Introduction

Although breast reduction looks like a cosmetic surgery performed to restore a woman’s appearance, in fact it is a reconstructive surgery that eliminates back pain, stance disorder, headache, shoulder pain, back and cervical disk hernia, difficulty in breathing, hollowness caused by bra straps, hygiene problems under breasts (e.g., rash or fungal infections), and limitations in some daily activities. However, the related literature has little information about the publications on this issue.

Bibliometrics is the statistical analysis of written publications such as articles or books in the academic literature [1, 2]. Bibliometric methods are used in many research fields to explore the effects of fields, researcher groups or an author, or the international effect of a specific study [3,4,5]. As for citation analysis, it is a common bibliometric method based on the web or graph demonstration of citations among scientific documents and the formation of the relationships between authors or articles [6]. In this study, we aim to provide researchers with important information to guide them by making a bibliometric analysis of breast reduction publications indexed in the Thomsen Reuters Web of Science (WoS) database between 1980 and 2016.

Materials and Methods

All the documents published between 1980 and 2016 that included “breast reduction,” “gigantomastia,” “reduction mammaplasty,” and “reduction mammoplasty” keywords (TITLE: (“breast reduction”) OR TITLE: (gigantomastia) OR TITLE: (“reduction mammaplasty”) OR TITLE: (“reduction mammoplasty”)) were downloaded from the WoS (Thomson Reuters, New York, NY, USA) and were subjected to bibliometric analysis (data Access date: 1st of October, 2017); those published in 2017 were excluded. Bibliometric network visualizations were formed using VOSviewer (version 1.6.5). Active authors, countries, scientific journals, and universities in biostatistics publications were identified using bibliometric analyses; relationships were investigated between co-authorship, citation, co-citation analyses, and mostly used keywords.

The network visualization map is expressed with labels, circles, colors, and lines. Cluster analysis is performed within the analysis, and the colors show the clusters to which they belong. Depending on the preference, the size of the circle indicates the size of the number of citations. The bigger the size, the more articles or citations it has. Closeness and distance of the elements to each other indicate their relationship. Generally, if two elements are close to each other, then they have a strong relationship. Besides, thickening of the lines shows the strength of the relationship. Colors range between blue and red in the density visualization map. As the number of elements in the area of an element increases, and the density of the neighboring elements becomes higher, then the color of the point gets redder. In opposite cases, the point gets blue. This graph demonstrates grouping or clustering between the graph elements.

Results

A total number of 1427 publications were found in the WoS database. The publications received 13,181 total citations and the average number of citations per publication was 9.1.

Publication Types and Research Areas

Of all these publications, 869 (60.90%) were articles, 293 (20.53%) were letters, 116 (8.13%) editorial material, 115 (8.06%) proceedings papers, 73 (5.12%) meeting abstracts, 23 (1.61%) reviews, 18 (1.26%) discussions, 10 (0.70) notes, and 10 (0.70%) were corrections. The top 10 research areas in which these publications were published included surgery with 1178 publications (82.55%), oncology with 78 publications (5.47%), obstetrics gynecology with 67 publications (4.70%), general internal medicine with 42 publications (2.94%), pathology with 28 publications (1.97%), research experimental medicine with 16 publications (1.12%), public environmental occupational health with 14 publications (0.98%), anesthesiology with 13 publications (0.91%), pediatrics with 10 publications (0.70%), and orthopedics with 9 publications (0.63%). By language, 1371 (96.2%) of these publications have been published in English, 26 (1.8%) in German, 25 (1.7%) in French, 3 (0.1%) in Spanish, 1 (0.1%) in Korean, and 1 (0.1%) in Russian.

Development of Publication and Citation Numbers

The change of the number of publications and citations according to years is presented in Figs. 1 and 2, respectively. An analysis of the figures shows that most publications were done in the year 2016, and the number of citations which started to increase after 1994 received the maximum value in 2013.

Fig. 1
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Numbers of publications according to years on breast reduction

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Fig. 2
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Numbers of citations according to years on breast reduction

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Active Countries

The three countries that had the most contributions according to the number of citations were the USA (515), England (147), and Turkey (83), respectively. The top 10 countries are shown in Fig. 3.

Fig. 3
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Top 10 countries according to total number of publications on breast reduction

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Active Institutes

The top five organizations that contributed to the literature in terms of the number of publications are Harvard University (15; 1.05%), New York University (15; 1.05%), The University of Texas (15; 1.05%), Federal University of São Paulo (14; 0.98%), and University São Paulo (14; 0.98%), and the top five organizations-enhanced ones are Harvard University (24; 1.68%), Karolinska Institute (19; 1.33%), Georgetown University (17; 1.19%), University of Hull (17; 1.19%), and New York University (16; 1.12%).

