10.24265/horizmed.2024.v24n3.02
Original Article
South American scientific research on the use of botulinum toxin in plastic surgery: a bibliometric analysis of articles indexed in Scopus
Oscar Darío Fuentes-Zamudio 10009-0005-1783-3214
Tatiana Caterine Martínez-Daza 2 0009-0009-2424-1638
Luz Amparo Ceballos-Madrid 3 0009-0008-4129-7361
Vanessa Becerra-Becerra 4 0009-0009-0399-3208
Sergio Antonio Barahona-Botache 5 0000-0003-3973-2324
Jacobo Senen Solano-Duran 6 0009-0006-5702-4179
Leydy Silvana Casanova-Chacon 7 0009-0005-7799-1396
Jhon Mike Romero-Madera 8 0000-0003-3153-7743
María Alejandra Angarita-Marzola 9 0009-0003-2075-2306
Yelson Alejandro Picón-Jaimes *10 0000-0002-7498-5346
1.Universidad de Antioquia, School of Medicine, Medellín, Colombia.
2.Universidad de Buenos Aires, Departamento de Cirugía Plástica (Department of Plastic Surgery), Buenos Aires, Argentina.
3.Universidad de Cartagena, School of Medicine, Cartagena, Colombia.
4.Universidad Industrial de Santander, School of Medicine, Bucaramanga, Colombia.
5.Universidad Surcolombiana, School of Medicine, Neiva, Colombia.
6.Corporación Universitaria Remington, School of Medicine, Medellín, Colombia.
7.Fundación Universitaria San Martín, School of Medicine, Pasto, Colombia.
8.Universidad del Sinú, School of Medicine, Montería, Colombia.
9.Universidad Libre, School of Medicine, Barranquilla, Colombia.
10.Universidad Ramon Llull, School of Health Sciences Blanquerna, Barcelona, Spain.
a. Primary care physician
b. Master’s degree in Epidemiology and Public Health
c. PhD in Health, Welfare and Bioethics
ABSTRACT
Objective: To analyze the scientific evolution of the use of botulinum toxin in plastic surgery in Latin America. Materials and methods: A cross-sectional bibliometric study was conducted using Scopus as the data source. Visual and bibliometric analyses were performed, and metrics were generated to evaluate the evolution, general characteristics and impact of the Latin American evidence on the use of botulinum toxin in plastic surgery. The bibliometrix R-package was utilized for this analysis.
Results: The study included 34 papers published between 2002 and 2023, out of which 52.9 % (n = 18) were original articles, while 44.1 % (n = 15) were review articles. International collaboration was identified in 32.3 % of the cases. The four most prolific authors were from Colombia and Brazil, each having published only two papers. Brazil (n = 20) was the most prolific country, followed by Chile (n = 5), Argentina (n = 4) and Colombia (n = 4). Regarding research trends, quality of life, dermal fillers, hyaluronic acid and wrinkles were the subtopics most related to the use of botulinum toxin in plastic surgery in Latin America. There were basically five associated research lines related to symptoms and aesthetic procedures, cosmetic complications and quality of life. The level of development of the topics was largely driven by the aesthetic interventions. A multiple correspondence analysis based on authors’ keywords revealed that patient follow-up, cohort studies, risk assessment, outcome evaluation, rejuvenation and adults were elements that primarily complemented the base subtopics.
Conclusions: Slow growth with low production and impact has been identified in Latin American research on the use of botulinum toxin in plastic surgery over the last 20 years. This research has focused on clinical studies related to clinical outcome assessment, quality of life and aesthetic techniques. Brazil leads research in the region and maintains a strong network of intercontinental collaboration.
Keywords: Botulinum Toxins; Surgery, Plastic; Research; Publications; Latin America. (Source: MeSH NLM)
INTRODUCTION
Over time, advancements in research and technology within plastic surgery have expanded the application of techniques originally confined to aesthetic procedures (1). The novel pharmacological mechanisms of certain drugs and the cellular properties of specific tissues have made it possible to derive additional benefits from traditional techniques (2,3). One notable example is botulinum toxin, commonly known as Botox. Typically, Botox was used exclusively to treat wrinkles and lines on the face and other areas of the body. However, its application in other medical interventions, such as direct injection into muscle tissue during reconstructive and plastic surgeries, has demonstrated certain benefits, including reduced recovery time and improved outcomes (4).
