Bibliometric Analysis of the Top 100 Most Cited Papers in Mohs Surgery

Background: Mohs micrographic surgery is a specialized tissue-sparing technique used to treat skin cancers. Objective: By understanding the attributes that make a research paper one of the top 100 cited papers on Mohs surgery, we hope to illuminate seminal research in this field. Methods and materials: The global literature about Mohs surgery published between 1900 and 2023 was searched on the Web of Science. Publication data for all results meeting the search criteria were exported and analyzed. Results: In total, 4,961 publications with 81,405 citations were identified. Dermatologic Surgery was the most cited journal, with 1,073 publications. Papers from the top 100 most cited that were published in the year 2000 or prior had an average of 22.1 citations in the first five years after publication, whereas papers published after 2001 had an average of 56.0 citations in the first five years. Conclusion: Analysis of the most cited papers on Mohs surgery demonstrates the influential role of the Dermatological Surgery journal in advancing the field. Noteworthy studies addressing cost, safety, and efficacy have received substantial citations, reflecting their significance within the literature. A trend toward more citation in the first five years after publication over time was identified.


Introduction
Mohs micrographic surgery, named after pioneering surgeon Dr. Frederick Mohs, is a specialized tissuesparing technique for the treatment of skin cancers.This method maximizes tissue preservation while offering complete microscopic margin control of the entire surgical margin.Over the years since the inception of Mohs surgery, numerous clinical and scientific papers on this excision method have been published in prestigious journals with varying impact factors.As the pace of scientific discovery has intensified, so has the pace and extent of publication, making it challenging to identify the most influential papers on the topic of Mohs surgery.
Citations play a crucial role in acknowledging the contributions of other authors and quantifying valuable work in a field.The number of citations received by an author's published work is often seen as an indicator of the article's reputation and impact.This is similarly the case for scientific journals.The impact factor (IF) of a journal is a metric that reflects the average number of citations its articles receive [1].It is calculated annually and serves as a proxy for the relative importance of an academic journal within its field.The Hirsch index (h-index) is defined as the number of papers with citation number ≥h and is another widely accepted quantitative method used to characterize the scientific output of a researcher or journal.A scientist or journal has an index h if h number of papers (Np) have at least h citations each and the other (Np -h) papers have ≤h citations each [2].Journals with higher impact factors and higher h-indices are generally considered more influential.
Bibliometric citation analysis examines the citation history of published papers [3,4].Various medical specialties have previously conducted analyses to identify the most cited papers in their respective fields [5,6].These studies are beneficial in that they catalog works of significance which may be most beneficial for trainees, practitioners, and researchers alike.However, there has been no bibliometric analysis of the most cited papers on Mohs micrographic surgery to date.
In this study, we performed a bibliometric analysis on the most influential papers on Mohs surgery, based on their number of citations.By understanding the attributes that make a research paper one of the top 100 cited papers in the field of Mohs surgery, we hope to illuminate seminal research in this field.This analysis contributes to the existing body of knowledge and provides a reasonably comprehensive overview of the impactful contributions to Mohs surgery.

Materials And Methods
The global literature about Mohs surgery published between 1900 and 2023 was searched in English in the Web of Science (WOS) Core Collection platform (Clarivate PLC, London, England).The WOS platform is the most accepted citation database within the scientometric community [3,7,8,9].This query was performed on a single date (April 12, 2023) by a single researcher using predetermined keywords.The search terms used were "Mohs surgery" OR "Moh's surgery" OR "Mohs' surgery" OR "Mohs micrographic surgery" OR "Moh's micrographic surgery" OR "Mohs' micrographic surgery" and were intended to capture commonly used semantic variations.The data for all publications meeting this search criteria were exported in CSV format.The data downloaded from WOS included title, author(s), journal name, publication date, author affiliation, and total citations.

Results
Our search returned 4,961 publications with a total of 81,405 citations.The average number of citations per paper for all publications meeting the search criteria was 16.4.Dermatologic Surgery was the most cited journal, with 1,073 publications.The Journal of the American Academy of Dermatology was second, with 559 publications (Table 1).The five-year impact factors for these journals as of May 2023 were 1.244 and 3.556, respectively [10,11].

