INTRODUCTION
Described by some as the “last true general surgeons,” plastic surgeons have a history of innovation both in and out of the operating room [
1]. Historically, the roots of hand surgery, head and neck surgery, craniofacial surgery, solid organ transplantation and abdominal wall reconstruction all bear pioneering influences from plastic surgeons. Digital replants, head and neck free flaps, cleft lip repair, kidney transplants, and abdominal component separation were all introduced, at least in part, by plastic surgeons [
2-
6]. Despite this early history in establishing multiple subspecialties within plastic surgery, each of these fields have evolved to include surgeons from various training backgrounds including orthopedic surgeons, general surgeons, otolaryngologists, neurosurgeons and oral maxillofacial surgeons. The encroachment of other surgical specialties into areas of practice historically held by plastic surgeons, or “specialty creep,” has taken place despite no evidence of superior outcomes by surgeons in different specialties. With plastic surgeons competing with other specialties in the clinical arena for volume in several areas of practice, it is necessary to ask whether similar competition exists with regards to contributions to the literature. In a 2016 article published by Dolan et al. [
7], the authors found that non-plastic surgeons contribute robustly to the aesthetic surgery literature with regards to five specific aesthetic procedures. Unfortunately, data regarding areas of research beyond aesthetic surgery is very sparse and the literary contributions of non-plastic surgeons to the aesthetic surgery literature beyond these procedures has not been examined. To comprehensively examine the phenomenon of specialty creep in plastic surgery research, we performed a literature database study examining publishing patterns over time, including an investigation of the most influential papers that are published in specific areas of plastic surgery. Several key areas of practice were selected where non-plastic surgeons are prominent and compared the quantity and impact of publications over time to those of plastic surgeons (
Table 1). Through this method of investigation, we aimed to highlight the changing role of plastic surgery in multiple areas of study.
DISCUSSION
Our study demonstrates that plastic surgeons share publishing space with several competing specialties including dermatology, oculoplastic surgery, orthopedic surgery, general surgery, otolaryngology, neurosurgery, and oral maxillofacial surgery. While plastic surgery maintains a publishing presence in multiple areas of practice, several have become increasingly dominated by competing surgical specialties. However, plastic surgeons have maintained a robust publishing presence in several areas, most convincingly aesthetic surgery and breast reconstruction. Furthermore, publication trends in all areas studied have largely demonstrated year-on-year increases in publishing volumes. Additionally, even in fields where plastic surgery is outperformed in publishing volume by other surgical disciplines, a large proportion of top cited articles are still published by plastic surgeons with this assertion holding true over the course of the last 10 years. This is perhaps best seen in craniofacial surgery and head and neck reconstruction where plastic surgeons published the largest plurality of top papers over the time period studied.
Head and neck reconstruction is an area which has become increasingly dominated by otolaryngology. Based on data from the American College of Surgeons National Surgical Quality Improvement Program, between 2005 and 2015, otolaryngologists performed 1,429 free tissue transfers for head and neck reconstruction compared to 893 performed by plastic surgeons [
8]. In spite of this, flap outcomes appear to be either comparable or superior for plastic surgeons as compared to otolaryngologists [
8,
9]. Beyond the operating room, over the period studied, otolaryngology publications on head and neck reconstruction outnumbered those published by plastic surgeons every year. Interestingly, the divide between the volume published by each specialty appears to have narrowed over the time of the study period, perhaps suggestive of increasing plastic surgery contribution to research in this field. Additionally, despite publishing fewer papers on head and neck reconstruction, plastic surgeons published the top most cited article for 3 of the last 10 years compared to three articles published by otolaryngologists.
Despite some fluctuation, the difference between volume of hand surgery publications written by orthopedic surgeons and those by plastic surgeons has remained relatively constant with orthopedic surgeons consistently publishing more. In spite of these lower publishing volumes, plastic surgeons again published a greater number of top-cited articles (five compared to three). There has been significant concern raised in recent years over the diminishing presence of plastic surgeons. High volume hand fellowships such as the Curtis Hand Center have seen significantly more fellows of orthopedic background graduate recently as compared to fellows with primary plastic surgery training [
10]. This is reflected in national trends; 204 hand fellows with a primary plastic surgery background graduated between 2000 and 2010 compared with 785 hand fellows from a primary orthopedic surgery background [
11]. Although orthopedic surgeons publish a larger proportion of the hand surgery literature, plastic surgery contributions have kept pace and have had an overall larger impact based on citations.
One area that has remained primarily under the realm of plastic surgery is breast reconstruction. An exception to this is the area of oncoplastic breast reduction in which a majority of oncoplastic procedures are performed by general/breast surgeons with no difference in complication rates [
12]. The proportion of breast reconstruction papers published by plastic surgeons has grown over time to over 50% of the literature published each year. In recent years, the proportion of articles published by breast and general surgeons has also grown, perhaps reflective of increasing surgical contributions. However, with the top cited article for 7 of the last 10 years, plastic surgeons remain both academically and clinically dominant in breast reconstruction.
