Implant-based breast reconstruction (IBR) restores the breast contour following mastectomy, with various techniques ranging from Direct-to-Implant Reconstruction (DTI) to Two-Stage Reconstruction with Tissue Expanders (1, 2). IBR not only improves the physical proportions of patients post-mastectomy, but also additionally restores and sometimes elevates, from baseline, the patient’s psychological confidence, and thus their quality of life (QoL) (3–5). Advancements in techniques have shaped patient expectations and aesthetic standards for breast appearance. Whilst traditional clinical outcome measurement is necessary, it is no longer sufficient (6). Measuring patient-reported outcomes (PROs) assessing physical, psychosexual, and social wellbeing and overall QoL is paramount for optimal outcome assessment, with the utilisation of validated tools such as the BREAST-Q, given the significant impact the implications of requiring IBR and undergoing the procedure can have on one’s QoL and bodily self-esteem (7, 8).

Bibliometric analyses have the capacity to scrutinise vast data sets and leverage citation metrics to pinpoint research trends and identify gaps in the literature. In the context of IBR, two previous bibliometric analyses have been completed, following global research on breast reconstruction post-mastectomy and research trends within breast reconstruction (9, 10). Both studies covered both IBR and autologous breast reconstruction. A major drawback of both studies is their lack of discussion and assessment of patient-reported outcome measures (PROMs) and, by extension, QoL, which are a paramount tenet of the reconstructive breast surgery outcome set (11). Given this gap within the literature, our unique bibliometric analysis aims to provide an objective evaluation and discussion regarding QoL within patients who have experienced IBR.

We conducted the first comprehensive bibliometric analysis of articles published on IBR, to evaluate the quality and characteristics of the top 100 cited articles, and to highlight key findings from cited articles on QoL measures. We hypothesise that amongst the top 100 cited articles on IBR, there is a predominance of lower-level evidence research and a notable scarcity of studies assessing psychological wellbeing and PROs—a trend observed in previous bibliometric analyses within reconstructive breast surgery.

A comprehensive literature review was conducted to identify the 100 most cited publications on IBR. We searched all journal publications available on the Web of Science online database (Clarivate Analytics, Philadelphia, PA), with the search strategy being available as a Supplementary Table 1 . The search terms inputted appeared as a “topic” and was completed on 10 March 2024. The time span included all available years (1977–2024). The criteria for inclusion were publications in journals from this research strategy. Exclusion criteria were publications in non-English language, papers not focussed on breast reconstruction with implants, not pertaining to QoL measures as at least one of their studied outcomes, animal studies, other surgical procedures, and duplicate publications. The LOE was assessed in accordance with the Oxford Centre for Evidence-Based Medicine (OCEBM) system (12).

The search yielded a total of 10,975 publications in journals, which were then ranked according to the number of citations. Publications with the same amount of citations were separated according to the mean number of citations per year; if the average number of citations per year was equal, they were sorted based on the journal’s impact factor. To guarantee that all publications were directly relevant to IBR, two reviewers (KD and FR) independently screened titles and abstracts independently until 100 journal publications were included. Any discrepancies that could not be resolved between KD and FR were solved by consensus-based discussion with the third (RM) and senior author (AK), in addition to ratification by reviewing the full text of the publication. A total of 769 journal papers were screened to obtain the 100 most frequent publications for inclusion. Reasons for other publication exclusions are specified in Figure 1 .

Data were extracted from full-text publications in a standardised online spreadsheet (Google Sheets: Google LLC, Mountain View, California, USA). Data retrieval included publication title, list of authors, corresponding author, year of publication, journal of origin, total citations, the average number of citations per year, geographic context of the study, source of funding, study design, LOE, main topic/content focus, conflict of interest (CoI) statement, and use of validated clinical, psychological, cosmetic, and PROMs.

To the best of our knowledge, this is the first bibliometric analysis comprehensively reviewing IBR and QoL measures. Notably, the most cited articles predominantly used the validated BREAST-Q to assess QoL, underscoring its widespread recognition as a psychometrically robust tool, demonstrating accuracy, reliability, and being sensitive to change (7). However, our analysis highlighted several trends and gaps in the literature.

