As is true in many fields of medicine, craniofacial surgery is a rapidly evolving field across the globe, with ever-growing academic opportunities and insights. The rise of online journals and publications has allowed for a dynamic and rapid spread of knowledge. It is easier than ever to find research from around the globe pertaining to any topic of interest.1 Most recently, the proliferation of open access publishing has greatly increased the availability of scientific knowledge to readers who cannot afford access to journals with paid subscription models. While these journals are sometimes criticized for their significant publication fees and lax review processes, they provide a further means of disseminating scientific research to the global community.
The advent of online journals and publications allows for enhanced consolidation of knowledge into a single, easily accessible location and has expanded horizons for collaboration worldwide. Globalization of knowledge has become necessary, not only to create a shared, up-to-date understanding of the latest evidence within the specialty, but also to ensure that new research is tackling questions not previously addressed by researchers in other countries.2 The benefits of global academic collaboration include not only a shared expertise in the specialty, but also the further advancement of patient care and outcomes.3
While new advances in craniofacial surgery can be shared through a variety of media, the Journal of Craniofacial Surgery (JCS) is a highly regarded journal in the field, with monthly publications spanning topics from pediatric plastic surgery and craniomaxillofacial surgery. Many journals, including the JCS, have made it a goal to represent global innovation in the field,4 and welcome manuscript submissions from authors in countries other than the journal's own country of origin. Past JCS publications have acknowledged the limitless possibilities of international collaboration across craniofacial and plastic surgeons, mentioning potential outcomes such as efficient dissemination of contributions to the specialty, improving overall quality of the specialty, and leveraging global partnerships to make products and materials more affordable.5 Other studies have discussed specific examples of prior global collaboration success stories in subspecialized topics of interest such as Apert syndrome and orbital hypertelorism.6,7
There is currently a lack of objective measurement of worldwide participation in craniofacial research. Although the field strives to broadly represent global research and innovation, there are no studies that have evaluated the success in achieving this goal. This study aims to address this gap through a bibliometric analysis of all JCS publications between 2010 and 2019. By evaluating the global contributions of research through continent, country, and state-level analyses, this study highlights the trends and factors affecting the globalization of craniofacial surgery research.
MATERIALS AND METHODS
All publications in the JCS from January 1, 2010 through December 31, 2019 were cataloged in PubMed. The date of publication, article title, and authors were then extracted using PubMed2XL.8 A country was assigned to each publication based on the primary author's affiliation. In cases where the primary author's country of origin was not immediately available, the original paper was retrieved from the JCS website. In instances of co-first author publications, the first listed author and the affiliated address were still used. In instances where the first author had 2 different countries listed for their correspondence, a decision was made to determine where the majority of the work in the paper was conducted and the total incidence of this was less than 5 articles. U.S. state data was produced by identifying the primary author's affiliations for all U.S. based publications.
The data were also stratified by country income. Using World Bank country income level,9 data was divided into high income (HI), upper-middle income (UMI), lower-middle income, and low-income.
All data were entered into Excel, which was also utilized to make the graphs and supplemental tables.
In total, there were 8147 articles produced over the decade with 2015 being the year of greatest production with 998 articles (Supplementary Digital Content, Table 1, http://links.lww.com/SCS/C334). There was an increase in production from Asia and North America that year, which contributed to the increased volume (Supplementary Digital Content, Tables 2 and 3, http://links.lww.com/SCS/C334). From the start to the end of the decade, the journal increased production by 1.9-fold. Over the course of the decade, 78 unique countries contributed publications to the journal.
There was increased representation from all country income levels over the course of the decade. The greatest overall production came from HI countries (4247, 52.1%), which as a collective published more articles in 2019 than any other year in the decade (524) (Supplementary Digital Content, Table 4, http://links.lww.com/SCS/C334). Upper-middle income countries produced the second-most (3599, 44.1%), and had their peak in publications in 2015 (490). The journal's peak production year was 2015, indicating that UMI countries may be involved in the peak. Lower-middle income countries had a steady increase in representation, with their peak contributions occurring in 2019.
Analyses by Continent
Asia contributed the most to the journal across the decade, with 55.8% (4553) of the total articles (Fig. 1). The number of publications from Asia has a general upward trend throughout the decade, with peak in production in 2015 (595). Twenty-six unique countries within Asia contributed to the journal over the decade. 2019 was the most diverse year, with 20 countries contributing publications.