The modern component separation technique for closure of ventral hernia defects was pioneered by Ramirez et al. [
3], a plastic surgeon. However, over the past 30 years, ventral hernia repair has largely become the domain of general surgeons. At least some of this is likely due to advances in laparoscopic technique and increasing prevalence of laparoscopic ventral hernia repairs. Accompanying this, publications addressing ventral hernias have been overwhelmingly published by general surgeons. This is also seen with authorship patterns of the top cited articles. However, when focusing specifically on abdominal component separation, it is only in recent years that general surgeons have published larger volumes than plastic surgeons and since 2014, this difference has only increased. As such, it appears that this is one field in which plastic surgeons have seen diminished influence in the primary literature.
Injury of the brachial plexus often requires multidisciplinary approaches and multiple specialties provide important contributions to the literature. While both plastic surgeons and neurosurgeons provide modest contributions to the literature that have grown at approximately the same rate, neither approach the volume of literature contributed by orthopedic surgeons. Despite this, each of the three specialties studied appear to have contributed approximately equal numbers of top cited articles over the last 10 years. Given the collaborative nature of care for brachial plexus injuries, plastic surgery is likely to maintain an academically significant, albeit modest, contribution to the literature.
Craniofacial surgery is a vast area of subspecialization ranging from care for traumatic injuries to correction of congenital abnormalities of both the soft tissue and skeletal structures of the face and cranium. Both plastic surgeons and OMFS surgeons contribute similar volume of publications with substantially less contributed by neurosurgeons. Despite OMFS surgeons contributing slightly more in recent years, plastic surgeons contributed six of the top cited articles over the last 10 years demonstrating both a robust and impactful literary contribution.
Aesthetic surgery is perhaps the most public facing aspect of plastic surgery. A proliferation of non-plastic surgeons offering aesthetic procedures has seen increasing marketplace competition between specialties [
13,
14]. This competition occurs at a time when a significant proportion graduating plastic surgery residents feel uncomfortable performing certain cosmetic surgery procedures without pursuing further training [
15]. Previously published analyses of aesthetic surgery publication trends have found that plastic surgeons maintain a strong publication presence with regards to selected areas of the aesthetic surgery literature [
7,
16]. Our analysis concurs with these findings, demonstrating that authors with plastic surgery affiliations are responsible for an overwhelming majority of the aesthetic surgery literature, however with specialties such as obstetrics and gynecology responsible for highly cited papers, plastic surgeons must continue to cultivate research in aesthetic surgery to remain leaders in this field.
This study has several limitations based on research methodology. The number of publications analyzed is directly influenced by the Pubmed.Gov search syntax utilized and while searches were designed to target as many relevant papers as possible, it is always possible that some proportion were missed. Additionally, rather than using medical subject heading (MeSH) terms, keywords were used in searches. This is due to the fact that MeSH terms do not have the required specificity for many of the subjects studied here and do not allow a similar level of flexibility as keywords for search refinement. Furthermore, the number of articles published in a practice area by a particular specialty is likely to be, in part, a function of the total number of surgeons practicing in the field as well as the academic productivity of individual members of those specialties. However, performing a “per capita” adjustment would be difficult to do without specific data regarding the number of actively practicing surgeons in each specialty.
In selecting for all papers returned by a search with a specific keyword, there is potential for confoundment of results based on regional differences. For instance, inclusion of breast reconstructive papers published by European surgeons, where much breast reconstruction has been traditionally performed by breast surgeons, may affect the perception of publishing trends in the United States where the majority of breast reconstruction is performed by plastic surgeons. Furthermore, our analysis of the various practice areas does not parse the data to the level of specific procedures.
While we endeavored to include a wide variety of areas of practice in which plastic surgeons contribute to the literature, the list chosen here is by no means comprehensive. The areas selected were chosen based on their prominence within the field of plastic surgery including several with defined fellowships (hand and peripheral nerve, craniofacial, aesthetic, microsurgery for both breast and head and neck reconstructions). However, the breadth of the field of practice of plastic surgery means that there were many areas not included here. Additionally, there may be surgical specialties which also practice in these areas which were not included for brevity purposes.
Plastic surgery has perhaps the widest breadth of any surgical subspecialty, operating all over the human body. This broad clinical purview, along with a strong history of innovation, means plastic surgeons have pioneering influences in many areas of clinical practice. However, due to clinical overlap with other subspecialties, many of these clinical areas have been adopted by other surgical specialties that continue to both develop surgical technique and publish in these areas. Despite sharing intellectual space with a multitude of other specialties, plastic surgery maintains a robust publishing presence and appears to have an outsize influence on the literature as compared to other subspecialties. These findings are perhaps most obvious within aesthetic surgery, however with the increasing presence of other specialties in the clinical practice of aesthetic surgery, we must strive to continue to innovate and publish, marrying research with clinical practice to provide superior results to patients.