Introduction

Today’s world is changing faster than ever due to worldwide accessibility of the Internet [1]. With the rise of social media mass communication that has revolutionized the way we interact with people and our culture, an unstoppable shift in the dramatically changing social mind-set and consciousness has resulted from the “new media” revolution [1,2,3]. Six Degrees, the first recognizable social media platform, was created in 1997. In 1999, the first blogging sites became popular, following which social media began to explode in popularity. Sites like MySpace and LinkedIn gained prominence in the early 2000s. Culture and social engagement witnessed drastic changes since the advent of Facebook in 2004. YouTube came out in 2005 and by 2006 Facebook and Twitter became available to users throughout the world. The tremendous variety of social networking sites available today has created an environment with endless possibilities of interactive communication where users can reach specific audiences and a maximum number of people [4,5,6].

The use of Internet for collecting health-related information is increasing among the general population and has changed how information related to medicine might be obtained [7]. Due to cultural predisposition, aesthetic plastic surgery is inherently receiving more attention [8]. Moreover, as we are embracing the evolution of marketing strategies, the use of social media sites and platforms has grown in numbers by leaps and bounds with an enormous seemingly limitless potential to reach and geographical locations [4, 9,10,11,12,13,14]. Social media, the most powerful marketing tools one can use to portray a sense of expertise and promote his practice, are impacting tremendously for better or for worse on the current practice of plastic surgery. It has undoubtedly changed the way plastic surgeons engage with their patients [15,16,17]. With social media, a surgeon’s sphere of influence is strongly amplified [18]. When used correctly, social media can offer tremendous benefits, for both educational and marketing purposes, particularly for the growing millennial population [19, 20].

Surgeons utilize now social media for marketing and branding, educating the public, communicating directly with patients, and for the maintenance of a successful practice [5, 17, 21]. Given the current cultural climate and the expectations of the public, social media engagement is inevitable [5]. Apart from the traditional ways to measure the success of a physician, “social media currency” will be tomorrow’s yardstick by which professional success, potential, and public influence of a surgeon might be measured [11]. There is, however, a gap between what is being shared and how likely the intended audience is to understand it [14]. Regardless of some negative consequences, there is no doubt that the marriage of aesthetic plastic surgery and electronic platforms is here to stay for at least the foreseeable future [16, 19].

As the demand for elective plastic surgery, in particular for aesthetic procedures, continues to rise, there is a need to evaluate the influence of social media advertisements, how it motivates the public to undergo plastic surgery procedures, and how it impacts on the practice of plastic surgery [4, 22]. Most importantly, there is an urgent need to determine how the social media are impacting plastic surgery practice building and what is proper and efficient marketing while upholding ethics of the medical profession? [1].

Materials and Methods

A PubMed search of title and abstract keywords “plastic surgery,” “aesthetic surgery,” and “social media” of related publications over the very limited time frame of the last 2 years from 2018 till present identified 42 papers and 28 letters-to-the-editor, discussions, and comments that were most relevant witnessing to the great importance and the interest this topic elicits in modern aesthetic plastic surgery practice.

A more thorough PICO tool-based comprehensive literature search for “social media versus no social media for practice of plastic or cosmetic or aesthetic surgeon or surgeries” was conducted from 2015 till present. Advanced PubMed search for the terms ((((“social media” OR “social-media”) AND (“plastic surg*” OR “aesthetic surg*” OR “cosmetic surg*) AND (career))) OR ((“social media” OR “social-media”) AND (“plastic surg*” OR “aesthetic surg*” OR “cosmetic surg*) AND “consult*” OR ((“social media” OR “social-media”) AND (“plastic surg*” OR “aesthetic surg*” OR “cosmetic surg*) AND (refer*)) identified 107 publications. After reviewing all the titles, 32 publications were excluded for irrelevance. Excluding also letters-to-the-editor, comments, and editorials, 59 peer-reviewed publications with abstracts were found to be relevant to the use of social media in plastic surgery and were selected for this review. After viewing all selected manuscripts, eight general reviews, analyses, and presentations were excluded leaving 52 publications for the final analysis.

Results

Of these 51 peer-reviewed publications, 15 are patient-centered, 33 provider-centered 13 of which are descriptive, and three combined patient/provider by the same first author. One patient-centered and 15 provider-centered manuscripts are reviews or general analyses. Patient-centered studies focus was on patient greatest use, engagement, and perspective regarding social media, while provider-centered reports dealt with plastic surgery perceptions in social media, patterns of use, plastic surgeons' communication methods with the public, practice promotion, and ethical considerations.

