In recent years, social media have revolutionized the way we access information and communicate with one another. Social media encompass a range of Internet-based applications that allow users to communicate by means of messages, pictures, videos, and links. Among these, Twitter is the most popular microblogging website1,2 and is widely used among physicians.3
One of the difficulties in medicine today is keeping up with the vast amount of regularly published literature. Fraser and Dunstan4 illustrated this challenge well when they estimated that it would take a trainee in cardiology 11 years to read all articles currently related to echocardiography alone. A social media forum, such as Twitter, serves as a useful tool to quickly disseminate information that is available for easy review by a large and specific audience.5
Physicians and physician trainees use social media as frequently as the general population.6 Plastic surgeons are among those using social media for both professional and personal use.7 Several prominent plastic surgery journals have begun connecting with plastic surgeons, the academic community, and patients by means of their Twitter profiles.
On Twitter, users communicate through tweets, which are messages of 280 characters or less, which may include pictures, videos, and/or links. As of late 2017, Twitter had more than 330 million active users,8 and 500 million tweets are posted daily.9 Twitter allows the filtering of information based on one’s interests through the use of hashtags. A hashtag symbol is placed immediately preceding a word or phrase to group similar topics together. By searching a certain hashtag, one can identify all tweets related to a certain theme. Twitter also serves as a forum for daily discussion, particularly during academic conferences. This has been demonstrated at multiple global surgical conferences where Twitter has facilitated communication among attendees locally and abroad.10 Furthermore, Twitter has created a new format for academic journal clubs. An academic journal may tweet an article and allow discussion among its followers at any time, replacing the traditional one-encounter journal club meeting. Eysenbach11 proposed that Twitter activity may predict highly cited articles. It is unclear whether increased exposure on Twitter leads to more citations or whether the underlying qualities of the article itself lead to both more Twitter activity and more citations.11
The purpose of this study was to assess the use of Twitter by plastic surgery journals and the content of the tweets posted. Twitter may serve as a platform for quicker and easier access to information; thus, we hypothesize that there will be a positive association between the presence of a Twitter account and the impact factor of a plastic surgery journal.
We searched the top 12 journals in the domain of plastic surgery, as defined by impact factor, based on the Institute for Scientific Information’s Journal Citation Reports. This included the following journals: Plastic and Reconstructive Surgery; Annals of Plastic Surgery; Journal of Plastic, Reconstructive and Aesthetic Surgery; Clinics in Plastic Surgery; Aesthetic Plastic Surgery; Aesthetic Surgery Journal; The Cleft Palate-Craniofacial Journal; Journal of Craniofacial Surgery; Burns: Journal of the International Society for Burn Injuries; Journal of Hand Surgery (European Volume); Journal of Hand Surgery (American Volume); and Microsurgery.
All journals were searched on Twitter to identify the presence of a Twitter profile. For those with Twitter accounts, the following were recorded: the age of their Twitter profile, number of followers, number of tweets, and whether the journal’s website contained a link to their Twitter account or another form of social media (including Facebook, Instagram, LinkedIn, or YouTube). For all journals with Twitter accounts, Facebook and Instagram were also searched to identify the presence of accounts for these journals. If present, the numbers of followers on Facebook and Instagram were recorded in addition to the number of Instagram posts (the number of Facebook posts is not available online).
All tweets from May to July of 2017 for all journals with Twitter profiles were accessed, and the level of evidence of each article linked in these tweets was recorded, according to the American Society of Plastic Surgeons’ rating scale (i.e., I includes high-quality, multicenter or single center, randomized controlled trials with adequate power, or systematic review of these studies; II includes lesser-quality, randomized controlled trials, prospective cohort or comparative study or systematic review of these studies; III includes retrospective cohort or comparative study, case control study or systematic review of these studies; IV includes case series with pretest/posttest or only posttest; and V includes expert opinion developed by means of consensus process, case report or clinical example, or evidence-based physiology).12 Articles that did not fall under any of the five levels of evidence were categorized as miscellaneous.
Impact factor information was recorded for all journals as of September of 2017. For those journals with Twitter profiles, impact factor at the time of Twitter account creation was also recorded.
The Klout score was used as a means of measuring social media influence of the journals’ Twitter profiles. The Klout score assesses the influential effect of a social media platform on its audience by taking into account over 3600 features related to markers of influence. A score between 1 and 100 is created, where a higher score indicates a higher influence.13 An Internet extension was downloaded for the Google Chrome Internet browser. This allowed for the identification of Klout scores when Twitter profiles were visited. The Klout score for all plastic surgery journals with Twitter accounts was recorded on September 14, 2017.
