What Is Driving Paradigm Shifts in Plastic Surgery and Is Cosmetic Surgery Keeping Up?

Background: Cosmetic surgery represents 20 to 30 percent of total plastic surgical volume. The authors hypothesize that with current capitalization and market share, cosmetic surgery should be proportionally represented in scientific innovation. Methods: All journals that may contain articles relevant to plastic surgery were selected from the 2016 edition of Journal Citation Reports. The authors identified, reviewed, and analyzed the 100 top-cited plastic surgery clinical articles using the Science Citation Index Expanded (1900 to 2017) as a proxy for innovation. Results: The top-100 articles were cited a median of 329.5 times (range, 240 to 1709 times). Sixteen journals were represented, led by Plastic and Reconstructive Surgery (45 percent) and Annals of Surgery (15 percent). Fifty-six percent were reconstructive, 13 percent were breast, 11 percent were pediatric/craniofacial, 11 percent were cosmetic, and 9 percent were hand/peripheral nerve articles. Only 11 percent of articles represented level of evidence I or II, with the majority (79 percent) of articles being level IV. Sixty-seven percent of publications originated from United States. The 11 cosmetic articles originated from different subspecialties: injectables, fillers, and fat grafting ( n = 7); contouring ( n = 2); facial cosmetic ( n = 1); and general cosmetic ( n = 1). Conclusions: Cosmetic innovation is not keeping up with reconstructive innovation; it is unknown why cosmetic surgery is lacking. The authors offer several speculations as to why there is a gap in cosmetic surgical research and, by proxy, innovation.