Study designs mainly comprised single-centre prospective cohort studies and case series, thus precluding achievement of the highest LoE. This is not unexpected as patient satisfaction and psychological wellbeing are often assessed on a smaller scale within individual centres, to evaluate the impact of a particular surgical procedure on QoL. Many centres used their own non-validated scales, potentially precluding accurate and reliable data interpretation. Moreover, many retrospective cohort studies did not specify if they used the BREAST-Q pre-operatively in addition to post-operatively, or whether they standardised the timing of questionnaires. Only one study specified they used BREAST-Q post-operatively only. Timing of QoL questionnaires in IBR is important, and a single post-operative BREAST-Q, usually in the early post-operative period, is not sufficient to reflect medium- to long-term complications associated with IBR; serial long-term QoL assessment is required for accurate reflection of the need for future adjustment and revision surgery associated with IBR (14). More recently, the BREAST-Q real-time engagement and communication tool (REACT) has been developed to aid with BREAST-Q score interpretation and guide patient-centred, clinically relevant action recommendations based on longitudinal BREAST-Q scores (15).

In our study, we further assessed the studies utilising the BREAST-Q, which is divided into distinct modules: Augmentation, Reduction/Mastopexy, Mastectomy, Reconstruction, Reconstruction Expectations, and Breast Conserving Therapy. We found that 38 studies employed the BREAST-Q, with many incorporating more than one of these individual modules. Specifically, the “Augmentation” module was used in 1 study, “Breast Conserving Therapy” appeared in 2 studies, “Mastectomy” was utilised in 3 studies, and “Reconstruction” was the most frequently used, appearing in 32 studies. Additionally, “Reconstruction Expectations” was used in one study, and six studies did not specify the module used; however, it is inferred that they most likely utilised the “Reconstruction” module. This distribution indicates a predominant focus on reconstructive outcomes within IBR research.

These findings have significant implications for the interpretation of PROMs. The high prevalence of the “Reconstruction” module highlights the emphasis on reconstructive procedures and patient expectations post-surgery, which can greatly influence the reported satisfaction and QoL. Conversely, the limited use of the “Augmentation” and “Breast Conserving Therapy” modules suggests a potential underrepresentation of these patient groups in the literature at least within the subsection of IBR. Understanding these nuances is crucial for accurately interpreting PROMs and for the development of comprehensive patient care strategies that address the specific needs and expectations of all breast surgery patients.

These findings are consistent with a bibliometric analysis completed by Miller et al., evaluating the 50 most cited breast reconstruction publications between 2000 and 2010; although they focussed on all autologous and implant-based surgical techniques in breast reconstruction primarily assessing surgical outcomes, one single study made it to their list that included PROMs (16). Unlike Miller et al, we did not limit the study time frame for our search to capture all relevant trends from studies published in any year, and focussed purely on PROMs associated with IBR to understand IBR QoL studies in further depth. However, they also noted a lack of high-quality evidence to guide surgical decision-making in the face of increasing surgical options (16). This is even more so for psychological wellbeing assessment, which was usually a secondary outcome in many initial landmark studies on IBR. However, we found many prospective cohort studies, which, as a tool for studying this subject, are valuable and not to be underestimated as suitable evidence for progress in the field.

Whilst the BREAST-Q remains a widely used tool, few studies assessed patients’ psychological wellbeing using validated psychiatric tools like Hospital Anxiety and Depression Scale (HADS) (n = 6) or Depression Anxiety Stress Scale (DASS)-21 (n = 2); interestingly, the most cited research in our analysis used the HADS tool (13, 17, 18). Moreover, our analysis shows that the presence of a formal existing psychiatric diagnosis was evaluated only in the study by Hopwood and colleagues (19). This represents a gap in the literature, considering that a psychiatric diagnosis can significantly impact QoL and PROs in patients undergoing IBR (20, 21). Validated tools such as the BREAST-Q may assess symptom domains that may be more sensitive to the impact of a psychiatric diagnosis but cannot discriminate the presence of formal psychiatric diagnoses such as major depression, generalised anxiety disorder, or body dysmorphic disorder (21).

Volume replacement and displacement oncoplastic techniques that facilitate breast conservation achieve superior QoL measures compared to simple or flat mastectomy, but significant heterogeneity and the lack of a unified questionnaire preclude meaningful comparison of BCS with mastectomy associated with breast reconstruction, including IBR (22, 23). Although it is recognised that pre–pectoral is better for pain, and aesthetic long–term look with fewer capsular contractures and animation deformities, there is no significant difference in QoL based on current available data, and this did not make it to the 100 most cited articles (24).