Univariate descriptive analyses were performed for all variables. Pearson correlation and t test were performed to assess relationships among variables. IBM SPSS Version 24 (IBM Corp., Armonk, N.Y.) was used for all analyses. A value of p ≤ 0.05 was considered significant.
Of the 12 journals examined in the study, six had a dedicated Twitter profile (50 percent) (Table 1). The mean impact factor for all 12 journals and impact factor at the time of joining Twitter was 1.85 ± 0.84 (range, 0.49 to 3.78) and 1.71 ± 0.64 (range, 0.82 to 2.74), respectively. Plastic and Reconstructive Surgery was the first to join Twitter and has the highest number of both followers and tweets. The mean age of Twitter profile was 4.72 ± 2.39 years (range, 1.75 to 8.17 years). The mean number of followers and number of tweets were 3889.33 ± 5252.42 (range, 94 to 13,000) and 4729.17 ± 5829.09 (range, 691 to 16,200), respectively. The mean Klout score was 42.8 ± 15.38 (range, 19 to 61) (Table 1). The top social media–influencing journal in plastic surgery was Plastic and Reconstructive Surgery (Klout score, 61). This was followed by Aesthetic Surgery Journal (Klout score, 54) and Journal of Hand Surgery (American and European Volumes) (tied, with a Klout score of 46) (Table 1).
The presence of a Twitter profile was not associated with a higher impact factor for the journal (mean ± SD, 2.08 ± 1.02 versus 1.62 ± 0.64; p = 0.21). There was no correlation between the number of followers and the impact factor (p = 0.064) or between the number of tweets and the number of followers (p = 0.31). There was a correlation between the number of followers and the age of the profile (p = 0.045), and journals with some other form of social media (e.g., Facebook, Instagram, LinkedIn, or YouTube) were more likely to have a Twitter profile (p = 0.031). The Klout score was also correlated with impact factor (p = 0.002).
Since joining Twitter, five of the six journals (83.3 percent) with Twitter profiles experienced increases in their impact factor. Between 2015 and 2017, journals with Twitter profiles increased their mean impact factor by 15.1 percent (from 1.77 to 2.08), compared with only 8.6 percent (from 1.48 to 1.62) for journals without Twitter profiles. This difference was statistically significant (p = 0.03).
Of the six journals that had Twitter profiles, all six had links on their websites to their respective profiles, and five had links to another form of social media profile. Of these five journals with links to other social media profiles, five were linked to Facebook profiles, two to LinkedIn profiles, one to a YouTube profile, and one to an Instagram profile. The journal with a Twitter profile but without any other sort of social media profile—Journal of Hand Surgery (European Volume)—had a link to their publisher’s social media, but not their own. No journal without a Twitter profile had any other type of social media profile.
Of the five journals that experienced an increase in impact factor since the time they joined Twitter, four also have a Facebook account and two also have Instagram accounts (Table 2). Those with Facebook have more followers on Facebook than Twitter in all cases, but for those with Instagram, there are more followers on Twitter than Instagram in all cases. Of the journals with a Facebook account, one journal had zero posts on their Facebook page (Annals of Plastic Surgery). In the case of the Journal of Hand Surgery (American Volume), which did not have an increase in impact factor since joining Twitter, this journal has both Facebook and Instagram accounts. The number of posts on Facebook is not included given that this information is not listed online (Table 2).
Over a 3-month period from May to July of 2017, the mean number of tweets linked to articles was 59 ± 71.5 (range, 13 to 187) (Table 3). Of these 295 articles, three were Level I evidence-based articles, 30 were Level II, 47 were Level III, 66 were Level IV, 112 were Level V, and 37 were miscellaneous (Table 3). Thus, the majority (38 percent) (Fig. 1) were level V evidence-based articles. For the two most active Twitter profiles, Plastic and Reconstructive Surgery tweeted 183 articles and Journal of Hand Surgery (American Volume) tweeted 57 articles. The total number of tweets linked to articles was not correlated with impact factor (p = 0.074), the age of Twitter profile in years (p = 0.083), number of followers (p = 0.065), or Klout score (p = 0.48). The total number of tweets linked to articles was correlated with the overall number of tweets (p = 0.049).
To the best of our knowledge, this is the first study that explores whether an association exists between having a social media presence and the impact factor of plastic surgery journals. We found that the presence of a Twitter account did not directly correlate with a higher impact factor for the journal. Nevertheless, five of the six journals with a Twitter account did experience an increase in their impact factor since joining Twitter. Interestingly, over the past 2 years, there was also a significantly higher increase in the impact factor for journals with a Twitter account compared with those without.