Active Authors and Citation analysis

The top two authors who contributed most according to the number of publications were Drew PJ and Iwuagwu OC (13; 0.91%). Other authors are presented in the first three columns of Table 1. The top two authors according to the citation rankings were Schnur PL (323) and Hall-Findlay EJ (259). The top 10 authors are presented in the last two columns of Table 1.

Table 1 First 10 authors by record count and citation on breast reduction
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Citation Analysis

The top 10 articles that received the most citations are given in Table 2. With 189 citations, the top-cited publication was the document entitled “A Simplified Vertical Reduction Mammaplasty: Shortening the Learning Curve” written by Hall-Findlay, EJ published in Plastic and Reconstructive Surgery Journal in 1999 [7]. The study entitled “Experience with Reduction Mammaplasty Combined with Breast Conservation Therapy in the Treatment of Breast Cancer” written by Spear et al. [8] and published in Plastic and Reconstructive Surgery in 2003 was the top-cited document according to average citations per year. Of the 1427 articles, there were 50 articles that received at least 50 citations. The network map and density map in relation to the bibliometric analysis of these top-cited articles are shown in Figs. 4 and 5, respectively. An analysis of Fig. 4 shows that the authors are divided into 5 different clusters. The size of the circle indicates the number of citations the document received.

Table 2 Ten most cited manuscripts in breast reduction
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Fig. 4
figure 4

Network visualization map of citation analysis of active authors according to documents on breast reduction

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Fig. 5
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Density map of citation analysis of active authors according to documents on breast reduction

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Active Journals

The journals with most publications were Plastic and Reconstructive Surgery (483; 33.85%), Annals of Plastic Surgery (164; 11.50%), and Aesthetic Plastic Surgery (147; 10.30%), respectively. The average number of citations according to year belonged to a journal out of these three journals, which was British Journal of Plastic Surgery. The first 4 columns of Table 3 present the first 10 journals that contributed to the literature most and the number of citations they received. The top 10 rankings according to the number of citations are given at the end of the last two columns of Table 3. Among 210 journals with a total number of 1427 publications, citation analysis relationships were performed with 79 journals that had at least two articles on this issue (Fig. 6). Circle size indicates the number of citations that the journals received.

Table 3 First 10 journal sources by number of publications and citations in breast reduction
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Fig. 6
figure 6

Network visualization map of citation analysis of active journals in publishing articles

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Co-citation Analysis

The top three journals with most co-citations were Plastic and Reconstructive Surgery (6333), Annals of Plastic Surgery (1300), and Aesthetic Plastic Surgery (946). Among 2290 journals, co-citation analyses were performed with 60 journals that received at least 30 citations (Fig. 7). Circle size indicates the number of citations. Robbins TH, 1977 (128 citations) [9], Courtiss EH, 1977 (122 citations) [10], Lejour M, 1994 (112 citations) [11], Mckissock PK, 1972 (96 citations) [12], and Dabbah A, 1995 (91 citations) [13] were the five top-cited publications. From 8026 co-citations, analyses were performed with 40 articles that were cited at least 40 times (Fig. 8). Circle size indicates the number of citations.

Fig. 7
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Network visualization map of co-citation analysis of active journals in cited references

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Fig. 8
figure 8

Network visualization map of co-citation analysis of active journals in cited sources

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Trend Topics Related to Breast Reduction

It was found that a total of 987 different keywords were used in 1427 publications. Analyses were performed with 53 keywords that were used at least 5 times. Mostly used keywords were reduction mammaplasty (204), breast reduction (176), breast (47), mammaplasty (mammoplasty) (60), gigantomastia (39), macromastia (33), breast cancer (32), breast hypertrophy (28), complications (24), mastopexy (24), breast surgery(21), reduction (17), quality of life (15), breast reconstruction (12), oncoplastic surgery (11), outcomes (11), plastic surgery (11), vertical scar (10), complication (9), surgery (9), pregnancy (9), breast reduction surgery (9), body mass index (8), obesity (8), mastectomy (8), and superomedial pedicle (8), respectively. Others are demonstrated in Fig. 9. The top-cited keywords among these are demonstrated in Fig. 10. The right bottom of the graph demonstrates the number of citations according to color. The number of citations increases from blue to red. The top-cited trend keywords included body image, outcome, quality of life, smoking, complication, bilateral breast reduction, and self-esteem (Fig. 10).

