Trends in Breast Augmentation Research: A Bibliometric Analysis

From 1985 to 2021, a total of 4637 publications were identified from the Web of Science core collection online database (2022.2.8). These included 2235 (48.20%) original research articles, 747 (16.11%) letters, 552 (11.90%) meeting abstracts, 546 (11.77%) editorial materials, 234 (5.05%) review articles, 168 (3.62%) proceedings papers, and 155 (3.34%) other articles, including early access papers, among other publications (Fig. 1). A total of 1053 (22.71%) papers were open access. The growth of the annual publication output is shown in Fig. 2. Of these, 457 (9.86%) papers were published in 2021, and 412 (8.89%) papers were published in 2020. The annual publication output increased annually and increased to 457 in 2021 to more than two times the annual publication output in 2011.

All publications were distributed among 78 countries/regions. The annual national publication output of the ten most productive countries/regions is shown in Fig. 3. Since 2017, the annual growth rate of publication output has increased in England, followed by China, Germany, and Brazil. The ten most productive countries/regions are shown in Table 1. The USA had the highest output, with 1682 publications (36.27% of 4637 publications), followed by England (9.08%, with 421 publications), Italy (7.85%, with 364 publications), Canada (4.72%, with 219 publications), China (4.27%, with 198 publications), and Germany (4.23%, with 196 publications). The international collaboration network analysis is shown in Fig. 4. The size of the node indicates the number of publications issued in a specific country/region, and lines represent the frequency of cooperation between countries. Ten clusters were obtained based on this information. As shown in Fig. 4, the USA was the main driving force with a high academic reputation in breast augmentation research, which was confirmed by the following characteristics: number of publications (1682), H-index value (81), number of partners (45), total number of citations (31099), and TLS (388). Brazil had the highest number of citations per publication (CPP: 28.47). The total number of research publications from other countries, such as England, Italy, Canada, Germany, France, and Australia, was relatively low. However, their publication output still reflected the considerable progress made by these countries in this field, which was closely related to their collaborations with the USA.

All publications were distributed among 3450 institutions. The ten most productive institutions are shown in Table 2. The leading institutions were the University of Texas MD Anderson Cancer Center (2.37%, with 110 publications), Memorial Sloan Kettering Cancer Center (2.09%, with 97 publications), Mayo Clinic (1.34%, with 62 publications), University of Toronto (1.34%, with 62 publications), and Chinese Academy of Medical Sciences (1.21%, with 56 publications). Most of the ten most productive institutions came from the USA, showing the strong academic influence of the USA in this field. The University of Texas MD Anderson Cancer Center (USA) and Vanderbilt University (USA) had the highest H-index (30), and Vanderbilt University (USA) had the highest number of citations per publication (38.81), which showed that they published more high-quality publications and played a pivotal role in promoting the development of this field.

The network visualization map of cooperative institutions related to this research field is shown in Fig. 5. The nodes represent institutions, and lines between the nodes represent cooperative relationships. As shown in Fig. 5, the major institutions cooperative with the University of Texas MD Anderson Cancer Center were the Mayo Clinic, Memorial Sloan Kettering Cancer Center, Macquarie University, and University of Washington. Nineteen clusters were obtained from the analysis. For example, Cluster 1 (shown in red, 37 items) represented American academic institutions, such as Harvard University (links: 22, TLS: 30, publications: 34), New York University, University of Michigan, Loma Linda University, University of Pennsylvania, University of California San Francisco, and Northwestern University.