Seventeen manuscripts are studies based on surveys, seven patient-centered, seven provider-centered, and three combined patient/provider studies. Others were mostly Web site searches of various posts, platforms, and trends. Details of all publications included in this review are provided in Tables 1, 2, and 3 and Fig. 1.

Table 1 Patient-centered manuscripts included in the review
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Table 2 Provider-centered manuscripts included in the review
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Table 3 Combined patient-/provider-centered manuscripts included in the review
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Fig. 1
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Distribution of manuscripts included in the review regarding study design

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Discussion

Social media is defined as Web-based and mobile technologies intended to make communication an interactive dialogue, and social media marketing is the use of these social networking sites to promote commercial enterprises [51, 54]. In a medical practice, the primary role of social media is to provide information [61]; however, it is taken for granted by most surgeons that attracting more patients and increasing revenue is the main goal in creating or increasing Web presence [57].

Plastic surgery is a unique deep-rooted service-based surgical practice with many cutting-edge developments. It relies essentially on word-of-mouth referrals from other physicians and patients’ family and friends [39, 44]. Word of mouth is a most persuasive form of promotion allowing direct to consumer marketing. It is essential for early branding to rapidly grow a new practice base; however, it does not necessarily offer continued growth [18]. Given the consumer-driven nature of plastic surgery and its high public profile that relies on visual results, its services have been significantly affected by the new media revolution that has provided a new platform of interaction greatly magnifying word-of-mouth benefits ensuring as well the potential for sustained and continued practice growth [3, 11, 18].

Despite the fact that online communication cannot substitute for the patient–physician encounter, 59–70% of plastic surgery patients believe that the Internet and the social media are a source of unbiased opinion and are a valuable resource for evaluating surgeons and understanding potential surgical procedures [1, 5, 11, 43, 65]. A vast majority of plastic surgery patients, particularly with higher income and education, utilize online rating services nowadays to identify a plastic surgeon and are increasingly searching the Internet before a consultation. Patients are most interested in before and after photographs and information about the surgeon’s practice; live videos are considered as their favorite social media format. Potential patients are also interested in real patient testimonials, treatment videos, doctor’s videos, doctor’s blogs, and in posts of contests to win a free treatment or product [11, 36, 66]. There is, however, in general, lack of studies conducted to determine the factors that influence the decision of patients to undergo a plastic surgery procedure or treatment after viewing these posts and advertisements [22].

The competitive market, coupled with patients’ growing expectation of continuous personal contact and mounting new technological and conceptual challenges, poses new challenges to the plastic surgeon [11]. Failure to adopt new methods of communication to stay visible and to meet the increasing number of patients searching online for information would render a surgeon obsolete rapidly leading to irrelevance and failure of his business as a whole. It may lead patients down a path toward less qualified “cosmetic surgeons” [51, 67, 68]. The days of relying on word-of-mouth and academic pedigrees for practice building seem to be long gone [36]. At present, a significant determinant for patients’ decision to undergo cosmetic surgery, particularly for patients 21–30 years old, is surgeon’s self-advertisement on any form of social media [4]. Those aged younger than 35 years are 3.9 times more likely to follow plastic surgeons on social media than older patients who are 3.13 times more likely to rely on their friends’ opinion and are 1.92 times more likely to be indifferent to a plastic surgeons’ social media professional activity [25]. A recent survey utilizing several new research tools, importantly Amazon Mechanical Turk (Mech Turk) and presenting a crowd-sourcing-based assessment of patient preferences related to social media conducted by Nayyar et al. [33] on Internet users considering having a facial rejuvenation procedure with a mean age of 40 years (range 22–74 years), concluded that only 33% ranked social media as the most important attribute determining their choice with the most preferred platform being Facebook (53.65%) followed by YouTube (44.72%).

Few years ago, social media were believed to have no impact on practice building. Now, some years later, they became a popular means of advertisements for professional providers [22, 36]. In an increasingly competitive market with many presenting themselves as plastic surgeons performing procedures outside the scope of their training [68, 69, 53], social media have been demonstrated to be a powerful tool for genuine plastic surgery marketing, branding, communicating, and educating the public, particularly in cosmetic surgery and medicine [1, 11, 22, 43, 67]. Social media are even gradually eclipsing plastic surgeons’ practice Web sites and other traditional electronic marketing platforms [36]. Similar to private practice, social media use in academic plastic surgery is growing exponentially to promote plastic surgery training programs and improve their reputation. Nevertheless, academic surgeons are still reluctant to adopt a higher acceptance of social media use [16, 19, 20, 53].

