The nose is considered the most noteworthy feature in the face. Rhinoplasty (RP) is one of the most popular surgical cosmetic procedures performed worldwide, which improves the appearance or/and function, within the domain of the plastic surgeon as well as the otorhinolaryngologist (1). Ever since the first thesis that illustrated nose surgery by Edwin Smith Papyrus in 1930 (2), literature studies concerning RP are increasing with the rapid growth of surgical procedures being performed, including new methods, basic research, outcome measurement, artificial intelligence, and so on. However, it is still an inspiring task to imply macroanalysis based on a large amount of literature data to grasp the development trend of a particular field accurately, especially in such an extremely intricate field as RP.

In recent years, bibliometric analysis has gained great attention for it can evaluate quality trends through literature metrology. Meanwhile, research trends or hotspots within a certain field can be predicted. However, very few bibliometric studies on RP are available now. Only Sinha et al. summarized the 100 most cited articles in RP (3) and Lalezari et al. evaluated global trends in rhinoplasty research spanning 20 years between 1994 and 2013 (4). The former lacks a fully and comprehensively analysis due to the limited scope of included literature. The latter lacks updated information in the latest decade. Both of them mainly focus on publication information instead of analysis and prediction of research hotspots. Therefore, research hotspots verified through co-occurrence keywords biclustering in the last decade were highlighted in this study (5), providing a reference for in-depth research direction and clinical practice related to RP.

Though the research directions of rhinoplasty are relatively extensive, summary and analysis of relating hotspots are still hard to find. Keywords can represent the research content of literature studies and the order of magnitude keywords can depict the current research status and trend of the region. According to a qualitative and co-word biclustering analysis by bibliometric software, analogical keywords can be recognized and classified into clusters. Paying attention to and digging deeply into these clusters can help identify valuable future directions.

In this article, we get seven clusters through the biclustering analysis. Cluster 0 mainly concentrates on augmentation rhinoplasty. Since many Asians have a short nose that is generally characterized as having low dorsum, short columella, poorly defined nose tip, flare nostril shape, and wide alar base (9), augmentation surgery has become increasingly popular to correct above features for esthetic purposes. In the past, simple augmentation of the dorsum using an implant has been widely operated and reported; with the improvement of esthetic cognition, recent literature studies show that this procedure will result in disharmony of the nasal base, leading to visible nostrils, a longer supratip lobule, and shorter columella (10–12). Accordingly, it is commonly believed that Asians need to augment and elongate the nose simultaneously to achieve satisfying augmentation rhinoplasty (13).

Cluster 1 mainly concentrates on cleft rhinoplasty. Since primary rhinoplasty should be performed at the time of cleft lip repair, it becomes a common practice among cleft surgeons (14). After that, more related publications from 2012 to 2021 focuses on secondary cleft rhinoplasty. Key elements in successfully secondary rhinoplasty are the replacement of bony structures and reconstruction of the absent/asymmetric cartilages. The increasing use of autogenous costal cartilage enables the surgeons to create various different grafts and fortify the soft tissue to resist persistent deformities (15). Other keywords in this cluster deserve attention is anthropometry. Over the years, surgeons have been realizing that it is essential to know how nasolabial features change over time after the primary repair and subsequent surgical and orthodontic interventions, which provides references about residual deformities that may need further revision, and 3D anthropometric technology has been developed rapidly and widely used nowadays in cleft anthropometry (16). Series of longitudinal studies have been implemented according to different interventions (17–20).

Cluster 2 mainly concentrates on functional rhinoplasty. The functional rhinoplasty patient requires improvements in breathing and olfaction instead of shape (21). Internal nasal valve obstruction, external nasal valve collapse, and septal deviation are the three major causes of nasal airway obstruction. Among them, septal deviation is the most common reason and a prevalent problem in the general population (22). Many septoplasty techniques including endonasal, endoscopic, and open procedures have been described. Much of the literature in the latest 10 years focus on comparing the above approaches. However, each of the septoplasty techniques contains advantages and disadvantages, but none of them has been proved as the most successful means to correct septal deviation (23, 24).

Cluster 3 mainly concentrates on crooked/deviated nose and osteotomy. Both extrinsic forces and intrinsic forces can lead to nasal structure distortion and nasal deviation; nevertheless, majority of them share septal deviation in common. Key operative principles for correcting the crooked nose include rectification of deviated septum and nasal osteotomy. Generally, hybridization of preservation and structural rhinoplasty is required (25, 26). Due to the emergence of potential negative implications of excision techniques, surgeons nowadays pay much interest to dorsal preservation. The maintenance of the structural integrity at the nasal keystone, dorsal esthetic lines, and the patency of the internal nasal valve are points of dorsal preservation (27, 28). In addition, osteotomy is closely associated with postoperative eyelid edema and ecchymosis. Though much publications report above complications in different surgical methods, there is no consensus on which method is the most effective in reducing them (29).