The ten most productive and co-cited journals are listed in Tables 3, 4. A total of 520 journals published the relevant publications, of which 100 journals published more than five publications. In total, 2663 publications were published in the top ten active journals, which accounted for half of the publications on the Web of Science core collection online database. Plastic and reconstructive surgery (998 publications, 21.52%) published the most research in this field and had an IF of 4.73 in 2021, followed by Aesthetic Plastic Surgery (481 publications, 10.37%), Aesthetic Surgery Journal (391 publications, 8.43%), Journal of Plastic Reconstructive and Aesthetic Surgery (240 publications, 5.18%), and Annals of Plastic Surgery (233 publications, 5.02%). Among the top ten most productive journals, International Journal of Radiation Oncology Biology Physics had the highest IF (7.038), and plastic and reconstructive surgery had the highest number of citations per publication (21.3). Additionally, more than half of the top ten productive journals were classified in Q1 (the top 25% of the IF distribution). The most frequently co-cited journal was plastic and reconstructive surgery (22,351 citations, TLS: 409,301) (Fig. 6). The next most frequently co-cited journals were Annals of Plastic Surgery (3954 citations, TLS: 112,531), Aesthetic Surgery Journal (3689 citations, TLS: 99,091), and Journal of Plastic Reconstructive and Aesthetic Surgery (1944 citations, TLS: 54,254), showing that they were all important information resources. Among the top ten co-cited journals, New England Journal of Medicine had the highest IF (91.253), and plastic and reconstructive surgery had the highest H-index (70). More than half of the top ten co-cited journals were in Q1. Plastic and reconstructive surgery was recognized as a breast augmentation research resource and had an important influence on this research field.

A total of 13,320 authors have published papers on breast augmentation. The ten most productive authors and the ten top co-cited authors are shown in Table 5. Clemens MW (68 publications, 1.47%) published the most publications, followed by Adams WP (59 publications, 0.99%), Miranda RN (43 publications, 0.93%), Heden P (38 publications, 0.82%), Deva AK (36 publications, 0.78%), Medeiros IJ (33 publications, 0.71%), Pusik AL (27 publications, 0.58%), Cordeiro PG (26 publications, 0.56%), Maxwell GP (26 publications, 0.56%), and Mclaughlin JK (24 publications, 0.52%). The network visualization map of the co-cited authors is shown in Fig. 7. Five clusters were obtained from the analysis. The largest nodes were associated with the most frequently co-cited authors, including Spear SL (1,456 citations, TLS: 27,231, Cluster 1), Adams WP (653 citations, TLS: 14,432, Cluster 2), Handel N (404 citations, TLS: 8,941, Cluster 3), Tebbetts JB (874 citations, TLS: 13,323, Cluster 4), and Clemens MW (555 citations, TLS: 11,837, Cluster 5).

Figure 8 is a network map of co-cited references in this field, where there are 574 nodes and 49,315 links. According to Fig. 8, the size of the node represents the number of specific publications that have been cited. The more the literature is cited, the larger the diameter of the node. Table 6 summarizes the top 100 most-cited references according to the number of citations, including author, title, and year of publication. According to the 100 most-cited references, the title of “Anaplastic T-cell lymphoma in proximity to a saline-filled breast implant” published in Plastic and Reconstructive Surgery (IF 2021, 4.73) was the most-cited article, which was authored by Keech JA, with 705 citations, followed by “Yoshimura et al., 2008, Aesthetic Plast Surg”, “Albornoz et al., 2013, Plast Reconstr Sur”, “Breuing et al., 2005, Ann Plast Surg”, “Chun et al., 2010, Plast Reconstr Sur”, “Handel et al., 2006, Plast Reconstr Sur”, “McCarthy et al., 2008, Plast Reconstr Sur”, “Cordeiro et al., 2004, Plast Reconstr Sur”, “Yueh et al., 2010, Plast Reconstr Sur”, and “Pajkos et al., 2003, Plast Reconstr Sur”. Most of the top 100 most-cited references by citation count were in Q1. Most articles were published after 2005. We found that the research hotspots included the following four aspects: safety and effectiveness of breast implants (Cluster 1, red zone), implant-based breast reconstruction (Cluster 2, green zone), breast cancer incidence after breast implantation (Cluster 3, blue zone), and breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) (Cluster 4, yellow zone) (Fig. 8).

