Why Cosmetic Surgery Is Not Better Represented in Top-Cited Plastic Surgery Articles of the Last 50 Years.

Abstract

Sir: The recent article entitled “What Is Driving Paradigm Shifts in Plastic Surgery and Is Cosmetic Surgery Keeping Up?,”1 based on an evaluation of top-cited journal articles in plastic surgery, makes a number of excellent points, among them the ongoing need for new research in cosmetic surgery and higher level of evidence research in plastic surgery as a whole. However, there are at least two aspects to the study by Tang et al. that beg questioning. First, it would seem that the outcome of the study was in some ways predetermined by the decision to go back 50 years in the review and the selection of cited articles. This means that the starting point for citations was right around the time of the founding of the American Society for Aesthetic Plastic Surgery (The Aesthetic Society), a time when cosmetic surgery was still regarded by many plastic surgeons as something one might do “on the side” but should not talk about. For most of the Tang et al. study period, cosmetic surgery was undervalued by the plastic surgery specialty and underrepresented in organized plastic surgery, academic programs, and journal publications. Aesthetic Surgery Journal—today ranked 33 of 203 surgery journals for impact factor—did not exist as an indexed journal until the end of 2008. I would be interested in the authors’ rationale for having selected such a broad timeframe for the study, as the results might have had greater relevance to all their hypotheses if the timeframe were more reflective of the relatively late recognition of cosmetic surgery’s importance within the specialty of plastic surgery. Second, the authors’ hypothesis that innovation in cosmetic surgery should be proportionally equivalent to its share of total plastic surgical volume—in other words, 20 to 30 percent of the top-cited articles should be from cosmetic surgery—is a “neat” but perhaps arbitrary assumption. The intervening factors are numerous. The authors, in their very thorough Discussion, lay out many excellent observations and theories as to why cosmetic surgery research might be approached differently or face unique challenges. More important, however, we are convinced the authors’ claim that cosmetic surgery lags behind in innovation can be demonstrated on the basis of examining the 100 top-cited plastic surgery articles over the past 50 years. In the article “A Critique of the Impact Factor and Ramifications of Its Misuse in Plastic and Reconstructive Surgery: The Real Impact of the Impact Factor” by Nair and Adetayo,2 the authors argue that citation results are unavoidably skewed in favor of large-readership journals and that smaller subspecialty journals have an “undervalued” importance. In addition, although Tang et al. chose to exclude basic science articles from their selections, over the past 10 years or so there has been a concerted effort to conduct and publish basic science studies related to cosmetic surgery.3 Such studies generally have a higher level of evidence and may tend to be cited more widely than clinical articles in the field. These publications, however, would not have been considered in the Tang et al. evaluation. In conclusion, the authors have raised interesting questions about why cosmetic surgery is not better represented in their list of top-cited plastic surgery articles of the past 50 years. It might be worthwhile to conduct another study with more relevant parameters and to compare results against the same hypotheses. DISCLOSURE Dr. Nahai is the Editor-in-Chief of Aesthetic Surgery Journal. Dr. Kenkel is the Associate Editor of Aesthetic Surgery Journal and receives research grants from Bellus Medical and Venus Concept. No funding was received for this communication. Foad Nahai, M.D.Department of SurgeryEmory University School of MedicineAtlanta, Ga. Jeffrey M. Kenkel, M.D.Department of Plastic SurgeryUniversity of Texas Southwestern Medical CenterDallas, Texas