Landmarks in facial reanimation – a bibliometric analysis of the 50 most cited papers in dynamic facial reconstruction

Authors: J. E. Telich-Tarriba ¹; A. Rivera Del Río-Hernández ²; R. Esquiliano-Raya ³; X. González-López ³; C. Domínguez Suárez ³
Authors‘ workplace: Plastic Surgery Department, Hospital Angeles Pedregal, Mexico City, Mexico ¹; Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA ²; School of Medicine, Universidad Panamericana, Mexico City, Mexico ³
Published in: ACTA CHIRURGIAE PLASTICAE, 67, 1, 2025, pp. 55-63
doi: https://doi.org/10.48095/ccachp202555

Introduction

Facial palsy is a profoundly disabling condition that negatively affects multiple aspects of a patient’s life, including interpersonal communication, ocular protection, nasal airflow, and self-image [1,2]. Historical records document clinical observations of facial palsy in ancient times, but it was not until Charles Bell’s seminal description of the seventh cranial nerve that the underlying pathology of this condition began to be understood [3].

In the late 19^th century, numerous surgeons developed static procedures to restore facial symmetry at rest; however, achieving effective facial reanimation remained largely elusive. At the beginning of the 20^th century, procedures such as temporalis muscle transfer gained popularity. Yet, it was the advent of the surgical microscope in the latter half of the century that revolutionized the field. This breakthrough enabled surgeons to perform precise nerve repairs and free muscle transfers, marking a pivotal moment in the evolution of facial reanimation surgery. This progress sparked a surge of interest in the field and led to a proliferation of scholarly publications [4–6].

Citation analysis is an established bibliometric method that catalogs research papers based on the number of times they have been referenced. This type of study provides an index of the most influential themes, articles, and authors within a field [7]. Moreover, citation analyses are valuable for identifying “classic” or seminal publications within medical specialties [8].

While citation analyses have been conducted in various subfields of plastic surgery, such as craniofacial surgery and microsurgery, few efforts have been made to define the most influential literature in the field of facial reanimation [9–11]. Therefore, the objective of this work is to identify and analyze the 50 most-cited articles in facial reanimation surgery over the past 70 years.

**1. Fifty most cited papers in facial reanimation surgery.**

**Tab. 1 – continuing. Fifty most cited papers in facial reanimation surgery.**

Methods

A literature search was performed using Clarivate Analytics’ Web of Science Citation Index (SCI) to identify the 50 most cited articles related to facial reanimation surgery published between 1950 and 2022 [15–64]. The database was accessed in October 2023. Search filter terms included: facial nerve, facial paralysis, facial palsy, facial nerve reconstruction, and facial reanimation.

The authors browsed through all the titles and abstracts to ensure that articles referring exclusively to facial reanimation procedures were included. Only original research articles were included; review articles or editorials were excluded.

Each article was examined for its number of citations, authors, study design (case series, cohort studies, randomized control trials, reviews), level of evidence as described by the Oxford Centre for Evidence-based Medicine, type of procedure (nerve repair, cross face nerve grafts, nerve transfers, functional muscle transfers), year of publication, citation index (number of times cited / years since publication), journal’s impact factor and country of origin.

All data was entered into a Microsoft Excel spreadsheet. Descriptive statistics were employed for analysis. Continuous variables are expressed in central tendency measures, and categorical values are presented as percentages.

Results

The 50 most cited papers in facial reanimation surgery accumulated a total of 5,660 citations, with individual citations counts ranging from 65 to 516 (mean 113.2 ± 72.32). The average number of years since publication were 25.52 ± 13.69, and the mean citation index was 5.27 ± 2.85. The earliest publication dated back to 1953, while the most recent one was published in 2015 (Tab. 1).

The most cited paper was “Free gracilis muscle transplantation, with microneurovascular anastomoses for the treatment of facial paralysis. A preliminary report”. With this article from 1976, Dr. Harii’s group revolutionized the field of facial reanimation by showing that microvascular techniques could deliver reliable results and recreate a spontaneous and symmetrical smile, laying the foundation for multiple innovations and refinements in years to come. This landmark study remains a cornerstone in reconstructive microsurgery and plastic surgery as a specialty.

The article with the highest citation index was “Smile reconstruction in adults with free muscle transfer innervated by the masseter motor nerve: Effectiveness and cerebral adaptation” by Manktelow et al. (SCI 12.3) [17]. The study highlighted that the masseteric nerve’s anatomical location and axonal count make it a reliable and powerful donor for smile restoration. Furthermore, the article delves into the concept of cerebral adaptation, emphasizing the brain’s ability to rewire motor pathways to integrate the masseter nerve into facial expressions (Tab. 2).

The articles were published across 16 different journals, with Plastic and Reconstructive Surgery leading with 27 articles (54%), followed by JPRAS/British Journal of Plastic Surgery with 5 papers (10%) and the Journal of Neurosurgery with 4 articles (8%). A total of 16 countries contributed to the top 50 articles, with the USA contributing the most (N = 17, 34%), followed by Canada and Japan with 6 papers each (12%).