As research and innovation in neurotoxins continue to evolve, they may offer solutions to longstanding challenges in medicine (5,8). However, no comprehensive study has yet examined the diversity, trends or research patterns concerning botulinum toxin. This gap is particularly evident in regions like Latin America, where the scientific progress of this topic remains unexplored. In order to provide a novel and updated view of the historical gaps and trends in research on the use of botulinum toxin, this study aimed to analyze the scientific development and trends in botulinum toxin research within the context of plastic surgery in Latin America.
MATERIALS AND METHODS
Study design and population
This bibliometric study utilized the Scopus database as its primary source. The selection of this database and citation index was based on prior discussions highlighting its advantages (9,10). Notably, Scopus houses the world’s largest collection of peer-reviewed literature.
Variables and measurements
A search strategy using Medical Subject Headings (MeSH) terms was designed and structured to identify publications related to the use of botulinum toxin in plastic surgery. Following a pilot test, the final search query was as follows: TITLE-ABS-KEY (“Botulinum Toxin”) OR TITLE-ABS-KEY (“Botulinum Neurotoxins”) OR TITLE-ABS-KEY (“Clostridium Botulinum Toxins”) OR TITLE-ABS-KEY (“Botulinum Neurotoxin”) OR TITLE-ABS-KEY (“Botulin”) AND TITLE-ABS-KEY-AUTH (“Plastic Surgery Procedure”) OR TITLE-ABS-KEY-AUTH (“Plastic Surgical Procedure”) OR TITLE-ABS-KEY-AUTH (“Esthetic Surgical Procedure”) OR TITLE-ABS-KEY-AUTH (“Esthetic Reconstructive Surgical Procedures”) OR TITLE-ABS-KEY-AUTH (“Reconstructive Surgical Procedure”) OR TITLE-ABS-KEY-AUTH (“Cosmetic Surgical Procedure”) OR TITLE-ABS-KEY-AUTH (“Cosmetic Reconstructive Surgery”) OR TITLE-ABS-KEY-AUTH (“Cosmetic Reconstructive Surgical Procedures”) OR TITLE-ABS-KEY-AUTH (“Plastic Surgery”) AND AFFILCOUNTRY (Antigua AND Barbuda) OR AFFILCOUNTRY (Argentina) OR AFFILCOUNTRY (Bahamas) OR AFFILCOUNTRY (Barbados) OR AFFILCOUNTRY (Belize) OR AFFILCOUNTRY (Bolivia) OR AFFILCOUNTRY (Brazil) OR AFFILCOUNTRY (Chile) OR AFFILCOUNTRY (Colombia) OR AFFILCOUNTRY (Costa AND Rica) OR AFFILCOUNTRY (Cuba) OR AFFILCOUNTRY (Dominicana) OR AFFILCOUNTRY
(Ecuador) OR AFFILCOUNTRY (El AND Salvador) OR AFFILCOUNTRY (Grenada) OR AFFILCOUNTRY (Guatemala) OR AFFILCOUNTRY (Guyana) OR AFFILCOUNTRY (Haiti) OR AFFILCOUNTRY (Honduras) OR AFFILCOUNTRY (Jamaica) OR AFFILCOUNTRY (Mexico) OR AFFILCOUNTRY (Nicaragua) OR AFFILCOUNTRY (Panama) OR AFFILCOUNTRY (Paraguay) OR AFFILCOUNTRY (Peru) OR AFFILCOUNTRY (Dominican AND Republic) OR AFFILCOUNTRY (Saint AND Lucia) OR AFFILCOUNTRY (Suriname) OR AFFILCOUNTRY (Trinidad AND Tobago) OR AFFILCOUNTRY (Uruguay) OR AFFILCOUNTRY( Venezuela).