Fig. 9
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Network visualization map of relationships between the most commonly used keywords in the abstract on breast reduction

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Fig. 10
figure 10

Network visualization map of the most cited keyword in the abstract on breast reduction. Right bottom of the graph demonstrates number of citations according to color. Number of citations increases from blue to red

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Discussion

Parallel to communication networks and economic developments, there has been an increase in the awareness about breast reduction, leading to an increase in the number of patients operated on. However, the literature has a limited number of studies about the analysis of breast reduction publications. This study will enlighten specifically researchers in terms of the collaboration between trend topics, journals, countries, authors, as well as top-cited notable articles. This study is the first bibliometric study about the issue of breast reduction. International collaboration and some other analyses have been cited firstly in this present study.

An analysis of the publications in three plastic surgery journals in 2002 was performed in the article entitled “Analysis of publications in three plastic surgery journals for the year 2002” written by Huemer et al. [14] and published in Plastic and Reconstructive Surgery in 2004. The breast reduction section of the article presented breast reduction articles, new methods of reduction techniques, and analyses of post-operative results such as different scar patterns and nipple areola complex sensation; however, it was inadequate in terms of reflecting the publications about breast reduction. The article entitled “Plastic Surgery and the Breast: A Citation Analysis of the Literature” written by Cormac W et al. in 2014 and published in Plastic Reconstructive Surgery Glob Open journal reported 100 top-cited articles about breasts in the plastic surgery literature and analyzed the features of these articles. Features such as topic, article type, country of origin, institution, authorship, and publication year of the articles were investigated separately. Findings showed that, with the top-cited 100 articles and 81 articles including the top-cited article, Plastic Reconstructive Surgery was identified as the journal that provided the most contribution. The USA produced 73% of the top 100 articles. The most productive institution was Texas University and M. D. Anderson Cancer Center [15]. The study included only citation analyses and a limited number of article analyses; there were no research analyses that were performed directly with breast reduction. In the study entitled “A Bibliometric Analysis of the 100 Most-cited Articles in Rhinoplasty” published in Plastic Reconstructive Surgery Glob Open journal in 2016, Sinha et al. [16] made an analysis of the most cited 100 publications about rhinoplasty. There are no bibliometric studies about breast reduction in the literature.

Findings showed that apart from surgery, breast reduction was used widely in the fields of oncology and obstetrics gynecology. An analysis of the number of publications and citations according to years showed that the number of publications and citations has increased rapidly in recent years; the number of studies on this issue seems to be increasing. Specifically, 1965 seems to be a critical year. It was found that the USA contributed to the literature most, followed by England and Turkey. Not only the developed countries but also developing countries, particularly Turkey and Brazil, were found to have contributions to the literature significantly higher than other developed countries. Most publications were found to be produced by Harvard University. The most active authors, according to the number of publications, were Drew PJ and Iwuagwu OC, and Schnur PL, and Hall-Findlay were the most active authors according to the number of citations. “A Simplified Vertical Reduction Mammaplasty: Shortening The Learning Curve” written by Hall-Findlay, EJ was the most important study in terms of the average number of citations per year. The second most important study in terms of the average number of citations per year was “Experience with Reduction Mammaplasty Combined with Breast Conservation Therapy in the Treatment of Breast Cancer” by Spear, SL; Pelletiere, CV; Wolfe, AJ; et al. An analysis of the figures obtained from the bibliometric analysis showed that in terms of both publication productivity and citation-co-citation, the most important journals in this field were Plastic and Reconstructive Surgery, Annals of Plastic Surgery, Aesthetic Plastic Surgery, and British Journal of Plastic Surgery. The study entitled “A reduction mammaplasty with the areola-nipple based on an inferior dermal pedicle” by Robbins TH published in Plastic Reconstructive Surgery journal in 1977 was the publication that received most co-citations. Body image, outcome, quality of life, smoking, complication, bilateral breast reduction, and self-esteem were the trend keywords that received the most citations. Keyword analysis enabled to reveal the titles mostly highlighted in breast reduction operations.

Conclusion

The rapid increase, specifically after 1995, indicates that the following years will involve more and more studies on the issue of breast reduction. The USA contributed to the literature about breast reduction most. Other remarkable journals were Plastic and Reconstructive Surgery, Annals of Plastic Surgery, Aesthetic Plastic Surgery and British Journal of Plastic Surgery. Although the literature was contributed by the developed countries, developing countries, specifically Turkey and Brazil, also had significantly high contributions to the literature.