Although some surgeons feel social media have impacted them positively, others on the contrary describe their impact as negative [17]; nevertheless, reliance on social media to improve practice has been increasing steadily [11, 19, 48, 69]. Unfortunately, available evidence on how social media influences the medical practice and how it helps to promote one’s career is scarce [63]. Though it is widely acknowledged that number of aesthetic procedures performed can increase following posting on a physician’s social media review Web site [15], this current literature search could demonstrate only few publications with hints as to its efficacy. In one study, a statistically significant positive correlation between average annual Google search volume of “breast augmentation” and the annual volume of breast augmentations performed in the USA was demonstrated by Wilson et al. [31]. Analyzing Google search data using Google Trends, Ward et al. [27] examined the impact of highly publicized plastic surgery-related events on the interest level of the general population. The authors reported that after Kylie Jenner announced that she had lip augmentation injections, interest level in fillers increased by 30.31%, while interest level in plastic surgery decreased after Joan Rivers’ death by 21.3%. To quantify the return on investment for social media in plastic surgery, Gould and Nazarian [18] conducted probably the first study to transparently quantify the value of social media in a start-up practice in Beverly Hills without preexisting clients and with a broad approach to marketing. They demonstrated that social media have a relatively high return on investment. They create the potential for better customer insight and better accuracy of market intelligence. Interestingly, the authors have observed that after the social media establishment phase of the practice, referrals from word of mouth begin to grow, confirming the critical importance of this traditional form in developing a patient base. This may explain why some platforms have no effect in established practices, as established referral patterns are already in place [18].

Choosing the right digital platform to attract the right public attention is certainly critical for effective engagement with prospective patients [11, 36]. There is, however, no single best social network; instead, various networks exist with unique characteristics and each has the potential to attract patients and promote a practice [47]. Nevertheless, the debate continues about the superiority of Facebook, Twitter, Instagram, Snapchat, Pinterest, or YouTube [3]. Studies have confirmed that Facebook has the greatest plastic surgery patient use and engagement with YouTube second in use; Instagram is second in number of engaged users, and Twitter is the least popular network [1, 24, 34, 36, 70]. Surprisingly, there is a significant disconnection between plastic surgeons and the highest impact platforms. Most still prefer to focus electronic marketing efforts on practice Web sites instead of social media platforms, and only 15% of them post on social media daily [1, 3, 36], 63% on Instagram compared with 18% on Facebook, and only 13% on YouTube [11]. Twitter is popular among plastic surgeons. Though this platform does not operate with a business-minded approach and may not be the best for commercial use, it is nevertheless a good platform for reaching patients offering a more personal experience with less negative behavior like shaming [11]. Unfortunately, most surgeons’ posts on Instagram are not educational with 83% being self-promotional [11, 19, 53]. It is alarming also to note that the minority of social media content related to plastic surgery is produced by worthy well-trained experts. Most content is posted by patients or by providers with less training and expertise, or with no medical background at all. As an example, 70.6% of posts on Twitter are by patients versus only 6.0%, by plastic surgeons [42, 68]. Though use of professional social media by plastic surgeons is rising, a dichotomy in its acceptance as a valuable and efficient way to increase visibility and develop a patient base still exists. Younger surgeons and surgeons in private practice are more likely to view social media as an acceptable method of reaching patients [37]. Plastic surgeons are certainly lagging behind in the growing competition for attention; very few know how to effectively take advantage of this expanding communication tool [11].

It is legitimate to advertise and make one’s services known. Social marketing as a driver of growth is definitely understandable. It is understandable also that to ensure that their brands stay ahead of the competition, many plastic surgery practices are employing services of professional social media marketing companies capable of developing solid strategic and tactical plans [54]. But as plastic surgeons are engaging more frequently and forcefully in social media’s many forms of communication, entertainment, and marketing, they are increasingly tempted to skirt the limits of professionalism [71]. Many are compelled to “outdo” competitors by pushing the boundaries of their posted contents [25]. Social media are a domain with potential professional pitfalls creating a nebulous zone of comfort between patient confidentiality and entertainment [19]. The line between innocent information and misleading deceptive information is very thin [11, 19]. Social media may convey certain controversial personal point of views that are lacking scientific basis [6, 53]. Platforms may be paid or sponsored to promote medical brands, and followers can be purchased same as viral marketing for Web top pages prominence. Thus, increased visibility and the number of followers do not reflect a surgeon’s experience, skill, or dedication to education [3, 5, 6, 11, 19, 51] making rather obsolete the metric utilized to guide ranking and trending on which potential plastic surgery patients base their decisions [6]. While there are tools to distinguish automated bots from regular user accounts, plastic surgery consumers in particular have little or no experience with these tools. Moreover, they may not have experience with some forms of advertising in the social media space and may have great difficulty in distinguishing paid advertisement from independent organic user-generated content.

