Bibliometric analysis of the top 100 most-cited articles on tissue expander use in breast reconstruction: insights from CiteSpace, VOSviewer, and Bibliometrix

Introduction

Tissue expanders are widely used in postmastectomy breast reconstruction to provide soft tissue coverage for implants and restore breast symmetry and aesthetics (1). Research in this field increasingly focuses on optimizing surgical strategies, preventing complications, advancing biomaterials, evaluating patient-reported outcome measures (PROMs), and developing prognostic models (2,3). Although numerous clinical and translational studies exist, no bibliometric analysis has systematically mapped the literature on tissue expanders. Narrative reviews summarize clinical experiences but cannot capture broader publication patterns, key contributors, or evolving research priorities. To address this gap, we conducted a bibliometric analysis of the 100 most-cited publications, examining research themes, publication trends, journal distribution, and leading authors and institutions. This study aims to provide a comprehensive overview of the field and a reference framework to guide future research and clinical practice. We present this article in accordance with the BIBLIO reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-338/rc).

Methods

Study design

This study adopted a systematic literature review (SLR) approach to comprehensively analyze the academic output related to the use of tissue expanders in breast reconstruction. Literature retrieval was conducted using the Web of Science Core Collection (WoSCC) database (4).

As a key component of evidence-based research, SLR ensures transparency and reproducibility through standardized procedures for literature search and selection. This study strictly followed SLR guidelines, with detailed documentation of the search strategy, inclusion criteria, and analysis methods. The goal was to provide a clear chain of evidence and to position the findings within the context of existing research.

Search strategy

To enhance search sensitivity, two researchers (X.C. and J.S.) independently screened the literature for inclusion. As shown in Figure 1, relevant publications were retrieved from the WoSCC using professional search tools. The language was limited to English, and the document type was restricted to “Article” or “Review Article”. To minimize potential bias in bibliometric analysis using WoSCC and to avoid the inclusion of irrelevant studies, only articles with search terms appearing in the title, abstract, keywords, or author keywords were included. The search query was set as: topic search (TS) = ((“tissue expander” OR “tissue expansion”) AND (“breast reconstruction” OR “postmastectomy reconstruction” OR “breast implant”)).

Figure 1 Workflow of the bibliometric analysis for identifying studies on tissue expanders in breast reconstruction. TS, topic search.

Based on predefined inclusion criteria, two reviewers independently screened the titles, abstracts, or full texts to identify articles related to the use of tissue expanders in breast reconstruction. In cases of disagreement, a third reviewer (S.Z.) participated in discussion to reach a consensus on the final selection of studies.

The search was conducted on July 10, 2025, with detailed steps as shown in Figure 1. The detailed search strategy is shown in Table 1.

Bibliometric analysis

We employed CiteSpace, VOSviewer, and Bibliometrix to conduct bibliometric and visualization analyses. CiteSpace was used to construct and visualize bibliometric networks, including keyword co-occurrence and the academic influence of countries, journals, researchers, and individual publications (5). VOSviewer facilitated the analysis of institutional collaborations and author co-authorship networks (6). Bibliometrix was applied to generate thematic evolution and thematic quadrant maps based on keywords (7). Additionally, Microsoft Office Excel was used for data organization and statistical analysis. These tools provided comprehensive support for data processing, visualization, and network analysis, ensuring the robustness and accuracy of the findings.

Clinical trial analysis

Data were extracted from ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (ICTRP) on July 10, 2025. The search strategy used was: ((“tissue expander” OR “tissue expansion”) AND (“breast reconstruction” OR “postmastectomy reconstruction” OR “breast implant”)). Initially, 66 trials were identified from ClinicalTrials.gov and 37 from ICTRP. After screening for duplicates and relevance, data from both databases were merged, and redundant trials were removed. A total of 78 clinical trials involving tissue expanders in breast reconstruction were included in the analysis. Relevant variables such as study design, status, phase, conditions, interventions, outcomes, and start dates were reviewed.

