AbstractPlastic surgeons have evolved their methods of reaching potential patients by using various forms of social media. Such platforms can educate, inform, and, for some, entertain. Social media now allows consumers to compare themselves to a much wider, if not global, set of peers that might further exacerbate their anxiety regarding their appearance. Plastic surgeons should ensure that use of patient images does not violate privacy or create unreasonable expectations about the results that can be obtained; nor should plastic surgeons’ marketing objectify women. Professionalism on the part of plastic surgeons, along with the utmost respect for patients, must remain paramount.
The internet has been a boon to the marketing of plastic surgery, as surgeons, patients, and entrepreneurs have developed ways to satisfy the public’s desire for hearing real patients’ stories, seeing before-and-after photos, and having a front-row seat in the operating room to observe the performance of various procedures. Surgeons post videos of surgical procedures on their personal websites, as well as on YouTube and Snapchat. Some surgeons tout the educational aspect of such videos and their ability to allay patient fears regarding surgery . Many patients have written about their cosmetic surgical experience, posting on blogs or posting testimonials on their surgeon’s website. Web entrepreneurs have cashed in on this hunger by creating sites like RealSelf, Healthgrades, and Vitals®, which enable patients to rate surgeons and procedures as well as providing a forum where patients can query surgeons. Plastic surgeons who were early adopters of the internet and social media found their practices flourishing, as the celebrity associated with being an online sensation translated into instant credibility and long lines of prospective patients [2-4]. Some physicians have even gone so far as to “franchise” their online personas to earn money, helping other surgeons achieve similar success . Online marketing raises a number of ethical issues, some of which have been addressed in professional guidelines.
Ethical Issues in Online Marketing of Plastic Surgery
The American Society of Plastic Surgeons (ASPS) lays as its cornerstone the promotion of the highest standard of personal and professional conduct among its member surgeons. The ASPS Code of Ethics demands that no communication with the public be false, fraudulent, misleading, or deceptive. ASPS members are to render services with the “full respect for human dignity” and to give each patient the “full measure of service and devotion” . In all public communications, which include all print or online marketing, members “shall strive to use accurate and respectful language and images” . However, the authority of a professional society’s code of ethics is limited by governmental regulations regarding restraint of trade . Because ASPS must rely on its members’ personal professionalism for the maintenance of respectful standards for advertising, professionalism and ethics have become a key part of the core curriculum of plastic surgical residency training .
Unfortunately, some posted videos have raised ethical concerns because they feature surgeons dancing and singing in the operating room, telling jokes to a camera instead of focusing on the patient, or cradling removed body parts in their arms like a baby [11-13]. Members of ASPS have been justifiably outraged when viewing such videos. Complaints have been lodged with the ASPS Ethics Committee for investigation. In fact, the ASPS Code of Ethics demands that members “expose, without hesitation, illegal or unethical conduct of fellow Members of the profession” . The ASPS Ethics Committee carefully evaluates any complaints. Those members found to be in violation are referred to the Judicial Council for adjudication. The member might simply be asked to make a correction or to withdraw the offending advertisement. In severe cases, a violation might result in a member being asked to resign or being expelled from the society . The second author (DJJ), who has served in leadership positions in ASPS, is aware of several such cases. To take one example, the ASPS Code of Ethics prevents plastic surgeons from offering surgery as a contest prize or even as a donation to a charity auction. When the reality television program The Swan aired in 2004, it featured a competition wherein “ugly duckling” personal stories were compared. The contestant with the most compelling story was awarded free plastic surgery. The surgeon involved is no longer a member of ASPS. As another example, a Snapchat posting of an ASPS member surgeon singing a rap song was deemed a violation not because it included expletives but because the ASPS member surgeon claimed superiority over other plastic surgeons, which is also a violation of the ASPS Code of Ethics. In this case, the surgeon was required to remove the posting.
Attempting to judge the ethicality of videos in which plastic surgeons show consenting patients and their procedures is much more subjective. The patient might be relatively nude, sometimes with strategically placed emojis covering nipples or genitalia. As such, these graphic videos can serve as unintended entertainment. The second author (DJJ) became aware of one surgeon’s Snapchat postings when a preteen related that she and her friends excitedly gathered daily to watch his videos of naked women undergoing surgery. While some might be offended by such nudity and the often lighthearted banter between patient and physician that accompanies it, patients have given written consent to have their body filmed and the images posted to the internet. Michael Salzhauer says patients particularly seek his services in the hope that their surgery will be posted on Snapchat or featured on his television program .
Guidelines for the Use of Patient Images on Social Media
The ASPS Code of Ethics contains general guidelines for the use of patient images. Patient images placed in a journal article, textbook, an educational PowerPoint presentation, or online require the patient’s consent . Patients have every right to refuse this use of their personal images. There can be no coercion on the part of a plastic surgeon to get a patient to participate in online marketing. Patients should, however, be informed that once an image is posted online, it might be permanently discoverable. Clark Schierle’s group at Northwestern recently published video recommendations, which basically reiterate the Code’s requirements . They also suggest the use of an independent videographer so that the surgical team’s attention is focused on the task at hand and not distracted by the filming of the video .
Patients who decide they no longer want their images used for educational or marketing purposes might find it is difficult to remove undesired images from the internet . Depending on where an image is posted, ownership of the image can default to the business entity that owns the website . Thus, both the patient and the physician can lose control over the images.
When filming a surgical video, the surgeon should put the patient’s safety and welfare first and foremost. Procedural videos, while educational, should never pull the surgeon’s attention away from the patient. Patient video images must be respectful and appropriate. Identifying marks or tattoos should be covered or eliminated, body parts not essential for understanding the procedure shown should not be in view, and all metadata attached to images must be scrubbed to prevent patient identification . Ideally, plastic surgeon websites should demonstrate real people with real outcomes, so that prospective patients can understand the variability and reality of achievable results . When models are used, they must be identified as such, and it must be clarified that “the model has not received the advertised services” .
Finally, there are ethical considerations regarding which patients are appropriate candidates for surgery. While some would never consider surgically altering their bodies, for many people, the correction of perceived faults is acceptable. It has been demonstrated that cosmetic surgery can improve self-esteem and confidence [18, 19]. Plastic surgeons are tasked with determining when patients have a “healthy” concern regarding their appearance and must strive to avoid treating patients with body dysmorphic disorder or those whose concerns far outweigh their perceived deformity [20-22].
The internet and social media have increased the penetration of cosmetic surgery into the public’s consciousness. Plastic surgeons are keenly interested in performing desired surgery and being remunerated for doing so, but they must strive to advertise in a professional and ethical manner. To maintain the respect of medical peers and the public, it will be critical for plastic surgeons to use social media to provide factual information regarding cosmetic surgery while protecting patient identity and professionally caring for the patient population. The ASPS, through its Social Media Subcommittee, monitors this ever-evolving landscape and will continue to provide education and guidance to its members and the public.
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