There were 126 different authors involved in the 50 articles, with 19 authors contributing with more than a single article. Dr. Julia K. Terzis was the most cited author with 7 works included in the list, she was followed by Dr. Ronald M. Zuker with 5 citations and Dr. Ralph T. Manktelow with 5 entries as well.

The subjects of the articles were mostly focused on free functional muscle transfers (N = 22, 44%) and nerve transfers (N = 20, 40%). Regional muscle transfers (N = 6, 12%), cross-facial nerve grafts (N = 4, 8%), direct nerve repairs (N = 2, 4%) and nerve grafting 2% (N = 1, 2%) were the subjects of the remaining articles.

Regarding article type, the vast majority were case series 70% (N = 35), followed by comparative studies 26% (N = 13) and two case reports. The level of evidence of the articles predominantly included level IV research (N = 36, 72%), level III publications (N = 12, 24%), and two articles were of level V.

Discussion

The evolution of facial reanimation surgery over the past seven decades has witnessed remarkable advancements, particularly following the advent of the operating microscope and microsurgical instruments. These breakthroughs resulted in a surge in research interest, fueling the development of diverse surgical techniques and management protocols aimed at restoring facial function and aesthetics [12].

The fields of peripheral nerve and facial reanimation surgery have matured significantly, prompting the quest for identifying “citation classics” – highly cited papers that serve as pivotal reference points within our specialty. Notably, several of these works transcend disciplinary boundaries, emerging as top papers in microsurgery and facial plastic surgery, highlighting the interdisciplinary nature of facial reanimation surgery and its interconnectedness with cooperating medical specialties [11,13].

A previous publication by Boonipat et al. from 2021 analyzed the 50 most cited publications in facial reanimation surgery, offering valuable insights into the field’s influential works. However this work did not present a full overview of the evaluated publications, leaving room for further comprehensive evaluation.

Our findings reveal a temporal trend wherein a majority (78%) of the identified classics were published during or after the 1990s. This stands in contrast to the broader field of microsurgery, where seminal publications often originate from the 1970s or 1980s, indicative of the accelerated pace of innovation and knowledge dissemination within facial reanimation surgery in recent decades [14].

Thematic analysis of the top cited articles unveils the dominance of free functional muscle transfers as the preferred technique in 44% of the studies, with the gracilis muscle emerging as the flap of choice for facial reanimation across multiple centers. Additionally, nerve transfers garnered significant attention, encompassing 40% of the analyzed papers, with donor nerves such as the masseter and hypoglossal nerves gaining prominence.

The geographic distribution of the articles shows that the United States contributed with a third of the most cited articles, followed by Canada and Japan with 12% each. While this trend likely reflects the availability of financial resources and robust academic infrastructure in the United States, potential publication bias cannot be discounted, particularly given the predominance of high-impact journals based in the US and “national-citation” bias.

The Plastic and Reconstructive Surgery emerged as the predominant journal in the analysis, holding 54% of the articles and making it a significant platform for spreading impactful research in this field. The prominence of pioneering figures such as Drs. Terzis, Zuker, and Manktelow among the list of authors reaffirms their enduring contributions to facial reanimation surgery, while the inclusion of 123 additional authors underscores the collaborative and ever-evolving nature of our specialty.

This study’s design presents certain limitations; first, the reliance on Web of Science as the primary database for citation analysis may lead to bias, and results might vary slightly with the use of alternative databases. On top of that, it must be considered that, while the study reflects the top cited articles in 2023, the dynamic nature of citations implies a constant reshuffling of rankings over time. Despite these limitations, this compilation provides a valuable reference for understanding the historical and scientific evolution of facial reanimation surgery, serving as a comprehensive “must-read” list for both newcomers and seasoned experts in the field.

Conclusion

The compilation of the 50 most cited articles in facial reanimation surgery provides a clear overview of the key milestones and advancements in this field. By identifying these influential works, the study highlights the foundational research that has shaped current practices and offers a framework to guide future investigations. This collection serves as a practical resource for clinicians and researchers striving to advance the science and practice of facial reanimation surgery.

Roles of authors

Jose E. Telich-Tarriba – original idea, project supervision, data analysis, text writing and editing; Alexa Rivera del Río-Hernández – project coordination, data examination, data analysis, text writing and editing; Ricardo Esquiliano-Raya – data retrieval, database construction, text writing; Ximena González-López – data retrieval, database construction, text writing; Cinthya Domínguez Suárez – data retrieval, database construction, text writing.

Conflicts of interest

The authors have no conflicts of interest to disclose. The authors declare that this study has received no financial support. All procedures performed in this study involving human participants were in accordance with ethical standards of the institutional and/or national research committee and with the Helsinki declaration and its later amendments or comparable ethical standards.

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Jose E. Telich-Tarriba, MD

Hospital Angeles Pedregal

Camino a Santa Teresa 1055

10700, Mexico city, Mexico

josetelich@gmail.com

Submitted: 31. 10. 2024

Accepted: 20. 3. 2025