The inclusion criteria consisted of peer-reviewed papers published in scientific journals with an explicit focus on the use of botulinum toxin in plastic surgery. Excluded materials comprised conference abstracts, errata, books, book chapters, among others, which did not follow the standard peer-review process. The search was conducted on January 30, 2024, with results filtered using the tags “humans” and “journals.” Due to the historical nature of the analysis, no specific publication time frame was considered.
Data on citation domains, bibliographic information, abstracts and keywords were exported in CSV format for manual review and standardization using Microsoft Excel 2016. Four authors independently reviewed the data for this study, removing unrelated papers based on their titles, abstracts and keywords. To ensure consistency, this review process was repeated collaboratively to resolve any discrepancies. The papers were categorized as follows: original articles (studies employing observational or experimental designs, including primary data or data reassessment), review articles (narrative reviews, systematic reviews with or without meta-analysis, umbrella reviews and exploratory reviews), case reports (single-case reports or case series) and correspondences (letters to the editor, commentaries, editorials and other brief formats sharing similar structure and intent).
A descriptive analysis and characterization of the scientific production was conducted. Metrics such as the h-index, g-index and m-index were used to measure the impact of authors, institutions and countries. Bibliometric studies have referenced definitions and specifications for the use of these metrics (11). Frequencies and percentages were calculated using Microsoft Excel 2016.
Statistical analysis
A bibliometric and visual analysis was performed to assess the evolution, general characteristics and impact of Latin American research on botulinum toxin in plastic surgery. This analysis utilized the bibliometrix R-package (version 4.3.1) to calculate quantitative scientometric indicators and generate data visualizations (12). Synonyms, errors, plurals and variations were standardized through a thesaurus to ensure consistency across keywords, authors and institutions.
Ethical considerations
This study did not require the approval of an ethics committee, as it did not involve human subjects, biological models or the use of medical records.
RESULTS
The study included 34 papers published between 2002 and 2023 based on the inclusion and exclusion criteria. Of these, 52.9 % (n = 18) were original articles, while 44.1 % (n = 15) were review articles. International collaboration was identified in 32.3 % of the cases, with an average article age of approximately 10 years and an annual production growth rate of 3.3 % (Table 1). A total of 103 authors were involved, out of whom 95.1 % had published only one article, in accordance with Lotka’s Law. Since 2002, scientific production has shown fluctuating growth, with 2013 being the most prolific year, producing five articles. A similar pattern was observed in citation trends, although a noticeable decline has been observed since 2008 (Figures 1A and 1B).
Table 1. Initial characteristics of Latin American research on the use of botulinum toxin in plastic surgery (N = 34)
|
|
n |
% |
|
Type of article |
|
|
|
Original article |
18 |
52.9 |
|
Review article |
15 |
44.11 |
|
Correspondence* |
1 |
2.99 |
|
Study design |
|
|
|
Case series |
1 |
2.99 |
|
Narrative review |
15 |
44.11 |
|
Longitudinal |
4 |
11.96 |
|
Experimental |
1 |
2.99 |
|
Clinical trial |
1 |
2.99 |
|
Cross-sectional |
10 |
28.98 |
|
Case report |
1 |
2.99 |
|
Letter to the editor |
1 |
2.99 |
|
Authors |
|
|
|
Authorships |
103 |
− |
|
Authors with single-author articles (N = 103) |
4 |
3.88 |
|
Collaboration |
|
|
|
Articles with a single author |
4 |
− |
|
Co-authorships per article (average) |
3.2 |
− |
|
International co-authorship |
− |
32.3 |
|
Keywords |
127 |
− |
|
Journals |
23 |
− |
|
Average article age (years) |
9.94 |
− |
|
Average citations per article |
17.7 |
− |
|
Annual growth |
− |
3.36 |
*Includes letters to the editor, editorials, commentaries, etc.
Figure 1. Evolution of Latin American research on the use of botulinum toxin in plastic surgery. A. Annual scientific production from 2002 to 2023. B. Average number of citations received per article per year.
