Ethical Concerns Regarding the Rise of Social Media use in Plastic Surgery

              The World Wide Web is the most disruptive technology of the modern era and allied to this, social media (SoMe), made possible by the introduction of Web 2.0, has created a new communication paradigm. Few, if any, anticipated the influence that SoMe would have on society and industry as a whole, but judging by the market capitalizations of companies like Facebook ($492.6B), Twitter ($11.91B) and Snapchat ($15.94B), and the fact that the average American spends about two hours per day using SoMe,¹ governments, companies and various organizations are being forced to adapt new communications strategies to harness the power and broad reach of this culture-changing phenomenon.

              The healthcare space is steadily grappling with ways to effectively employ SoMe as means for patient communication, conducting research, marketing to consumers, and providing accurate and up-to-date health and wellness education, raising a host of ethical concerns.² In addition to the common avenues of social media discourse (e.g. Facebook, Twitter, Instagram and Snapchat), niche social networks are providing even more focused networks for individuals to vent, ask questions and crowdsource information. In the space of plastic surgery, websites like Real Self and Reddit serve as unique forums for individuals to pose questions and engage in discussions about cosmetic procedures with targeted groups of individuals (and practitioners) who share similar interests and/or experiences whom would be more difficult to encounter in other avenues on the Web.

              Ethical issues surrounding the use of social media in the field of plastic surgery were most notably cast into the mainstream when Dr. Michael Salzhauer, a board-certified plastic surgeon also known as Dr. Miami, began live-streaming plastic surgery procedures to his many followers on Snapchat. Similar to the other SoMe applications listed above, Snapchat allows for a form of microblogging that is open to the public, but where Snapchat differs, at least initially, is that it is primarily driven by user-shared photos and videos that are only available to followers for a short period. Dr. Miami took advantage of this platform and created viral videos that were live, unfiltered and gave the public an unadulterated view of what actually takes place in the plastic surgery operating room. Dr. Miami quantifies his SoMe success on the number of views that occur during a procedure which averages around 1 million, and includes roughly 100,000 viewers per hour.³ A major concern over this form of social outreach is punctuated by the extreme exposure revealed about during their intimate transformation. While many may find this as an invasion of privacy, the majority of Dr. Miami’s patients sought him out because of what they observed on Snapchat, and in fact, approximately two-thirds of his patients sign a consent to have their surgical cases broadcast to the world.³

              Board certified plastic & reconstructive surgeons have increasingly felt the pressure to control the conversation surrounding plastic and cosmetic surgery on SoMe as other physician and surgical subspecialties have moved into this space, offering procedures like breast augmentations and Brazilian butt lifts, often with little to no formal training. It has been demonstrated that a practitioner with a strong social media presence can dramatically improve their perception as an expert in a field by generating online content, regardless of the extent of their training.¹ Above all, this raises safety concerns, as there is a tendency for a subset of the general public to be wooed by fancy marketing schemes and exciting social media presentations when selecting their provider, ignoring what is probably the most important factor when choosing a surgeon: experience and expertise.

              Thought leaders in the space of plastic & reconstructive surgery have made efforts to educate their colleagues on the most effective uses of social media to keep consumers engaged. For instance, in light of the notion that a plastic surgeon should establish a presence on social media to maximize one’s exposure to an untapped patient base, Humphries et al. queried the expertise of the Chair of Advertising at the Savannah College of Art and Design.⁴ They concluded that SoMe has changed the marketing landscape from an emphasis on creating content around a brand to a focus on creating a community around a brand. In order to achieve this, plastic surgeons should incorporate six facets of brand generosity to help build that community which include inspire: give consumers something beautiful and emotive; provoke: give consumers something that makes them think; entertain: give consumers something that’s fun to do; status: give consumers an acknowledgement that others in the industry are doing positive and value-added work; utility: give consumers information that makes their life easier and; access: give consumers something they couldn’t otherwise get.⁴ While these precepts will help traditionally trained plastic surgeons keep pace with the savvier and less qualified competitors in this space, the Plastic Surgery Society as a whole quickly realized an opportunity to harness the power of social medial for far greater endeavors.