Cluster 4 mainly concentrates on nasal reconstruction and reconstruction surgery. The missing tissue of nasal is categorized as lining, support, and cover, corresponding to mucosa, cartilaginous and bony skeleton, and the overlying skin (30). Literature studies about reconstruction published from 2012 to 2021 still concentrate on the above three aspects, especially on the flaps. Apart from the cases of classical flaps, many newly flaps such as the prelaminated temporoparietal osteofascial flap (31) and modified flaps such as the nasomentolabial flap (32) are reported.

Cluster 5 mainly concentrates on nonsurgical rhinoplasty (NSR). Comparing to the golden standard—surgical rhinoplasty for nasal correction—NSR possesses the advantages including lower cost, less downtime, and immediate effect, and thus are more and more favored by modern people (33). Also, NSR is more easily carried out by a wider range of practitioners and has a more mild learning curve than RP (34). The most well-known types of fillers include hyaluronic acid (HA), collagen, paraffin, and liquid silicon (35). Experienced doctors report their unique injection methods (36–38) without reaching a consensus. Typically, injection rhinoplasty is fairly safe but complications may occur occasionally. So many surgeons will introduce the technique they use during the procedure to avoid the complications. However, serious complications such as dermal necrosis due to vascular obstruction are rare but still reported (39).

Cluster 6 mainly concentrates on outcome and patient satisfaction of the rhinoplasty. In recent years, there is an increasing trend to use health-related quality of life (QoL) questionnaires or multiple patient-reported outcome measures (PROMs) to assess patient satisfaction after surgical procedure. An ideal assessment of RP outcome should have objective means of evaluation covering shape, function, and psychology (40). Currently available and most widely used outcome measures in rhinoplasty include Rhinoplasty Outcomes Evaluation (ROE), The Nasal Obstruction Symptom Evaluation (NOSE), FROI-17, Rhinoplasty Health Inventory and Nasal Outcomes Scale Description (RHINO), FACE-Q, and Standardized Cosmesis and Health Nasal Outcomes Survey Description (SCHNOS). Those specialized rhinoplasty PROMs can provide tremendous feedback information to surgeons; thus, the related research studies flourished in the last 10 years. In addition, the Body Dysmorphic Disorder (BDD) Questionnaire has also become essential to surgeons for assessing patients before surgery. It can reveal the psychological state of the patient and help understand the demands of patient, serving as an effective way to avoid the outcome of dissatisfied patients and depressed doctors (41).

Though we have analyzed the publications on RP from 2012 to 2021 as comprehensively as possible, some limitations still exist. First, since the RP databases update incessantly from 1870 to date, we only selected the publications from 2012 to 2021. Therefore, a discrepancy may exist between this bibliometric analysis and real publication conditions. In addition, the amount of RP literature may increase rapidly with the breakthrough of treatment methods or novel concept. Take Turkish delight, for example, a few relative literature studies were published between 2000 and 2011; however, 19 articles about Turkish delight were published in 2011–2021 and thus making it a highly frequent major keyword. Since it lacks the tight and continuous correlation with other conventional keywords, the biclustering method did not classify it into any prominent cluster. Most of the published rhinoplasty series are the final works of very prestigious experts working in a stationary location for decades, which limit the chances of collaborative work of different institutions and are also reflected in the calculated centrality and density. The majority of the augmentation RPs are from East like Korean and China, while most osteotomies that aim at hump nose are from NA and Europe. Surgical techniques and research trends can vary differently among regions.

We conducted a comprehensive summary of the publication information of RP-related literature studies in the latest 10 years from 2012 to 2021, pointing out the research trends over time. In general, the purpose of RP is mainly divided into two aspects: the appearance (including esthetic deficiency and deformity) and the function of nose. The literature studies about esthetic RP mainly focus on augmentation RP, which are usually reported by Asians. As for deformity, it mainly concentrates on cleft RP and nasal defect. 3D anthropometry has been used more popular than ever for cleft rhinoplasty, but systematic and large-scale measurement data have not been reported yet, which deserves multiple medical centers to cooperate in the future. The nasal defect mainly involves nasal reconstruction. Both classic flaps and innovative flaps have been reported incessantly; however, existing surgical methods still could not meet the needs of special types of patients or patients with higher requirements for appearance. More suitable ways need to be explored. For the function of nose, nasal obstruction that resulted from septal deviation accounted for over 90% of all related literature studies. The three mainstream surgical techniques including endonasal, endoscopic, and open procedures have been elaborated. However, the comprehensive advantages and drawbacks about the above three still need further studies. Another hotspot deserves scholars’ attention lies in the valuation of patients’ outcome. The patient self-reported outcome evaluation scale has become a very popular evaluation method. However, the scale is scored by the patients themselves, which has subjective consciousness defects. How to evaluate the postoperative outcome more reasonably, objectively, and comprehensively is a problem that doctors need to think about carefully.