Statistical analysis

This study was based on the 100 most-cited articles focusing on tissue expanders in breast reconstruction. These publications were carefully selected through a rigorous screening and verification process. The analysis employed a structured framework based on literature characteristics, keywords, countries, institutions, authors, and clinical trial data, enabling a comprehensive examination of influential contributors, collaborative networks, and thematic trends within the field of expander-based breast reconstruction. Descriptive statistics were used to summarize bibliometric indicators.

Results

Bibliometric analysis is an effective tool for information retrieval and is widely used for the quantitative evaluation of academic activities. It enables the exploration of the characteristics, structure, and development trends of scientific literature, and helps researchers quickly identify the core knowledge and research hotspots within a given field (8).

In this study, a total of 2,026 publications were initially retrieved from the Web of Science database using an SLR approach. After limiting the document type to “Article” or “Review” and the language to English, and excluding irrelevant studies, the top 100 most-cited articles were ultimately selected for bibliometric analysis. The top 100 publications by citation frequency included in the final analysis are listed in table available at https://cdn.amegroups.cn/static/public/gs-2025-338-1.xlsx.

Main information

Table 2 presents an overview of the top 100 most-cited publications on tissue expanders in breast reconstruction, covering the period from 2008 to 2020. The time span of the publications ranged from 2008 to 2020, covering 17 journals. The average citation per article was 117.61, with an average annual citation of 6.9 per article. Regarding document types, there were 78 articles, 14 conference papers, and 8 reviews. The total citation count ranged from 57 to 437.

The most cited article was a retrospective cohort study by Chun et al., published in 2010 in Plastic and Reconstructive Surgery. This study reviewed 415 breast reconstruction cases over 6 years and suggested that the use of acellular dermal matrix (ADM) could improve reconstructive support but significantly increased the risk of postoperative seroma and infection (9).

Table 3 lists the average annual citation counts of the top 10 articles (9-18), among which three were authored by Sbitany, Hani, spanning from 2009 to 2017. Notably, all 10 highly cited articles were published in Plastic and Reconstructive Surgery, which is also the most prolific journal among the 100 selected papers, with a total of 60 publications. The second most frequent journal was Annals of Plastic Surgery, with 7 articles included.

Analysis of contributing countries and regions

A total of 441 researchers from 12 countries contributed to publications on tissue expanders in breast reconstruction. The geographic distribution is shown in Figure 2A, with the USA, China, the UK, and Canada accounting for 94% of all publications (Table 4). International collaboration was analyzed using VOSviewer, Charticulator, and CiteSpace (Figure 2B,2C). Thicker lines indicate stronger cooperation, and the USA led in publication count, citations, and centrality (0.21), while Canada also showed notable centrality (>0.1), reflecting their pivotal roles in global collaboration.

Figure 2 Visualization of global publication distribution and collaboration in tissue expander research. (A) World map showing the total number of publications by country/region; (B) chord diagram of country/region collaboration; (C) centrality map of country/region collaboration.

Institutional analysis

A total of 172 institutions worldwide have conducted research on tissue expanders in breast reconstruction, with Memorial Sloan Kettering Cancer Center (n=18), Harvard University (n=14), and the University of Texas (n=13) being the most productive (Table 5). VOSviewer and CiteSpace analyses (Figure 3) showed that the University of Michigan, Memorial Sloan Kettering Cancer Center, Cedars-Sinai Medical Center, and Harvard University occupy central positions in the collaboration network. Node size represents publication volume, line thickness indicates collaboration frequency, and most core institutions were active between 2010 and 2015, forming a closely connected network predominantly centered in leading U.S. medical centers.

Figure 3 Visualization of institutional collaboration networks. (A) Institutional network showing publication volume and time distribution; (B) institutional collaboration map illustrating the structure and strength of cooperation. CST, central standard time; LBY, look back years; L/N, logarithm/normalization; LRF, link retaining factor; WoS, Web of Science.

Author and collaboration analysis

A total of 441 scholars participated in the research of tissue expanders in the field of breast reconstruction. Table 6 lists the top 10 authors ranked by the number of published papers, with Lee BT ranking first with 7 published papers and Pusic AL ranking second with 6 published papers.

