the first application of the disruption metric to plastic surgery and its sub-specialties. This review provides a unique perspective on the seminal research studies that shifted paradigms and pushed forward surgical innovations that have made plastic surgery what it is today. We hope this perspective will provide plastic, reconstructive, and subspecialty surgeons an understanding of how current and historical innovations have made a lasting impact on the field of plastic surgery and provide insight into how current and future studies may further shape the field in ways we have yet to observe.

Footnotes

REFERENCES