The most productive Asian countries, in descending order, are Turkey (31%, 1424), China (26%, 1178), South Korea (23%, 1023), Japan (7%, 306), and India (4%, 197) (Fig. 2). Turkey was the greatest producer overall, responsible for 17.4% (1424) of the articles produced from all countries across the decade. Turkey's greatest year of production was 2015 (192). Turkey ended the decade with a 1.245-fold increase from the start of the decade, showing a general upward trend in production. China was the second-greatest producer amongst the Asian countries, with 2015 being their greatest year of production (200). They increased production 4.97-fold throughout the decade, which is the greatest positive change observed of any Asian country. South Korea was the third-greatest producer among Asian countries, with 2016 being their greatest year of production (129). They also showed a strongly positive trend in production over the decade, with a 1.88-fold overall increase.
North America was the second-highest producing continent globally, publishing 1506 articles in the decade (18.5% of total journal publications). Within North America, the top producing countries are the USA (1397), Canada (88), and Mexico (18). The greatest year of production for the continent was 2019 (231), but they did see a small increase in 2015 (194) consistent with the uptick experienced by many of the Asian countries. USA was the second-most productive country globally, behind Turkey.
Europe is the third-highest producing continent globally (1264). As a continent, Europe increased publications by 1.19-fold over the course of the decade. Additionally, it was the continent with the most diverse contributions, with 28 unique European countries publishing over the decade. The greatest producers within Europe, in descending order, are Italy (644), UK (110), Germany (68), France (64), and Spain (62). Italy and the UK are ranked among the top 10 global contributors to the journal. Italy's peak in publications occurred in 2013, and they ended the decade with an overall decrease in production (62 versus 53).
South America was the continent with the fourth-highest number of publications across the decade (684). 2018 was their greatest production year, with 96 articles published. Brazil was by far the most productive country within South America (606) and the sixth-most productive country globally. Brazil ended the decade with a decrease in production (44 versus 42) but had 3 years with >75 articles published. Colombia was the next-highest South American producer with 25 total articles across the decade, followed by Chile with 21 and Argentina with 20.
Africa was the fifth-most productive continent, producing 93 publications across the decade. Notably, Africa had the greatest increase as a percentage production over the decade compared to the other continents, rounding out the decade with an impressive 5-fold increase. The peak in production for Africa occurred in 2018, but the last 3 years of the decade had consistently high production numbers. Within Africa, the greatest contributors were Egypt (55), Nigeria (14), and South Africa (10).
Oceania produced 47 articles in the span of the decade, making it the sixth-most productive continent. 41 of the 47 articles were from Australia. Other contributing countries included New Zealand (5) and Papua New Guinea (1).
United States – State Analysis
Among the United States, Florida was the greatest contributor (156), and it should be noted the JCS office is in Florida (Fig. 3, Supplementary Digital Content, Table 5, http://links.lww.com/SCS/C334). Following Florida, notable contributors include New York (130), California (117), Massachusetts (112), and Pennsylvania (106).
The 5 top-producing countries in the JCS are Turkey, USA, China, South Korea, and Italy (Fig. 4). This significantly contrasts with the top contributors to the Aesthetic Surgery Journal (ASJ) in the past decade, which were USA, Brazil, UK, Turkey, and Canada, according to Moore et al.10 The same study also identified 49 unique countries publishing in the ASJ in the past decade, while our study found 78 countries publishing in the JCS. This suggests that the JCS is a more geographically diverse journal.10 Similarly, the JCS had a more diverse collection of countries contributing to their publications in the past decade compared to Plastic and Reconstructive Surgery (PRS) which had 54 countries despite the similar total output between the 2 journals in the past decade (8147 from the JCS versus 8689 from PRS) (unpublished data).11 The content published within these journals is different, which could help to explain these differences, however, they do have overlap and all fall within the category of being PRS journals.
