International Collaboration Trends in Facial Plastic and Reconstructive Surgery

This systematic bibliometric scoping review characterizes international collaborations in published literature on facial plastic and reconstructive surgery care and whether manuscripts included authors from the low- or middle-income countries in which the studies took place.

Key Points

Question

What patterns exist in international collaboration in facial plastic and reconstructive surgery (FPRS) research?

Findings

In this systematic bibliometric scoping review including 286 studies, 49.5% of global health–focused FPRS articles included authors from the low- or middle-income country (LMIC) being studied.

Meaning

There is an opportunity for researchers investigating FPRS needs in LMICs to include voices and perspectives from individuals living in the country being studied.

Abstract

Importance

Research in facial plastic and reconstructive surgery (FPRS) in the global health setting, especially in low- and middle-income countries (LMICs), is increasing year by year. As this work progresses, it will be crucial to include voices and perspectives of individuals living in the LMICs being studied.

Objective

To characterize and understand international collaborations in published literature on FPRS care in a global health setting and report patterns in whether these articles included authors from the LMICs in which the studies took place.

Evidence Review

A systematic bibliometric scoping review of articles in Scopus from 1971 to 2022 was performed using a set list of search terms; studies were included using predetermined inclusion and exclusion criteria. Studies met criteria for inclusion if the abstract or text contained information regarding surgeons from a different country performing surgery or conducting research in an LMIC within the domain of FPRS. Exclusion criteria were studies that did not mention a facial plastic or reconstructive surgery and studies where both an HIC and LMIC were not mentioned.

Findings

A total of 286 studies met criteria for inclusion. The highest percentage of studies (n = 72, 25.2%) were conducted across multiple countries. A total of 120 studies (41.9%) discussed cleft lip/palate. Overall, 141 studies (49.5%) included at least 1 author from the host LMIC; 89 (31.1%) had first authors from LMICs, and 72 (25.2%) had senior authors from LMICs. A total of 79 studies (27.6%) described humanitarian clinical service trips without mentioning research or education in the text. The remaining studies described research, education projects, or a combination. The published literature on humanitarian service trips had the lowest rate of inclusion of a first or senior author from the host LMICs.

Conclusions and Relevance

In this systematic bibliometric scoping review, findings showed a general trend of increased international work in the field of FPRS. However, there continues to be a paucity of inclusive authorship trends, with the majority of studies not including first or senior authors from LMICs. The findings presented here encourage new collaborations worldwide, as well as the improvement of existing efforts.

Introduction

Though notable advances have been made in global health in the past several decades, the development and delivery of surgical and anesthetic care in low- and middle-income countries (LMICs) remains underprioritized. Five billion people worldwide currently do not have access to timely, safe, and affordable surgical care.¹ There is a particular need for the expert management of craniomaxillofacial pathologies from specialists in facial plastic and reconstructive surgery (FPRS).² The field of FPRS is wide reaching, encompassing congenital abnormalities such as cleft lip and palate repair, reconstruction after an infection or tumor resection, and treatment of craniofacial trauma, among others. Despite the profound international need for FPRS care, there is a paucity of specially trained surgeons for facial reconstruction worldwide. For example, cleft lip and palate affects 1 in 500 to 1000 live births,³ and there are an estimated 140 000 new cases of noma (necrotizing ulcerative stomatitis) annually, both of which necessitate surgical intervention—yet there is limited access to safe surgical operating theaters and staff.^1,4,5,6 It is crucial that affordable and effective care for conditions requiring facial reconstructive surgery be accessible globally, and the biggest unmet need currently exists in LMIC populations.⁷

Surgical service trips, also sometimes referred to as “mission trips” or “humanitarian trips,” have become a popular method of addressing the unmet need for reconstructive surgeons in resource-limited settings.⁸ However, these trips do not always emphasize both the provision of care and the implementation of sustainable infrastructure so that local health care clinicians can continue to treat patients after the conclusion of the trip.⁹ In addition, there has emerged a new emphasis on research and research collaborations between high-income countries (HICs) and LMICs. Recent analyses have found that the amount of research in global surgery has increased in the past 30 years, with authors from LMICs promoting awareness for the global need for surgical care.¹⁰ As research collaborations have increased, it is important to understand how these studies are conducted and how authorship is distributed. Authorship has been shown to have important academic, social, and financial implications, particularly for the first and senior authors listed.^11,12 Therefore, exploring authorship in collaborative studies between HIC and LMIC research groups is of vital importance.