The annual keyword publication output of breast augmentation research is shown in Fig. 9. A total of 3316 keywords were considered in the analysis. Figure 10 shows a network map of keyword co-occurrence, where there are 210 items (occurrence >5) and 2253 links. Each item represents the frequency of a keyword appearing in the topic articles of our research. The larger the item is, the more clinical research on the subject surrounding the specific keyword. The thicker the line between the keywords, the higher the frequency of this group of keywords appearing in the clinical articles. The rapid identification of these keywords can help us quickly identify the hot topics studied in the literature. In addition, there are 12 clusters in total, and the name of each cluster is determined according to the number of items. After this analysis, we can further determine specific categories with an overview of this study derived from all keywords. The clinical significance of the co-occurrence keyword cluster map is that each cluster contains several different keywords for the subtheme of the study. Therefore, it can provide a convenient approach to help researchers who are concerned about the subtheme of this research field to quickly identify which other relevant keywords are contained in the subline they are concerned about from a global perspective.

According to the citation count analysis of keywords, we found that the most popular keywords were “breast reconstruction,” “breast augmentation,” “breast implants,” “breast implant,” “breast cancer,” “breast,” “implant,” “capsular contracture,” “silicone,” and “complications.” Cluster 1 (32 items) labeling “breast augmentation” (TLS: 577, occurrences: 333) was the largest cluster, followed by “breast reconstruction” (TLS: 792, occurrences: 335) (Cluster 2), “breast implant” (TLS: 451, occurrences: 216) (Cluster 3), “complications” (TLS: 223, occurrences: 75) (Cluster 4), “silicone implants” (TLS: 42, occurrences: 23) (Cluster 5), “breast” (TLS: 370, occurrences: 133) (Cluster 6), “tissue expander” (TLS: 141, occurrences: 45) (Cluster 7), “breast cancer” (TLS: 423, occurrences: 200) (Cluster 8), “mammaplasty” (TLS: 76, occurrences: 42) (Cluster 9), “breast implants” (TLS: 523, occurrences: 255) (Cluster 10), “capsular contracture” (TLS: 262, occurrences: 108) (Cluster 11), and “tissue engineering” (TLS: 7, occurrences: 7) (Cluster 12).

As shown in Fig. 9, “breast augmentation” was strongly associated with “breast reconstruction,” “breast implants,” “complications,” “silicone implants,” “breast,” “tissue expander,” “breast cancer,” “mammaplasty,” “capsular contracture,” “silicone,” and “tissue engineering.”

Furthermore, several research directions, including “acellular dermal matrix (ADM)” (TLS: 170, occurrences: 67) (Cluster 2), “anaplastic large cell lymphoma” (TLS: 91, occurrences: 39) (Cluster 3), and “capsular contracture” (TLS: 262, occurrences: 108) (Cluster 11), have been the main topics since 2012 (Fig. 11).

The timing diagram showed that the research trends focused on breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), implant-based breast reconstruction, and autologous fat grafting (Fig. 11).

Clemens MW from the University of Texas MD Anderson Cancer Center published the most publications (68 publications, 1.47%). His most-cited article mainly reported that surgical management with complete surgical resection is necessary to achieve optimal event-free survival in patients with BIA-ALCL [18].

Spear SL from the Department of Plastic Surgery at Georgetown University Hospital (USA) ranked first among all co-cited authors. His three most-cited articles focused on the safety and effectiveness of silicone breast implants and capsular contracture after prosthetic breast reconstruction [19‐21]. These articles have been considered reliable reference resources for subsequent research.

Additionally, the paper entitled “Anaplastic T-cell lymphoma in proximity to a saline-filled breast implant” published in Plastic and Reconstructive Surgery was the most co-cited reference, which focused on the causal relationship between the presence of saline-filled breast implants and the development of non-Hodgkin’s lymphoma involving the breast. In this study, the researchers were involved in the care of a young woman with anaplastic T-cell lymphoma in proximity to saline-filled breast implants, in whom antineoplastic therapy was successfully accomplished without necessitating removal of the breast implants; the authors considered the presence of implants not to be an obstacle to the delivery of effective radiation therapy. A causal relationship between the presence of a saline-filled breast implant and the development of non-Hodgkin’s lymphoma involving the breast was not demonstrated [22]. Therefore, this article may provide insights for the study of the association of inflammatory or neoplastic diseases associated with saline-filled breast implants.