Author collaboration was analyzed using CiteSpace and VOSviewer to identify core research groups and their interactions. The network (Figure 4A) highlights central authors such as Cordeiro PG, Wilkins EG, Disa JJ, and Kim Hyungjin M, with node size representing publication volume and color gradients indicating temporal evolution. Distinct clusters indicate stable collaborative teams. Bar charts (Figure 4B) confirm prolific output, with Lee BT and Pusic AL leading with seven publications each. Clustering analysis (Figure 4C) reveals differentiated research teams and cross-institutional cooperation. Temporal evolution mapping (Figure 4D) illustrates generational shifts, with early influence from Wilkins EG, Robb GL, and others, and contemporaneous sustained activity by Cordeiro PG, Djohan Risal, and others, reflecting the ongoing development and continuity within the field.

Figure 4 Visualization of author collaboration and productivity. (A) Author collaboration network; (B) bar chart of prolific authors’ publication counts; (C) author collaboration clusters; (D) temporal evolution of author collaborations. CST, central standard time; LBY, look back years; L/N, logarithm/normalization; LRF, link retaining factor; WoS, Web of Science.

Author co-citation analysis helps identify key scholars widely recognized as the knowledge base in this field. The top three authors by co-citation frequency are Spear SL, Cordeiro PG, and Alderman AK. In the VOSviewer co-citation network (Figure 5A), node size represents co-citation frequency, and line thickness indicates the strength of co-citation links. Spear SL, Cordeiro PG, Nahabedian MY, and Alderman AK occupy central positions, reflecting their high influence and contributions to tissue expander breast reconstruction research. Different color clusters reveal thematic heterogeneity, representing distinct academic directions or technical approaches. The CiteSpace author co-citation centrality network (Figure 5B) confirms the central role of Spear SL and others, while illustrating the temporal evolution of highly cited authors. Node colors transition from purple to red, indicating citation activity over time. Notably, Spear SL, Clough KB, and Alderman AK were frequently cited from 2000 to 2015, demonstrating sustained impact on the field’s development. From the perspective of individual references, the most co-cited publication was Breuing KH’s 2005 study on AlloDerm-assisted direct-to-implant reconstruction, reflecting the close conceptual and methodological linkage between expander-based and direct-to-implant strategies, particularly regarding the integration of ADM.

Figure 5 Visualization of author co-citation analysis. (A) Author co-citation network; (B) author co-citation centrality network. CCs, connected components; CST, central standard time; LBY, look back years; L/N, logarithm/normalization; LRF, link retaining factor; WoS, Web of Science.

Journal analysis

The analyzed literature is published across 17 journals, with the top three being Plastic and Reconstructive Surgery, Annals of Plastic Surgery, and Aesthetic Plastic Surgery; notably, Plastic and Reconstructive Surgery alone accounts for 60% of the top 100 most cited articles (Table 7).

A dual-map overlay generated with CiteSpace (Figure 6) shows citing journals clustered in “Dentistry, Dermatology, Surgery” and “Medicine, Medical, Clinical”, reflecting concentration within clinical specialties. Cited journals are similarly concentrated in “Dermatology, Dentistry, Surgery”, indicating that the knowledge base is largely discipline-specific. Citation pathways extending into “Molecular, Biology, Genetics” highlight integration with basic tissue engineering research, while links to “Psychology, Education, Health” suggest growing attention to patient-centered outcomes, including psychosocial well-being and aesthetic satisfaction.

Figure 6 Dual-map overlay of journal citation pathways.

Overall, research on tissue expanders demonstrates a consolidated academic network within surgical disciplines, alongside emerging interdisciplinary integration with basic science and humanistic medicine.

Keyword and cluster analysis

As shown in Table 8, the most frequently used keywords include “Breast Cancer”, “Complications”, and a tie for third place between “Mastectomy” and “Acellular Dermal Matrix”, all of which appeared over 25 times in the analyzed records. The top seven keywords (each appearing over 20 times) and the top 14 keywords (each cited at least 10 times) reflect the primary research directions in this area.