The goals of the present study were to (1) characterize international collaborations in the existing published literature on FPRS care in the global health setting and (2) report patterns in whether these articles included authors from the LMICs in which they took place. A robust understanding of these patterns can clarify the dynamics underlying the care that HICs provide in LMICs and identify opportunities for further collaboration.

Methods

We conducted a systematic bibliometric scoping review of all literature published from 1971 up to February 3, 2022, the date of query. We used Covidence systematic review software (Veritas Health Innovation, available at https://www.covidence.org/) to search publications within Scopus, Elsevier’s abstract and citation database, which includes over 54 million articles and abstracts from around the world (S.K.). This research meets exemption criteria for human participants research as determined by the Duke Health System Institutional Review Board. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline.

The Medical Subject Headings (MeSH) database from the National Library of Medicine was searched to create a list of terms related to FPRS (S.K.). The entry terms and synonyms were added to this list, and then feedback was provided by the subject matter experts (G.B.S.-M., W.T.L.). Studies met criteria for inclusion if the abstract or text contained information regarding surgeons from a different country performing surgery or conducting research in an LMIC within the domain of FPRS. Exclusion criteria were studies that did not mention a facial plastic or reconstructive surgery and studies where both an HIC and LMIC were not mentioned. High-income countries and LMICs were denoted as defined by World Bank region.¹³ The MeSH terms for FPRS were defined by subject matter experts (G.B.S.-M., W.T.L.) with the assistance of an expert librarian (S.K.). Search terms are shown in the eTable in Supplement 1.

Study abstracts were screened, and full-length texts were analyzed for eligibility (J.C.), as shown in Figure 1. Publications were considered to be collaborative if they had authors from both the LMIC in which the research took place and at least 1 other country. Publications were reviewed, and predetermined data were extracted using a custom survey form on Covidence (J.C.). Data extracted from the studies included primary location of the study, World Bank classification of the first and senior authors, type of study, surgical subspecialty of the authors, and whether the study was collaborative. The country in which each study took place as well as countries of origin of both the first author and senior author were classified in each article into 1 of 7 global regions as defined by the World Bank¹³: East Asia and Pacific, Europe and Central Asia, Latin America and Caribbean, Middle East and North Africa, North America, South Asia, and sub-Saharan Africa. Figures were made using Microsoft Office Suite 2022 (Microsoft Corporation). There was only 1 study from 2022 that met criteria for inclusion, and thus this was excluded from Figure 2, depicting number of studies by year, because the search was conducted early in the year.

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Flow Diagram.

Figure 2. Number of Collaborative Studies Over Time.

Results

A total of 286 studies met criteria for inclusion. Overall, the number of studies involving FPRS research in LMICs increased during the study period (1971 to 2022). This ranged from very few studies prior to 2000 up to 18 studies in 2020. Within the past decade, multiregion studies showed the largest increase compared with the first decade of included studies (54 studies from 2011 to 2021; 0 studies from 1971 to 1981), followed by sub-Saharan Africa (46 studies from 2011 to 2021; 2 studies from 1971 to 1981) and East Asia and Pacific (38 studies from 2011 to 2021; 2 studies from 1971 to 1981).

Overall, 141 studies (49.5%) included at least 1 author from the LMIC in which the study took place and were thus categorized as collaborative. The other 145 studies did not contain any author from the country where the study took place and were thus categorized as noncollaborative. The overall number of studies increased over time; this trend held true when data were stratified by collaborative vs noncollaborative studies. Collaborative studies over time are shown in Figure 2.

The highest percentage of the studies were conducted across multiple regions (n = 72, 25.2%), while the remaining studies focused on 1 location. Sub-Saharan Africa was the most represented (n = 65, 22.7%; of these, 33 [50.1%] were collaborative). This was followed by studies in East Asia and Pacific (n = 53, 18.5%; 33 [61%] collaborative), South Asia (n = 40, 14.0%; 18 [45%] collaborative), and Latin America and Caribbean (n = 26, 9.1%; 16 [61%] collaborative). These results are summarized in Figure 3A.

Figure 3. Characteristics of Studies.