The analysis of the scientific development of this topic revealed that the four most prolific authors were from Colombia (Roxana Cobo) and Brazil (Marcus Castro Ferreira, Alessandra Salles and George Kroumpouzos), each having published only two papers. Authors from other countries have contributed only one paper. These authors exhibited low impact metrics, primarily due to the limited number of publications. At the institutional level, the Universidade de São Paulo (Brazil) was the most prolific in the region, with a total of six papers, followed by the Universidad de Chile (Chile) with three. Brazil (n = 20) was the most prolific country, followed by Chile (n = 5), Argentina (n = 4) and Colombia (n = 4) (Table 2).
Table 2. Metrics of affiliations and most prolific Latin American countries in research on the use of botulinum toxin in plastic surgery
|
Affiliation |
Papers published over time
|
Total articles
|
h-index |
Country |
|||
|
|
2002-2006 |
2007-2011 |
2012-2016 |
2017-2023 |
|
|
|
|
Universidade de São Paulo |
2 |
2 |
0 |
2 |
6 |
5 |
Brazil |
|
Universidad de Chile |
0 |
3 |
0 |
0 |
3 |
3 |
Chile |
|
Country |
Papers published over time
|
Total articles
|
h-index
|
||||
|
|
2002-2006 |
2007-2011 |
2012-2016 |
2017-2023 |
|
|
|
|
Brazil |
3 |
4 |
4 |
9 |
20 |
9
|
|
|
Chile |
0 |
1 |
2 |
2 |
5 |
3
|
|
|
Argentina |
0 |
2 |
2 |
0 |
4 |
3
|
|
|
Colombia |
0 |
2 |
2 |
0 |
4 |
3 |
|
*Article production was counted individually, meaning that a paper could have been counted multiple times depending on the level of international collaboration.
In terms of journal characterization, Aesthetic Plastic Surgery has published the highest number of articles (n = 5) and accounts for the majority of the citations (152). However, due to the relatively low production volume, the overall impact has remained modest, with the Journal of Cosmetic Dermatology holding the top position (h-index = 4) (Figure 2A - 2F).
Figure 2. Frequency and impact of journals derived from Latin American publications on the use of botulinum toxin in plastic surgery. A. Journals with the highest number of publications. B. Journals with the highest h-index. C. Journals with the highest g-index. D. Journals with the highest m-index. E. Journals with the highest number of citations. . Annual production of the most prolific journals over time.
Regarding research trends, quality of life, dermal fillers, hyaluronic acid and wrinkles were the subtopics most related to the use of botulinum toxin in plastic surgery in Latin America (Figure 3A). There were basically five associated research lines related to symptoms and aesthetic procedures, cosmetic complications and quality of life (Figures 3B and 3C). The level of development of the topics were largely driven by the aesthetic interventions (Figure 3D). A multiple correspondence analysis based on authors’ keywords revealed that patient follow-up, cohort studies, risk assessment, outcome evaluation, rejuvenation and adults were elements that primarily complemented these subtopics (Figure 3E).
Figure 3. Trends, co-occurrence and level of development of topics on the use of botulinum toxin in plastic surgery. A. Word cloud of the most frequently used keywords. B. Co-occurrence of keywords. C. Co-occurrence of titles. D. Thematic map showing the level of development of the topics under study. E. Multiple correspondence analysis based on keywords.
A regional research collaboration network led by Brazil was identified, with notable involvement from the United States, as well as countries in Europe and Asia. Additionally, Colombia, Argentina and Chile stood out for their strong collaborations with other nations within the region (Figure 4).
Figure 4. Collaboration network between countries related to Latin American research on the use of botulinum toxin in plastic surgery.
The papers from the region with the highest number of citations include: 1) “The minimal approach: an innovation in facial cosmetic procedures” (published in Aesthetic Plastic Surgery, 2004, with 70 citations, DOI: 10.1007/ s00266-004-0037-1); 2) “Elderly skin and its rejuvenation: products and procedures for aging skin” (published in Journal of Cosmetic Dermatology, 2007, with 59 citations, DOI: 10.1111/j.1473-2165.2007.00289.x); and
3) “Botulinum toxin injection in long-standing facial paralysis patients: improvement of facial symmetry observed up to 6 months” (published in Aesthetic Plastic Surgery, 2009, with 51 citations, DOI: 10.1007/s00266-009-9337-9).