Our study found that Asia is, by far, the continent with the highest number of publications in the JCS. It produced a staggering 55.8% of JCS publications in the decade, which provides strong evidence for what others have noted as an interest in increasing Asia's presence in the world of plastic and craniofacial surgery research.11–13 In addition, prior studies have noted that almost 5% of the population in Asia is affected by craniofacial deformities that require surgery for definitive treatment.14 This high volume of cases observed could certainly be a driver for increased research within the field. However, this does contrast with results found in a similar bibliometric study, which found Asia to be the 3rd highest contributor (behind Europe and North America) to research submitted to PRS in the past decade.11 It is possible that countries within Asia direct a greater volume of resources toward craniofacial medicine than other areas of plastic surgery commonly published on in PRS, such as hand, breast, and aesthetic topics. Turkey's large number of publications throughout the decade may be attributable to the notion that Turkish based authors are aware of an affinity of the JCS for foreign authors, which may cause an increase in manuscripts submitted to the JCS over other journals. Of note, China showed an impressive increase in the JCS publications during the past decade, increasing their output by approximately 5 times.
A similar trend in production was observed by Africa, which as a continent increased production of JCS publications approximately 5-fold from the start of the decade to the end. Nigeria in particular has experienced an increase in awareness of and focus on craniofacial surgeries in the past decade, in part due to a greater presence of international donor organizations, which could have contributed to the notable increase in craniofacial surgery research in that time period.15
Within the United States, the top-producing states of Florida, New York, California, Massachusetts, and Pennsylvania are home to both plastic surgery residency and craniofacial surgery fellowship programs, which likely contribute to the relatively large amount of craniofacial surgery publications coming from those states. This is supported by the fact that none of the 10 states with the lowest production in JCS over the past decade (Nevada, Vermont, New Mexico, South Dakota, Hawaii, South Carolina, Mississippi, Oregon, Arkansas, and New Hampshire) are home to a craniofacial surgery fellowship programs. It is important to note that many articles from Florida, where the JCS is based, were editorial features from the editor of the journal.
Unsurprisingly, the highest overall production came from HI countries, followed by UMI countries. This can likely be attributed to increased government and private funding for medical research as a whole, which would be relatively limited in countries with a less robust economy. This is similar to the pattern seen in PRS and the ASJ, as the majority of their publications in the last decade came from HI countries.10,11 However, there are exceptions to this general trend such as Australia and New Zealand, despite being HI countries, had a relatively low contribution to JCS.
Our study has multiple limitations. First, many of the publications in the JCS and other scientific journals list authors with affiliations in multiple countries. As discussed in the methods section, this was addressed by using the affiliations of the first-listed author and, if necessary, the country of origin for the majority of the authors. However, our quantified data were not able to represent the collaborative efforts of many of the publications. This can be problematic not only in terms of providing an accurate representation of the data as a whole, but also because prior work has shown that low-income countries are less frequently listed as first authors in publications completed in their own countries.16 Second, while the JCS is a prominent academic journal in the specialty, it is not the only one. Our analysis does not consider publications in other craniofacial journals, such as The Cleft Palate – Craniofacial Journal, Orthodontics & Craniofacial Research, The Journal of Oral Biology and Craniofacial Research, or other plastic/maxillofacial surgery journals with sections dedicated to craniofacial surgery research. Future bibliometric analyses could study the patterns of publication in additional journals for a more comprehensive view of global contribution to the field. Future studies should stratify results based on publication/study type, which would allow us to consider the amount of time and resources necessary to produce various types of publications.
Further work should investigate the barriers preventing certain HI and UMI countries such as Russia, Australia, and New Zealand from contributing more publications to the JCS. Additionally, it would be worthwhile to begin investigating factors that are common amongst top-producing countries, such as government funding programs, international teaching partnerships, prevalence of craniofacial disease, with the eventual goal of being able to make more educated recommendations for increasing craniofacial research in lesser producing countries.
The Journal of Craniofacial Surgery increased production by 1.9-fold from the start to the end of the decade and also increased number of countries contributing in a given year from 35 in 2010 to 55 in 2019, indicating a 1.6-fold growth in diversity in the past decade. Asia is the highest producing continent of craniofacial research with both Turkey and China leading the way in production. Within the United States, Florida, New York, and California were the most prevalent contributors to the journal. The Journal of Craniofacial Surgery has the most diverse representation of countries when compared to other top plastic and reconstructive journals, such as ASJ and PRS. Our study makes it clear that JCS has become more diverse and well-balanced in the past decade. The work that's been done to get to this point should be celebrated, and we look forward to seeing how this journal continues to grow in the upcoming decade, as well as how other journals follow suit in increasing their own diversity.
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