A, Study location (World Bank region). B, Type of surgery.

The highest percentage of studies were conducted by authors from multiple surgical subspecialties (n = 86, 30.1%). Of studies with authors from a single field, the most common specialty was plastic surgery (n = 65, 22.7%), followed by oral and maxillofacial surgery/dental (n = 43, 15.0%), then ear, nose, and throat (n = 32, 11.2%).

The highest percentage of articles discussed procedures repairing congenital anomalies (n = 147, 51.4%). Most of these studies were specifically focused on cleft lip and palate (n = 120; 81.6% of congenital studies, 41.9% of all studies). Fewer than half of congenital anomaly studies (n = 68, 46.2%) included coauthors from the country of the study, while the remainder (n = 79, 53.7%) did not include any collaborative authorship. The second most common procedure studied was facial trauma (n = 67, 23.4% of all studies), followed by cancer/tumor reconstruction (n = 50, 17.5% of all studies), reconstruction after infections (n = 38, 13.3% of all studies), and rhinoplasty (n = 18, 6.3% of all studies). These results are summarized in Figure 3B.

Studies discussing congenital abnormalities were present worldwide; however, other pathologies were clustered by region. Reconstruction after infection, namely noma, was most common in sub-Saharan Africa, while rhinoplasty was most commonly discussed in the Middle East and North Africa. Cancer reconstruction was most commonly explored in the East Asia and Pacific and the sub-Saharan Africa regions (Figure 4).

Figure 4. Types of Surgeries by World Bank Region.

The majority of studies published were purely international research projects without any charitable surgical service or education (n = 153, 53.5%). These were followed in frequency by studies that were solely humanitarian clinical service trips, with no discussion of education in the text (n = 79, 27.6%), then by studies that discussed humanitarian clinical service trips that also discussed ongoing education for health care workers of the local country (n = 47, 16.4%). The fewest studies were solely focused on the education of local health care workers, without the provision of care on the trip itself (n = 7, 2.4%). The highest percentage of all studies focused on congenital anomalies. However, of all 153 non–service-based trips, 55 (35.9% of nonhumanitarian studies, 19.2% of all studies) were focused on facial trauma research (Table). The majority of nonmission trips (n = 99 of 153, 64.7%) and education-only trips (n = 4 of 7, 57.1%) were collaborative, while many fewer studies about humanitarian clinical service–only trips (n = 23 of 79, 29.1%) included coauthors from the host country. About one-third (n = 15 of 47, 31.9%) of combined trips were collaborative.

Table. Breakdown of Included Studies by Type of Trip, Type of Surgery, and Collaboration Status.

Trip type	No.	Surgery type	No.	No. collaborative
Humanitarian only	79	Cancer reconstruction	7	4
		Congenital abnormalities	55	17
		Cosmetic	0	NA
		Facial reanimation	0	NA
		Facial trauma	14	3
		Other	1	0
		Reconstruction after infection	15	6
		Rhinoplasty	0	NA
Education only	7	Cancer reconstruction	2	1
		Congenital abnormalities	5	2
		Cosmetic	0	NA
		Facial reanimation	1	1
		Facial trauma	3	2
		Other	0	NA
		Reconstruction after infection	0	NA
		Rhinoplasty	1	1
Humanitarian service and education	47	Cancer reconstruction	14	7
		Congenital abnormalities	35	10
		Cosmetic	0	NA
		Facial reanimation	1	1
		Facial trauma	8	3
		Other	0	NA
		Reconstruction after infection	6	1
		Rhinoplasty	0	NA
Nonhumanitarian trip	153	Cancer reconstruction	27	18
		Congenital abnormalities	52	39
		Cosmetic	17	6
		Facial reanimation	0	NA
		Facial trauma	55	20
		Other	6	5
		Reconstruction after infection	17	10
		Rhinoplasty	17	13

Abbreviation: NA, not applicable.

Overall, the majority of both first and senior authors had affiliations from HICs. Many fewer had a first author from an LMIC (n = 89, 31.1%) or a senior author from an LMIC (n = 72, 25.2%). Of the 89 studies with LMIC first authors, the majority were research-based studies (n = 79, 88.8%), followed by case studies (n = 7, 7.9%); the fewest were discussions of humanitarian-based clinical service trips (n = 3, 3.3%). This pattern was similar in senior authorship, whereby of the 72 studies with senior authors from an LMIC, the majority were research based (n = 63, 87.5%), followed by case studies (n = 7, 9.7%); 1 study was about a humanitarian clinical service trip (n = 1, 1.4%), and 1 study was about a combined mission and education trip (n = 1, 1.4%).