Keyword analysis reveals internal connections and research hotspots in tissue expander studies. Co-occurrence mapping (Figure 7A) highlights core topics—“breast cancer”, “mastectomy”, “implant”, “complications”, and “radiotherapy”—while bridging keywords such as “allograft dermal matrix” and “capsular contracture” connect subfields. Timeline analysis (Figure 7B) shows a shift from procedural focus to patient-centered outcomes, with recent emphasis on satisfaction and complication monitoring. Cluster and thematic evolution analyses (Figure 7C,7D) identify well-established themes (ADM, expander/implant reconstruction), foundational but developing areas (complications, mastectomy), and broader topics under refinement (breast reconstruction). Overall, the analysis demonstrates a multidimensional, evolving research landscape combining technical optimization with outcome evaluation.

Figure 7 Visualization of keyword networks and thematic evolution. (A) Keyword co-occurrence network; (B) keyword thematic evolution over time; (C) keyword cluster map; (D) theme quadrant map. CCs, connected components; CST, central standard time; LBY, look back years; L/N, logarithm/normalization; LRF, link retaining factor; WoS, Web of Science.

Overall, research on tissue expanders in breast reconstruction is evolving from a technique-driven to a patient-centered approach. Current hotspots focus on postoperative complications, material selection, and patient satisfaction, reflecting a shift from structural reconstruction toward functional recovery and PROMs (19).

Clinical trial analysis

Table available at https://cdn.amegroups.cn/static/public/gs-2025-338-2.xlsx summarizes clinical studies of tissue expanders in breast reconstruction. The earliest retrievable trial, “Quantification of Breast Sensation Following Postmastectomy Breast Reconstruction” (NCT00588419, 2008, Memorial Sloan Kettering), evaluated recovery of touch, vibration, pain, and temperature after mastectomy with or without reconstruction, and compared implant-based with autologous techniques. This observational study provided early evidence on sensory outcomes. Research activity subsequently increased, peaking in 2013 with seven registered trials (Figure 8A).

Figure 8 Analysis of clinical trial characteristics related to tissue expanders. (A) Annual distribution of clinical trials; (B) distribution of phases in clinical trials; (C) distribution of clinical trial directions.

Among the 78 included studies, tissue expander trials, as medical device studies, generally do not follow the traditional drug trial phases I–IV. Phase-designated trials mainly involved ADM and postoperative pain management, with phase IV being most frequent (6 studies), followed by phase II (5 studies) (Figure 8B).

Current research emphasizes optimization of expanders, ADM use, and surgical techniques. Trials explore expansion methods, shaping outcomes, pain control, and device safety. Such as ADM studies emphasize safety and efficacy in breast reconstruction, comparing different ADM products with traditional implants, single-stage versus two-stage reconstructions, and their impact on surgical complexity, complications, and aesthetics.

Additional trials address surgical optimization (prepectoral, robot-assisted, nipple-sparing), complication prevention, autologous tissue/fat grafting, radiotherapy effects, sensory recovery, novel technologies, rehabilitation, patient satisfaction, cost-effectiveness, implant safety, and adjunct therapies, reflecting a multidimensional trend (Figure 8C).

Discussion

Key finding

Tissue expanders are a cornerstone of postmastectomy breast reconstruction, enabling progressive skin and soft-tissue expansion for definitive implant or autologous procedures. Advances in biomaterials and surgical techniques have optimized device design and complication management, yet complications such as necrosis, infection, and radiation failure persist, highlighting the need for refined operative strategies, expansion protocols, and adjunctive materials (20).

In this study, we analyzed the top 100 most-cited articles on tissue expanders in breast reconstruction using CiteSpace, VOSviewer, and Bibliometrix. CiteSpace identified the foundational knowledge and emerging research frontiers, VOSviewer visualized co-occurrence networks, and Bibliometrix validated findings and provided regional insights. This bibliometric synthesis offers a clear overview of key research trends, highlights knowledge gaps, and provides guidance for future studies or clinical research planning.

Research insights and positioning

From a temporal perspective, publication activity peaked in 2010–2013 and 2017–2022, with overall output remaining stable, reflecting a mature and sustained research trajectory. From an institutional perspective, research is dominated by the USA (85 publications, centrality =0.21), whereas other countries, including Canada, the UK, and China, each contributed only three publications with limited network connectivity. From an authorship perspective, core contributors such as Cordeiro PG, Wilkins EG, Kim Hyungjin M, and Lee BT address both clinical and translational topics, while co-citation analysis highlights foundational contributions from Spear SL, Alderman AK, and Cordeiro PG. Publications are concentrated in leading surgical journals, with citation trends increasingly linking clinical practice to molecular, engineering, and psychosocial research (21,22). Future progress will likely depend on strengthened international and interdisciplinary collaboration.