The second most-cited article was “Cell-assisted lipotransfer for cosmetic breast augmentation: supportive use of adipose-derived stem/stromal cells” published in Aesthetic Plastic Surgery. This article assessed the cell-assisted lipotransfer known as a strategy to overcome the problems with lipoinjection [23]. Lipoinjection is a promising treatment but has some problems, such as unpredictability and a low rate of graft survival due to partial necrosis. Yoshimura et al. used autologous adipose-derived stem cells in combination with lipoinjection and reported preliminary results suggesting that cell-assisted lipotransfer was effective and safe for soft tissue augmentation and superior to conventional lipoinjection [23].

The third most-cited article assessed long-term trends in rates and types of immediate breast reconstruction. Albornoz et al. suggested that the significant rise in immediate breast reconstruction rates in the USA correlated closely to an increase in implant use, and the reason for the increase in implant use was changes in mastectomy patterns, such as increased bilateral mastectomies [24].

As shown in the network map of co-cited references (Fig. 8), the research hotspots included the following four aspects: safety and effectiveness of breast implants, implant-based breast reconstruction, breast cancer incidence after breast implantation, and breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL).

“Safety and effectiveness of breast implants” (Cluster 1) included the most publications and indicated that the most common local complication was capsular contracture. In the sixth and tenth most-cited articles, Handel N et al. noted that the longer the implant was in place, the greater the cumulative risk of developing capsular contracture, and textured breast implants were better than smooth breast implants in decreasing the rate of capsular contracture [20, 21, 25‐29].

“Implant-based breast reconstruction” (Cluster 2) indicated that the significant increase in immediate implant-based breast reconstruction rates was closely related to the expansion of implant use [19, 30]. The fourth, eighth, and ninth most-cited articles assessed implant-based reconstruction and additional options for this treatment [31‐33].The fifth and seventh most-cited articles evaluated complications and clinical risk factors following implant breast reconstruction [34, 35].

“Breast cancer incidence after breast implantation” (Cluster 3) indicated the possibility that women who received implant-based breast augmentation for cosmetic purposes had an increased long-term risk of developing cancer. Janowsky EC et al. mentioned that there was no evidence of an association between silicone-gel-filled breast implants and any of the individual connective tissue diseases, all defined connective tissue diseases combined, or other autoimmune or rheumatic diseases [36, 37]. Brisson J et al. mentioned that women undergoing breast augmentation do not appear to have an increased long-term risk of developing cancer [38, 39].

“Breast implant-associated anaplastic large-cell lymphoma” (Cluster 4) showed that the association between breast implants and BIA-ALCL has been confirmed [22, 40‐45]. The eleventh most-cited article by De Jong D in 2008 discussed whether the risk of anaplastic large T-cell lymphoma was associated with breast implants [41]. This article was seminal in this field, as evidenced by publication in JAMA-Journal of the American Medical Association, a high-impact factor medical journal. BIA-ALCL is a rare cancer in patients with breast implants, but the incidence is increasing [46, 47]. The nineteenth most-cited article by Hu H in 2016 identified bacterial biofilms in BIA-ALCL. Bacterial biofilms and a distinct microbiome found in BIA-ALCL samples suggest a possible cause of infection, and thus strategies to reduce their contamination should be more widely studied and practiced [42]. The twenty-second and twenty-eighth most-cited articles detailed that high-surface-area textured implants had been shown to significantly increase the risk of BIA-ALCL [43, 48]. The overall incidence of BIA-ALCL was 1.15 per 1000 textured implants and 1.79 per 1000 patients with textured implants, and the median time to diagnosis was 10.3 years (range, 6.4–15.5 years) [49]. The National Comprehensive Cancer Network (NCCN) guidelines on BIA-ALCL have been endorsed by the FDA and widely advocated by national professional societies, and the consensus guidelines have helped establish standardization of treatment for BIA-ALCL at all stages of the disease [50]. The treatment includes capsulectomy and implant removal at an early stage. However, systemic therapy is needed to include chemotherapy, radiation therapy (residual disease), and brentuximab vedotin at stages II to IV; complete capsular removal is the most important factor, and most patients can be cured [51].

According to analysis of the most frequently used keywords and the timing diagram (Fig. 8), the research trends were as follows: breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), implant-based breast reconstruction, BREAST-Q, acellular dermal matrix (ADM), capsular contracture, and autologous fat grafting.