Rank
Journal Publications   Regarding author location, 14 countries were responsible for producing the top 100 most cited papers.The United States of America produced most of these papers (70%), followed by the United Kingdom (6%), Australia (5%), and The Netherlands (5%) (Table 3).The Mayo Clinic (6%) and The University of Michigan (6%) were the institutions which contributed most to the top 100 most cited papers on Mohs surgery (Table 4).

TABLE 4: The institutions which contributed the most publications to the top 100 papers on Mohs surgery
Articles with a topic specifically related to Mohs surgery by title rather than a general disease process (i.e., cutaneous malignancy) comprised 25 of 100, whereas the remaining 75% mention Mohs micrographic surgery as a treatment modality but are not focused on this technique.
A large proportion of the top 100 cited papers specifically set out to compare Mohs to an alternative or more traditional excision method; 24% of papers were comparison study case series, and another 7% of papers were comparison systematic reviews or metanalyses.A total of 25% of papers were review articles on either Mohs surgery or pathologies typically treated with Mohs surgery, and 11% of papers were published guidelines on the implementation of Mohs surgery.
The most cited paper meeting our search criteria was a systematic review and metanalysis of all studies from 1940 to 1992 on the prognosis of squamous cell carcinoma of the skin and lip.It found that local recurrences occur less frequently when treated with Mohs micrographic surgery.It was published in 1992 and has 981 citations [14], 38 of those 981 citations (3.87%) came in the first five years after publication.The second most cited paper was a review article for the New England Journal of Medicine on cutaneous squamous cell carcinoma.It was published in 2001 and has 845 citations [15].A total of 63 of those 845 citations (7.46%) came in the first five years after publication.
There was a trend towards more citation in the first 5 years after publication over time.Papers from the top 100 that were published in the year 2000 or prior had an average of 22.1 citations in the first five years after publication, whereas papers in the top 100 published after 2001 had an average of 56.0 citations in the first five years after publication (Figure 1).Another landmark systematic review and meta-analysis on the risk factors associated with recurrence of cutaneous squamous cell carcinoma, published in 2016, was the 11th most cited paper with 271 citations.This paper found that tumor depth is associated with the highest rate of local recurrence and metastasis, and tumor diameter exceeding 20 mm is associated with the highest rate of disease specific death [16].Although this paper did not specifically look at patients undergoing Mohs surgery, these findings are both applicable to the field and evidence for the efficacy of Mohs surgery.

Discussion
The analysis of landmark papers among the top 100 most cited in Mohs surgery revealed several key findings.Notably, studies addressing the cost, safety, and efficacy of Mohs surgery were prominent.For instance, Cook et al.'s study in 1998, which investigated the cost of Mohs surgery, ranked as the 50th most cited article with 165 citations [20].Similarly, Connolly et al.'s paper from 2012, focusing on appropriate use criteria for Mohs surgery, garnered 276 citations, emphasizing the importance of safety considerations [21].Additionally, Rowe's meta-analysis in 1992, which assessed the efficacy of Mohs surgery for squamous cell carcinoma, stood out as the most cited paper with 981 citations [14].These influential studies demonstrate that key research supporting the use and application of Mohs surgery continues to be highly cited years after publication.
While it is expected that highly cited papers would tend to be older, a phenomenon known as "obsolescence by incorporation" may explain the absence of Merritt et al.'s landmark 2012 multicenter study on the safety of Mohs surgery from the top 100 most cited papers [22].This study, highlighting patient safety considerations in Mohs surgery, may have been widely accepted and swiftly incorporated into subsequent research, leading to fewer explicit citations.
One important finding from our analysis is the considerable impact of the Dermatological Surgery journal in the field of Mohs surgery.This is the closest to a field-specific scientific journal as there is no publication dedicated to micrographic surgery specifically.Many papers published in this journal garnered significant citation counts, signifying their influence and relevance within the literature.As of 2023, the Dermatological Surgery journal is the 31st highest-ranking journal in the field of dermatology by impact factor, and the fifth highest ranking by h-index [23,24].However, our analysis reveals that it is by far the most impactful journal in the field of Mohs surgery.This discrepancy highlights that viewing a journal's impact within an entire discipline may diminish the nuanced impact that each academic journal has on individual specialties within the disciplines they serve.Further, articles published in an esteemed journal may garner more citations due to their perceived importance, regardless of content.
Another interesting finding from our analysis was the trend towards more citations in the first five years after publication over time (Figure 1).This trend may be explained by topic growth.One previous study on topic growth and citation impact demonstrated that publications in fast-growing topics have a citation advantage compared to publications in slow-growing or declining topics and that using citations as a proxy for research evaluation may give incentives for researchers to publish in fast-growing topics [25].Our analysis supports these findings.Another reason for this trend could be the general increase in scholarly activity over time, with the number of active journals increasing between 3.3% and 4.7% per year from 1900 to 1996 [26].This general trend toward more scholarly volume over time is specifically corroborated by our findings in Mohs surgery as evidenced by Figure 1, which shows a trend toward more citation within the first five years after publication in papers written between 2015 and 2020 as compared to older publications.
It is important to acknowledge certain limitations of bibliometric analysis.First, our search methodology was necessarily broad and thus included papers that were only tangentially related to Mohs surgery or were smaller studies that probably would not be included in a more curated top 100 list.Papers of this sort included in our top 100 focused on topics like the broad management of cutaneous melanoma and Paget's disease or were small scale case reports.These papers were ranked 16th, 32nd, 37th, and 57th in our top 100 [12,[27][28][29].
Further, there are several biases associated with bibliometric analysis.First, self-citation may introduce bias, as authors may cite their own previously published work more frequently.Additionally, the citation count of a paper is influenced by time dependency, with older papers generally having more citations due to their longer period of availability for citation.Moreover, it is essential to recognize potential language and geographic biases in bibliometric analyses.The predominant use of English-language databases may overlook non-English publications and research from specific regions or countries.Therefore, generalizations about the field should be made with caution.
Finally, it is important to acknowledge the limitations of using citations as a sole measure of impact.While citations reflect academic influence and recognition, they may not capture other forms of impact, such as societal or industry influence, policy impact, or practical applications.A comprehensive assessment of research impact should consider multiple factors as a high citation count does not guarantee high-quality research.