Research on tissue expander-based breast reconstruction can be broadly categorized into five interconnected areas: optimization of reconstructive strategies (23), prevention of postoperative complications (24), application of biomaterials (25), PROMs (26), and development of prognostic models (27). These themes reflect the field’s multidimensional nature and its shift toward individualized, evidence-based approaches. Evidence indicates that delayed and delayed-immediate reconstruction strategies, each applicable in specific clinical scenarios (e.g., anticipated postoperative radiotherapy), can reduce overall complication rates compared to immediate reconstruction in high-risk patients, emphasizing tailored surgical planning based on patient-specific factors such as radiotherapy needs, soft tissue status, and aesthetic goals (28). Complication prevention remains critical, with standardized operative protocols and intraoperative perfusion assessment using indocyanine green imaging shown to mitigate risks such as flap necrosis. Innovations in biomaterials, especially ADM, improve implant stability and contour but require careful patient selection and meticulous intraoperative management to minimize seroma and infection (29). Additionally, PROMs and prognostic models for risk stratification are increasingly employed to evaluate reconstructive success and guide precision breast reconstruction (30,31). Collectively, these directions highlight opportunities to optimize safety, efficacy, and patient-centered outcomes in future research (32,33).

Future research should refine surgical protocols, optimize individualized biomaterial selection, and integrate advanced technologies (34,35), including remote-controlled expanders, artificial intelligence (AI)-assisted risk prediction, and predictive modeling, to enhance safety, efficiency, and patient-centered outcomes (36). Multicenter studies and strengthened international collaboration will be essential to validate innovations, reduce complications, and advance precision breast reconstruction (37).

Comparison with similar research

Comparison with similar research Previous studies on tissue expander-based breast reconstruction have largely focused on single aspects, such as ADM application, surgical strategies, or PROMs providing valuable clinical insights but lacking a comprehensive overview of research trends. In contrast, our study integrates temporal, institutional, and authorship analyses with keyword clustering and emerging technology assessment, offering a multidimensional bibliometric perspective. This approach not only highlights persistent challenges, including complication prevention and variability in patient outcomes, but also identifies underexplored areas and emerging directions such as remote-controlled expansion systems, novel biomaterials, and AI-assisted predictive modeling (38), providing strategic guidance beyond descriptive clinical studies.

Strengths and limitations

This study has limitations. First, reliance on the WoSCC may have introduced selection bias by excluding other databases. Second, software-based screening and integration may have caused minor systematic errors. Third, citation counts favor older studies, potentially underrepresenting recent work. In addition, automatic figure generation led to formatting inconsistencies, though data validity was unaffected. Despite these constraints, the analysis identified representative literature and provided insights into research hotspots and future directions, offering meaningful guidance for subsequent studies.

Conclusions

This bibliometric review of the 100 most-cited studies on tissue expanders in breast reconstruction reveals a transition from technical exploration to personalized strategies, material innovation, and long-term evaluation. Research is led by the USA with increasing global participation. Future progress depends on enhanced international collaboration and multidisciplinary integration. Specifically, translating emerging trends identified in this analysis—such as the development of remote-controlled expansion systems, novel biomaterials, and AI-assisted predictive models for risk stratification—into clinical practice will be crucial. These innovations, guided by robust evidence, will help address complex scenarios like radiotherapy, ADM use, and implant positioning, ultimately advancing the field toward a more precise, efficient, and patient-centered reconstruction framework.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the BIBLIO reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-338/rc

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-338/prf

Funding: This work was supported by the Key Laboratory of Advanced Materials of Ministry of Education (No. Advmat-2510).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-338/coif). All authors report receiving financial support from the Key Laboratory of Advanced Materials of Ministry of Education (No. Advmat-2510) for this study’s design, data analysis, and manuscript preparation. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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