There are several reasons why we chose to explore the use of Twitter instead of other social media networks. The objective of this study was to explore how social media engagement affects a journal’s readership/impact factor. Twitter is one of the first platforms14 to engage plastic surgeons in the academic content of journals and thus has the longest track record/data.15
Furthermore, Facebook and Instagram use multimedia content such as videos and photographs more than Twitter and have more patient-directed content (e.g., before-and-after photographs), rather than academic content. Only very recently have certain journals begun using certain aspects of those platforms to promote academic video content and host journal clubs. Once those platforms are further developed, they would be an interesting avenue to explore. Therefore, although Facebook and Instagram have the most general public users, Twitter is the only social media outlet that is used by almost all the journals to promote academic content. It has the largest number of academic journals as users, which is the demographic we particularly targeted in our study (not the general public).
Based on Klout score, the top journals relating to social media influence were Plastic and Reconstructive Surgery, Aesthetic Surgery Journal, Journal of Hand Surgery (American Volume), and Journal of Hand Surgery (European Volume). Of those journals with Twitter accounts, these journals had the highest impact factors overall. Klout score was significantly correlated with impact factor. This is in contrast to similar studies in other medical specialties, where Klout score was not correlated with impact factor.16,17 Our findings do not prove causation between having a strong social media influence on Twitter and impact factor. However, the presence of a Twitter profile may improve an article’s exposure. Theoretically, this may then lead to more citations and subsequently an increase in impact factor. Nevertheless, impact factor changes depend on a number of other factors; these include, but are not limited to the level of the editorial board and reviewers, the type and quality of the articles published, and the language used.18
We recognize that other social media forums may have played a role in the augmentation of journal impact factors throughout the time that they have been active on Twitter. We found that, of those journals whose impact factor increased, 60 percent (three of five, not including Annals of Plastic Surgery, whose Facebook page had zero posts) were also on Facebook and 40 percent (two of five) were on Instagram. Of those with Instagram, there was a stark difference between the number of followers and tweets on Twitter, compared to Instagram, with substantially higher values for both on Twitter. However, for all journals on Facebook, there were more followers on Facebook, compared to Twitter. As described previously, Twitter tends to be more used for delivering academic content, whereas Facebook has more interaction with patients; thus, this should be taken into account when assessing for influence on impact factor. In addition, it should be noted that the data, including the number of followers and tweets, on Twitter were collected in 2017, whereas the information on the number of followers and posts on Facebook and Instagram was collected in 2018. Considering that these values tend to increase over time, this is likely undervaluing Twitter’s activity when compared to the other two platforms.
This study demonstrates that social media may be underused by plastic surgery journals. Only 50 percent of the included journals had Twitter accounts, and just over 40 percent were also active on other forms of social media, such as Facebook. There are several factors that can influence the popularity of a journal’s Twitter account to attract more followers and thus attract more readers of the journal’s articles. These include, but are not limited to, being active in tweeting useful materials, using multimedia in the form of videos/podcasts, using this platform to create interactive sessions (e.g., PRS Grand Rounds) and using posts that target a wide audience.
All journals with recent tweets on their profile had posted about scientific articles. The tweets included the titles of the articles, thus allowing followers to filter out topics of interest. They also consistently included links to abstracts and full articles for quick access. Over 85 percent of these articles fell into categories of one to five levels of evidence, demonstrating the ability to share evidence-based medicine on Twitter. It was found that Level I evidence articles were the least tweeted, whereas Level V evidence articles were the most tweeted about on Twitter. We believe this is likely because of a variation that exists within the literature. Generally, the total number of studies with a high level of evidence (I/II) is low in the plastic surgery literature.19 This could explain the low number of tweeted articles with Level I evidence among plastic surgery journals that are active on Twitter. It is also noteworthy that the journals that publish studies with the highest level of evidence (i.e., Plastic and Reconstructive Surgery) still tweeted about articles with the highest level of evidence. Therefore, we think that Level I studies are still suitable for a social media audience, but the lack of these studies in our literature is probably the main cause for why they are lacking on social networks.
As information has become more ubiquitous, keeping abreast of the latest significant developments in the medical field has become even more challenging.4 Busy surgeons might find it difficult to track all plastic surgery journals and keep up to date with the literature. An easily accessible Internet tool such as Twitter may be useful in providing a more efficient and convenient way to filter through and access articles.20 The ability to access Twitter through mobile devices such as cell phones and tablets further adds to its ease of use and convenience. Twitter and other forms of social media also offer the opportunity for global interaction between the authors of studies and readers by means of the tagging of author profiles and use of online journal clubs.