              Olivier Branford, a plastic & reconstructive surgeon with over 150,000 twitter followers, has led the charge in galvanizing the efforts of plastic and reconstructive surgery societies to take control of #PlasticSurgery in an effort to focus the message about plastic surgery in a manner that emphasizes safety, evidence based medicine, and best practices, and to dilute out the untrained and frequently off-message voice that has previously dominated the social media plastic surgery conversation. Branford et al. discovered that over 70% of the tweets regarding plastic surgery were made by the general public and the vast majority of these tweets related to celebrity and aesthetic surgery procedures.⁵ Using a non-scientific twitter poll, Branford discovered that 67% of the general public feel that plastic surgeons should be using SoMe as a means to educate the public. Indeed, in the era of social media where the public doesn’t want to be “relentlessly marketed to,” it is up to plastic surgery educators and innovators to become the curators of content from which the public derives their first, and therefore most impressionable source of information on the topic.

              As adults become more informed, increasingly engaged with their healthcare, and learn how to effectively use social media, it is important to understand that the youth, or ‘digital natives’ which include the millennial generation, regularly engage with social media, base their personal identities online, and view SoMe as their natural environment.² In light of this and some of the disturbing practices employed by marketers and social influencers, an editorial from one of the leading medical journals in the world has cautioned its readers to the ramifications that plastic surgery marketing can imprint on the fragile adolescent self-image without proper regard or oversight. Specifically, the author cautions that due to the impressionability of youth with regards to self-esteem and body image, when compared to their older counterparts, that they are more susceptible to the provocative marketing practices that can lead to poorly considered and life changing decisions and this may influence their behavior in perpituity.⁶

              Ultimately, it is the responsibility of practitioners to maintain a level of professionalism in social media that confers a message based on evidence, safety, and that which is within the confines of the Health Insurance Portability and Accountability Act. At the University of California, Irvine, no protected health information should be posted online that can be used to identify a patient without written consent.⁷ After analyzing the protection of information that is posted on social media, Teven et al. became concerned that one of the primary tenets of informed consent is the ability to revoke consent at any time. Unfortunately, due to the nature of SoMe, once information is posted online, one loses sole control and/or ownership of that information.⁸ Due to this fact, Teven et al. advocate an additional, more detailed level of consent be obtained before images are circulated on social media. As we delve further into an age of instant communication, feedback, and interpretation, it is up to plastic surgeons to lead the way with regards to safety, education and best practices as it pertains to communicating in the social media space. But perhaps more importantly, it is up to plastic surgeons to guide the morals of social media messaging and marketing as it relates to target audiences of all ages and interests.

References

1.           Gould DJ, Leland HA, Ho AL, Patel KM. Emerging trends in social media and plastic surgery. Ann Transl Med 2016;4:455.

2.           Denecke K, Bamidis P, Bond C, et al. Ethical Issues of Social Media Usage in Healthcare. Yearb Med Inform 2015;10:137-47.

3.           Schaefer K. How to Snapchat a Brazilian Butt Lift: Crossing the Final Privacy Frontier with Dr. Miami. Vanity Fair 2016 May 13, 2016.

4.           Humphries LS, Curl B, Song DH. #SocialMedia for the Academic Plastic Surgeon-Elevating the Brand. Plast Reconstr Surg Glob Open 2016;4:e599.

5.           Branford OA, Kamali P, Rohrich RJ, et al. #PlasticSurgery. Plast Reconstr Surg 2016;138:1354-65.

6.           The L. Cosmetic procedures: a cause for concern. Lancet 2017;390:2.

7.           Mallory M. HIPAA Social Networking Employee Policy. In: Healthcare UI, ed.2010.

8.           Teven CM, Park JE, Song DH. Social Media and Consent: Are Patients Adequately Informed? Plast Reconstr Surg 2017.