Sensational provocative and titillating content of some posts is even more disquieting [5]. The latest surge in video sharing and live broadcasts of aesthetic surgery operations is a source of real concern. These, besides being viewed as entertaining rather than educational and representation of patient care, may constitute potential but serious breaches of patient confidentiality that are not without serious consequences [5, 66, 72]. Moreover, photographs and videos graphically capturing sensitive anatomy in sometimes a casual manner render social media posts potentially unprofessional and disrespectful [5, 25, 67]. Little is known also about how the public stands on ethical debates regarding surgeon’s posting on his or her personal life and bluntly advertising one’s skills and credentials [25].

Social media platforms are very difficult if not impossible to monitor, control, and regulate [5]. Lack of regulation, oversight, rating scales, authentication protocols, and enforceable accountability may increase social media users’ vulnerability to exploitation [3]. Ultimately, the public expects professional conduct [8] and many question the ethics of surgeons’ social media practices [72]. However, identifying inappropriate social media content is not given; there is no clear definition in the literature about what constitutes both professional and ethical conduct [5, 67]. Moreover, it is often unclear where ethics ends and professionalism begins [71]. As plastic surgeons, serious reflection is in order whether this is the trajectory we want for our profession. If not approached with caution, social media may invite significant risks particularly since a large percentage of its audience is young and likely immature [6, 19, 67]. It may well be a quick way to end a plastic surgery practice [19].

As bluntly stated by Devitt and Kenkel [6], currently “surgeons promote their work, they gain followers, their practices potentially become busier, they do more cases, and they make more money.” Some colleagues unfortunately are becoming entertainers more concerned about their star image on social media than patient care. With more likes and followers, priorities unfortunately are shifting [6]. The real danger of social media resides also in the fact that nowadays patients can no longer decipher what a plastic surgeon really is. As stated in a recent editorial, “well-trained plastic surgeon” has been replaced by “influencer” or “public figure,” “educator” replaced by “entertainer,” “professional” replaced by “promoter” [19].

Conclusion

To date, quantifying the value of social media in plastic surgery is still elusive [18] and delineating how the patients engage online remains largely undetermined [25]. Most reviewed publications are subjective opinions with limited objective data about the real impact if social media in plastic surgery. Unfortunately, scientific posts fail in attracting people [12]. A post that is 100% ethical and 100% professional may also be 100% ignored [73]. “The Social 80/20” principle advises that for effective and successful social media engagement, any business or practice should not “ask” for something on its social media pages any more than 20% of the time giving freely interesting information for the remainder of the interactions while refraining at the same time from self-serving messages bragging about the qualities of the practice and the services it renders [54].

Social media platforms are powerful communication tools; with this power comes great responsibility [48]. Social media have been credited with the potential to transform medicine [74], but as in many other areas, plastic surgeons are at the frontier of developing novel ideas and products and have the opportunity to pioneer social media in medicine and set the bar high for all [20, 44]. Unfortunately, they are still lagging behind in this domain. It is probably the time now, as rightly stressed by Cho et al. [55], to recognize that plastic surgery residents should receive as part of their curricula special formal training in the proper and ethical use of social media. Ongoing courses online or at national and international conferences addressed to plastic surgeons in practice are also needed regardless of the fact that the most effective and professional manner to promote one’s practice while respecting general medical ethics is still unknown territory. How to strike a fair balance remains a difficult question; it does not need, however, to be impossible.

The issue is certainly complex and the challenges are enormous, but obviously, as eloquently stated by Fan et al. [25], “engaging potential patients through their preferred methods of communication will be the key to continued growth of practices and the field as a whole.” Facebook tends to be most favored among the older generation, while Instagram is more popular among younger patients with Twitter emerging as a new source for news and discussion [23, 25, 75]. When it comes to the ethical implications of social media, establishing ethical and professional guidelines is not easy. Even great philosophers might have been challenged by the task [73]. Moreover, rapid expansion and development of social media platforms are outpacing any codified ethical and professional guidelines [8]. It would be presumptuous for anyone or any organization to claim that strict regulations of social media content that may be difficult if not impossible to enforce would avert many of the pitfalls. Instead, expert guidance by professional national and international societies while keeping pace of the rapidly changing space and nature of the platforms is what is mostly needed. It must be kept, however, in mind that as familiarity with social media grows, attitudes toward practices may change with time and what was once abhorrent can become acceptable in a not so far future.