The paper entitled “Prepectoral Implant-Based Breast Reconstruction: Rationale, Indications, and Preliminary Results” authored by Sigalove S and published in 2017 is the most frequently cited article associated with implant-based breast reconstruction among recently published publications. In this study, Sigalove S reported that by placing the implant prepectorally, problems related to pectoralis muscle elevation could be avoided [52]. Breast implant pocket locations are subglandular, subpectoral, subfascial, partially retropectoral, totally submuscular, and dual plane. Shen Z reported that the subfascial and subpectoral planes were safe and effective for controlling the overall complication rate and achieving a high satisfaction rate. The muscles of the chest, which are related to the optimal placement of implants, play an important role in breast augmentation surgery. The amount of muscle varies from patient to patient and may be a factor in determining whether submuscular or subglandular placement is best [53, 54]. Tebbetts JB mentioned that dual-plane augmentation mammaplasty adjusts the relationship between the implant and tissue to ensure adequate soft tissue coverage while optimizing implant-soft-tissue dynamics to offer more benefits than a single pocket location for various breast types [55].

The BREAST-Q can be used to study the impact and effectiveness of breast surgery from the patient’s perspective. The BREAST-Q has the potential to support advocacy, quality metrics, and an evidence-based approach to surgical practice by quantifying satisfaction and health-related quality of life [56].

Acellular dermal matrix (ADM) is developed from human skin (such as FlexHD, AlloMax, AlloDerm) or animal skin (such as SurgiMend), from which the cells are removed and the support structure is retained [57]. ADM has been widely used as an adjunct material for tissue-expander or implant-based breast reconstruction [34]. Implant-based breast reconstruction has been enhanced by ADM, and immediate single-stage direct-to-implant breast reconstruction with ADM may achieve aesthetic optimization by preserving the mastectomy skin envelope [30, 34]. Some researchers have demonstrated that human cadaveric skin-based products such as FlexHD, DermaMatrix, and ready-to-use AlloDerm have a similar risk of complications compared with those of freeze-dried AlloDerm, which has been used longer [57]. Another researcher mentioned that ADM was related to a greater risk of major complications from immediate implant-based breast reconstruction, especially in patients with a high BMI [58]. However, further investigation is needed.

Capsular contracture is a common complication of breast augmentation, and many techniques for prevention and treatment have been reported with inconsistent or variable results. Wagner DS mentioned that surgical capsectomy, prosthesis replacement, and acellular dermal matrix placement are effective methods for the treatment of capsular contracture after breast augmentation [59]. Some investigators suggest that adherence to a surgical technique focused on minimizing bacterial contamination of implants has greater clinical significance than implant surface characteristics when discussing capsular contracture. [60].

Autologous fat grafting for breast augmentation is a growing field, and the safety of this technique has been extensively evaluated [61]. Many authors have explored the effectiveness and safety of breast lipoaugmentation, focusing on volume change, fat retention, overall cosmetic improvement, and patient satisfaction [62]. Li FC mentioned that liposuction and autologous fat grafting were suitable approaches for breast augmentation [63]. Maione L described that the combination of high-profile round implants and fat grafting in breast augmentation can eliminate the risk of implant rotation to improve the aesthetic outcome and patient satisfaction [64, 65]. Cell-assisted lipotransfer (CAL) is a novel and promising technique for breast augmentation [66]. In cell-assisted lipotransfer, autologous adipose-derived stem (stromal) cells (ASCs) are used in combination with lipoinjection. This process converts relatively ASC-poor aspirated fat to ASC-enriched fat [67]. ASCs-enriched fat grafts had significantly higher retention rates than conventional fat grafts [68] and these results suggested that cell-assisted lipotransfer is superior to conventional lipotransfer for improving the fat survival rate in breast augmentation [69]. No serious or unexpected adverse events in autologous fat grafting for breast augmentation were reported, and all procedures were found to be safe and well-tolerated in all patients [70]. Time will prove whether these studies, as we mentioned above, will be real trends. There may be shortcomings from insufficient data or analysis, and more progressive studies are needed in the future.