Another recent innovation to provide information in a more digestible format is the use of visual and video abstracts on Twitter. Recently, Annals of Surgery has started accepting visual abstracts for their publications. Previous studies have demonstrated how video-based materials are more effective than written materials in educating patients.21,22 Thus, by using visual tools on Twitter, this may serve to expand the role of scientific journals, from a medium that solely educates physicians, to a platform for educating the public as well.
Our study was limited by the fact that we reviewed all tweets during a specific timeframe. This could have had an impact on the results pertaining to the types of articles tweeted, because the content of tweets can change on a daily basis.
Our study is limited to only 12 journals. However, we believe that these high-impact journals within each subspeciality of plastic surgery represent the influential body of the literature.
Although social media have enabled journals to disseminate scientific articles to a wider audience, they also have the potential to be abused. Any user may post on the website, with little regulation of the content shared. Thus, guidelines have been developed by professional societies to ensure the best use of social media platforms.23
When properly used, social media offer many exciting possibilities for educating physicians and the public. Their wide reach and accessible format have made information easier to share than ever before. Despite this, there are many journals and physicians who have not incorporated social media as a tool for the exchange of knowledge. Exploring the barriers that have prevented some physicians from embracing social media may provide an avenue for future studies.
3. Chretien KC, Azar J, Kind T. Physicians on Twitter. JAMA 2011;305:566–568.
4. Fraser AG, Dunstan FD. On the impossibility of being expert. BMJ 2010;341:c6815.
5. Matta R, Doiron C, Leveridge MJ. The dramatic increase in social media in urology. J Urol. 2014;192:494–498.
6. Bosslet GT, Torke AM, Hickman SE, Terry CL, Helft PR. The patient-doctor relationship and online social networks: Results of a national survey. J Gen Intern Med. 2011;26:1168–1174.
7. Chang JB, Woo SL, Cederna PS. Worth the “likes”? The use of Facebook among plastic surgeons and its perceived impact. Plast Reconstr Surg. 2015;135:909e–918e.
10. Chung A, Woo H. Twitter in urology and other surgical specialties at global conferences. ANZ J Surg. 2016;86:224–227.
11. Eysenbach G. Can tweets predict citations? Metrics of social impact based on Twitter and correlation with traditional metrics of scientific impact. J Med Internet Res. 2011;13:e123.
12. Sullivan D, Chung KC, Eaves FF III, Rohrich RJ. The level of evidence pyramid: Indicating levels of evidence in Plastic and Reconstructive Surgery
articles. Plast Reconstr Surg. 2011;128:311–314.
13. Rao A, Spasojevic N, Li Z, Dsouza T. Klout score: Measuring influence across multiple social networks. Paper presented at: 2015 IEEE International Conference on Big Data (Big Data); October 29–November 1, 2015; Santa Clara, Calif.
14. Branford OA, Kamali P, Rohrich RJ, et al. #PlasticSurgery. Plast Reconstr Surg. 2016;138:1354–1365.
15. Kalandar A, Al-Youha S, Al-Halabi B, Williams J. What does the public think? Examining plastic surgery perceptions through the Twitterverse. Plast Reconstr Surg. 2018;142:265–274.
16. Kelly BS, Redmond CE, Nason GJ, Healy GM, Horgan NA, Heffernan EJ. The use of Twitter by radiology journals: An analysis of Twitter activity and impact factor. J Am Coll Radiol. 2016;13:1391–1396.
17. Nason GJ, Kelly FO, Kelly ME, et al. The emerging use of Twitter by urological journals. BJU Int. 2015;115:486–490.
18. Rodrigues MA, Tedesco AC, Nahas FX, Ferreira LM. Journal impact factor versus the evidence level of articles published in plastic surgery journals. Plast Reconstr Surg. 2014;133:1502–1507.
19. Sinno H, Neel OF, Lutfy J, Bartlett G, Gilardino M. Level of evidence in plastic surgery research. Plast Reconstr Surg. 2011;127:974–980.
20. Lubowitz JH, Provencher MT, Poehling GG. Follow us on twitter. Arthroscopy 2012;28:1747–1748.
21. Albert NM, Buchsbaum R, Li J. Randomized study of the effect of video education on heart failure healthcare utilization, symptoms, and self-care behaviors. Patient Educ Couns. 2007;69:129–139.
22. Armstrong AW, Idriss NZ, Kim RH. Effects of video-based, online education on behavioral and knowledge outcomes in sunscreen use: A randomized controlled trial. Patient Educ Couns. 2018;83:273–277.
©2019American Society of Plastic Surgeons
23. von Muhlen M, Ohno-Machado L. Reviewing social media use by clinicians. J Am Med Inform Assoc. 2012;19:777–781.