Similarly, studies have shown that there is no significant difference in the QoL between patients undergoing DTI reconstruction and those undergoing Two–Stage Reconstruction with Tissue Expanders, notwithstanding the exception of sexual wellbeing, where DTI patients fared better than the tissue expander, implant cohort (25, 26).

The UK–wide Get It Right First Time report recommends routine collection and reporting of PROMs in all breast reconstructive cases pre– and post–operatively (25). The Oncoplastic Breast Consortium also recommends the use of BREAST–Q amongst other PROMs and quality indicators of surgical morbidity (27). Therefore, universal adoption of PROMs is warranted in future IBR studies to enable effective informed consent and decision–making, it is also an important governance tool if standardised as a measure across a country and/or globally. Majority of the studies in our analysis are USA–based. The American breast units have a high–volume practice with a focus on long–term QoL measures supported by financial and healthcare resources, the majority of their studies are led by plastic surgeons who perform IBR, unlike the UK where practice is shared between plastics and breast oncological surgeons. Mastectomy rates are also higher in the USA compared to the UK and western Europe, in turn leading to more patients with IBR, and this may be reflected in the number of studies led by them (28, 29). Nevertheless, future research should encompass global representation, with diverse patient populations and practices. Plastic surgery journals contributed the vast majority of the most cited research, consolidating practice trends, whilst offering insight into how reconstruction improves QoL.

Despite the methodological robustness with which our analysis was conducted, there are few limitations, some inherent to bibliometric analyses. Citation choice can be subject to citation bias, distortion, amplification, and invention, which may result in the unfounded authority of certain publications (30). Importantly, neither LoE nor citation count equates to a study’s overall quality but may serve as a proxy for clinical impact resulting in potential change of practice. Lower LoE studies may add to future systematic reviews’ and meta–analyses’ databases and thereby contribute to the evidence base in the field. The impact of IBR on QoL would be subject to response and selection bias, especially if retrospective. Breast implant–associated lymphoma, although rare, has an impact on wellbeing as does the challenging, unclear diagnosis of breast implant illness (BII), these studies are not highly cited but crucial (31–33).

Despite these limitations, an extensive search of the literature was conducted and the articles presented here may be considered seminal in IBR and QoL. For future studies in this area, we recommend better–designed prospective studies that assess serial long–term QoL measures with validated tools. In the current economic climate, we must value the financial burden of IBR, and therefore, QoL is an important measure to sustain practice in terms of resource allocation prioritisation for otherwise seemingly high–cost elective surgery.

This comprehensive bibliometric analysis comprehensively examines the top 100 most highly cited publications regarding QoL in IBR and shows the evolution of trends in the field over the past five decades. Research areas that are materialising within this field entail assessing and optimising patient satisfaction and psychological wellbeing via validated patient questionnaires. Despite the quality of literature being reasonably high, more emphasis can be placed on undertaking the publication of methodologically robust studies with higher OCEBM LOE, such as well–designed RCTs or multicentre prospective studies with serial long–term QoL measures with validated tools. Additionally, the development and adoption of more validated PROMs designed for IBR is centrally important for calibrating patient satisfaction with clinical outcomes and providing a noticeable greater QoL following IBR.

The original contributions presented in the study are included in the article/ Supplementary Material . Further inquiries can be directed to the corresponding author.

KD: Writing – review & editing, Writing – original draft, Visualization, Validation, Software, Methodology, Investigation, Formal analysis, Data curation. FR: Writing – review & editing, Writing – original draft, Validation, Supervision, Software, Project administration, Methodology, Investigation. RM: Writing – review & editing, Writing – original draft, Validation, Supervision, Project administration, Methodology. TB: Writing – review & editing, Writing – original draft, Visualization, Project administration, Methodology. RA: Writing – review & editing, Writing – original draft, Validation, Data curation. MC: Writing – original draft, Writing – review & editing, Supervision, Conceptualization. AK: Validation, Writing – original draft, Writing – review & editing, Supervision, Resources, Project administration, Conceptualization.