Conclusions
In conclusion, our analysis of the 100 most cited papers on Mohs surgery demonstrates the influential role of the Dermatological Surgery journal in advancing the field and catalogs highly referenced works in the field.Noteworthy studies addressing cost, safety, and efficacy have received substantial citations, reflecting their significance within the literature.However, it is crucial to consider the limitations of bibliometric analysis, including time dependency, self-citation, potential biases, and the need for a holistic assessment of impact beyond citations.

FIGURE 1 :
FIGURE 1: Total citations in the first five years after publication for the top 100 most cited papers on Mohs surgery

TABLE 1 : Top 10 journals publishing on Mohs surgery
[13]top 100 most cited papers on Mohs surgery are listed in Table2, arranged in a descending order based on the total number of citations.The total number of citations per article ranged between 115 and 981.The mean number of citations per paper in the top 100 was 198.2.The most recent paper in the top 100 was written in 2019 and has 249 citations[12].The oldest paper in the top 100 was written in 1983 and has 178 citations[13].The 2000s contributed the most papers of any decade to the top 100 most cited papers.
18Surgical excision vs Mohs' micrographic surgery for basal-cell carcinoma of the face: randomized controlled trial Smeets et al.31The impact of in vivo reflectance confocal microscopy on the diagnostic accuracy of lentigo maligna and equivocal pigmented and nonpigmented macules of the face Guitera et al.Journal of Investigative Dermatology 2010 14.21 32 Mammary and extramammary Paget's disease Kanitakis Journal of the European Academy of Dermatology and Venereology 2007 11.53 2024 Nehila et al.Cureus 16(6): e62488.DOI 10.7759/cureus.624883 of 12 Epidemiologic characteristics and clinical course of patients with malignant eyelid tumors in an incidence cohort in Olmsted 35 Mohs micrographic surgery for the treatment of dermatofibrosarcoma protuberans-results of a multiinstitutional series with an analysis of the extent of microscopic spread Ratner et al.Update of the European guidelines for basal cell carcinoma management developed by the Guideline Subcommittee of the Trakatelli et 2024 Nehila et al.Cureus 16(6): e62488.DOI 10.7759/cureus.624884 of 12 64 Diagnosis of nonmelanoma skin cancer/keratinocyte carcinoma: a review of diagnostic accuracy of nonmelanoma skin cancer diagnostic tests and technologies 2024 Nehila et al.Cureus 16(6): e62488.DOI 10.7759/cureus.624885 of 12The role of radiation therapy in the management of dermatofibrosarcoma protuberans Ballo et al.