To assess the global relevance of Latin American research on the use of botulinum toxin in plastic surgery, filters by country were removed, resulting in a total of 678 papers. The most prolific countries in global research were the United States (n = 302), the United Kingdom (n = 47) and Germany (n = 40). Latin American scientific production accounts for only 5.01 % of the global production.
DISCUSSION
This study provided, for the first time, an overview of Latin American research on the use of botulinum toxin in plastic surgery, a tool that has gained increasing relevance in surgical and aesthetic practices, not only in plastic surgery but also in other specialties that complement their results with this tool. With advancements in biomedical and surgical sciences, innovative techniques have been developed for the application of botulinum toxin, not only for skin treatments but also in other organs, promoting regeneration and enhancing organic plasticity (13,18).
The findings of this study reveal that, over the past 20 years, the growth of Latin American research on the use of botulinum toxin in plastic surgery has been slow, characterized by a low frequency of publications and citations. However, more than 30 % of these publications involve international collaboration. To understand the possible causes of this slow growth, it is crucial to conduct a meta-research analysis that evaluates determinants such as research quality and biases (19,23), lack of funding or strong collaborations, deficits in infrastructure, limited access to high-quality databases, and variables related to the timing and training of researchers in plastic surgery. It is important to note that, despite recent advancements in the discovery and testing of biomarkers for outcomes and prognoses in plastic surgery and related specialties, a predominant pattern of clinical research was observed (18).
In comparison with other surgical specialties (9), the impact and frequency of publication in plastic surgery are notably low. This predominance of clinical evidence also highlights the absence of robust research lines and researchers focused on basic, translational and applied sciences in Latin American plastic surgery. Brazil leads research in the region, as is the case in other medical specialties (24). However, it is noteworthy that no studies have evaluated the usefulness of techniques or tools in plastic surgery from a perspective other than clinical research.
A novel finding in this study is the identification of emerging research lines and trends. Plastic surgery has traditionally been associated with cosmetic surgery, despite its much broader scope. The frequent appearance of terms such as “quality of life” and “hyaluronic acid” in these publications can be attributed to their strong connection to aesthetic interventions. These results should be used to reassess the research needs in plastic surgery within the region and to design a research agenda aligned with the health needs and priorities of the specialty (25, 26). Furthermore, they can help identify gaps in existing evidence and facilitate the design of more complex studies that address higher-level research problems (27,29). For instance, the low frequency of experimental studies suggests that efforts could be made to strengthen this area of research.
Strengthening national, regional and international interinstitutional collaboration could address the inherent limitations of the region, as described earlier (30, 31). Unlike Brazil, few other Latin American countries engage in significant collaborative efforts, which may explain why Latin American production represents only 5 % of global research on botulinum toxin in plastic surgery. Therefore, while Latin American research has grown gradually, it has not kept pace with the global trend.
One limitation of this study is that only a single database, Scopus, was used. While Scopus indexes a larger number of Latin American publications compared to PubMed and Web of Science, there is an inherent bias in the metadata recorded in the database. However, the process of standardization and manual review minimizes the margin of error.
In conclusion, slow growth with low production and impact has been identified in Latin American research on the use of botulinum toxin in plastic surgery over the last
20 years. This research has focused on clinical studies related to clinical outcome assessment, quality of life and aesthetic techniques. Brazil leads research in the region and maintains a strong network of intercontinental collaboration.
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Author contributions: ODFZ, TCMD, LACM, VBB and SABB contributed equally to the original idea, study design, literature review and analysis, draft writing, manuscript writing, and approval of the final version. JSSD, LSCC, JMRM, MAAM and YAPJ were involved in the manuscript conception and design, data analysis and interpretation, manuscript writing and critical revision, and approval of the final version.
Funding sources: The article was funded by the authors.
Conflicts of interest: The authors declare no conflicts of interest.
*Corresponding author:
Yelson Alejandro Picón-Jaimes
Address: Fac Ciències Salut Blanquerna, Universidad Ramon Llul. Barcelona, España.
Telephone: +34 645 685 460
Email: colmedsurg.center@gmail.com
Reception date: April 22, 2024
Evaluation date: May 29, 2024
Approval date: June 5, 2024