Background: Imaging studies have become indispensable tools in the perforator flap surgeon's armamentarium, significantly enhancing operative outcomes and reducing complications. We conducted the first bibliometric analysis on imaging studies for flap reconstruction to characterize any emerging trends and assess the methodological quality of the field.
Methods: The 100 most-cited articles in imaging studies for flap reconstruction were identified on Web of Science, across all available journals and years (1950-2024). Study details, including the citation count, main subject, outcome measures, imaging type, and evidence level, were extracted.
Results: The most-cited articles involved 21,619 patients and amassed a total of 9689 citations. Citations per article ranged from 41 to 302. The evidence base relied heavily on level 3 (n = 37) and level 4 (n = 34) studies, reflecting the prevalence of retrospective cohorts and case series. Only 1 study was a randomized trial achieving level 1 evidence. Validated patient-reported outcome measures were reported in only 1 study. Imaging outcomes were the most explored, followed by flap anatomy and comparisons of imaging modality, with cost-effectiveness being the least investigated. Imaging was most frequently used for preoperative flap planning (n = 62), with fewer studies using intraoperative (n = 27) and postoperative (n = 19) imaging for perfusion assessment and complication detection. Computed tomography angiography, Doppler ultrasound, and indocyanine green ICG angiography were the most frequently used imaging modalities.
Conclusions: The most influential studies lacked randomization and were conducted by single-center efforts. Promoting global collaboration and incorporating patient-reported outcome measures into high-quality research can advance a more patient-centered, holistic evaluation of reconstructive success.
Copyright © 2026 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.