Discussion

To our knowledge, this study is the first of its nature to conduct a systematic bibliometric scoping review of FPRS research performed in LMICs and to assess important trends in publication, study types, study subject matter, and authorship origins. Overall, the number of FPRS studies in the global health setting has increased over the past several decades. This is encouraging and unsurprising, given reported increases in international collaboration, likely due to the globalization of science and technology in the past several decades.¹⁴ Charitable humanitarian-based clinical service trips to lower-resource settings have become more popular in recent years,¹⁵ especially as researchers have grown aware of the worldwide burden of surgical disease and have become interested in implementing safe access to reconstructive surgery.³ We found the most common category of surgery in the published FPRS literature was congenital abnormality repair, the majority of which were repair of cleft lip and palate. This is likely secondary to increased support for international surgical nonprofits focused on quality of life for pediatric patients, especially those with pathologies such as cleft lip or palate that are correctable with access to safe surgery.¹⁶

The highest percentage of studies were conducted across multiple countries. Of those that focused on a single country or region, sub-Saharan Africa and East Asia and Pacific were most prevalent. This corroborates prior findings in other global health fields, including literature from The Lancet Global Health, which demonstrates that most published global health literature is from sub-Saharan Africa.¹⁷ In our study, 27.6% (n = 79) of all studies published discussed humanitarian-based clinical service trips, also known as mission trips, without mention of education or research in their text. Recent years have seen a movement to improve reporting of outcomes in global surgery trips,^18,19 include local authors in studies, and carry out local needs-based assessments prior to performing global surgical trips. While it would be optimal to include an educational component in service trips, these 79 studies represent a small minority of global surgery trips that publish their experience. The vast majority of trips do not, which confers a publication bias in the studies garnered for the present study, but also highlights the need for accountability in global surgical trips in this field.

Our data also corroborate prior literature demonstrating that published studies involving host LMICs do not tend to include authors from the host country itself.²⁰ A 2020 study on international authorship found that low-income country authors constituted 36.8% and 29.1% of first and senior authors, respectively, in publications related to their countries of affiliation.^17,21,22 This mirrors very similar data to our results, which found 31.1% and 25.2% had first and senior authors, respectively, from the host LMICs. In addition, our analysis found that published literature on humanitarian-based clinical service trips had the lowest rates of international collaborations in authorship. It is well established that authorship can serve as a proxy for status in an academic career and in particular promotion readiness¹¹; therefore, the bias in authorship toward HIC authors negatively affects LMIC authors directly. This finding highlights the continued inequality in publication trends, which can lead to bias in available literature and have marked downstream effects.

Limitations

By nature of this study exploring already published literature, it is limited by publication bias. There exists a known bias of studies and journals to accept English-language publications. Our study is one such example, as we were without the ability to include studies in other languages. Similarly, this study is biased to include journals that can be searched using English-language search engines. However, we attempted to circumvent this issue by working with a specialist librarian who helped us query Scopus, which includes numerous international databases and has been used for prior international investigations.^10,23 Publication bias also limits our ability to truly capture the breadth of international work in FPRS; this study is therefore likely to underestimate the work performed in clinical service trips abroad.

Despite these limitations, this study points to several important features of the current landscape of global collaborations in FPRS. Using the results from this review, we advocate for increased collaboration in global surgical care. As with prior studies, there is a clear dearth of needs-based assessment prior to clinical service trips, involvement of individuals from host LMICs as both first and senior authors, and published clinical service trips that include an educational component for local health care workers.

Conclusions

This systematic bibliometric scoping review provides a novel look at international FPRS studies conducted over the past several decades, along with trends by World Bank region, type of surgery, and type of research produced. Though half of the included studies were collaborative, there is still more progress to be made toward the inclusion of LMIC voices in these projects. The findings presented here can help encourage new collaborations worldwide, as well as the improvement of existing efforts.

Supplement 1.

eTable. Search Terms

Supplement 2.

Data Sharing Statement