The World Wide Web has evolved into a global network linking more people, businesses, and institutions than any other single communication channel.1 It is an expansive tool with seemingly endless implications for the modern plastic surgery practice. The ease with which ideas can be exchanged through the Internet will undoubtedly continue to alter how we conduct the business aspects of our practices and the process by which patients make choices about the services we provide. In a recent study, Walden et al2 demonstrated the power of the Internet in influencing patients’ choices regarding breast augmentation. They reported that more than half of patients began their search for information about the procedure via Web searches: 41% with Google, 18% with a breast augmentation portal website (such as http://loveyourlook.com), and 11% with a plastic surgeon’s website. Only 10% first consulted with a plastic surgeon.

Recognizing the vast power of the Internet, many plastic surgeons have developed practice websites to offer prospective patients information about their credentials, practice philosophy and facilities, and basic questions-and-answers about procedures. Yet most plastic surgery websites are static, rather than interactive, at a time when modern consumers have grown to expect a high degree of online interactivity. This expectation is evident in the increasing popularity of social networking and “social media.”

The term social media includes many individual Internet applications that provide different but complementary functions. Facebook, Twitter, Linked-In, Google +, Yelp, and Realself are examples of social media or “social networking sites.” With Facebook boasting 750 million active registrants and Twitter claiming 175 million, there is obviously widespread and continued growth in this arena. As experience with social media outlets has increased, the applications for plastic surgery have grown far beyond personal communications. Plastic surgeons are entering this nontraditional marketing space in increasing numbers not only to connect with their patients but to educate the community, advertise, and remain competitive. Social media offer an inexpensive yet expansive marketing tool with built-in data tracking capabilities.3 Social networking sites that provide weekly reports on user activity—such as number of “hits” and user demographics—offer a method to help us begin to gauge return-on-investment. However, even if a surgeon has registered for a social media profile, how does he or she know that the page is reaching a large number of potential or existing patients? What characterizes these “social media users,” and do their demographics match those of our typical patient populations?

Numerous surveys to investigate common characteristics of plastic surgery patients utilizing social media have demonstrated that they tend to be a younger, employed, and educated group.4 Surprisingly, however, sites such as the social media giant Facebook have seen significant growth in users older than age 55, up 922.7% from 2009 to 2011. Clearly, it is important for plastic surgeons to connect with the increasingly Internet-savvy patient population by becoming educated about and involved in social networking.

Social media have already been embraced by professional plastic surgery organizations, including the American Society for Aesthetic Plastic Surgery (ASAPS) and the American Society of Plastic Surgeons (ASPS), both of which have incorporated Twitter, Facebook, and YouTube (as well as iPhone) applications into their national meetings and their websites.4 In addition, ASAPS and ASPS have developed separate websites devoted to patient interactivity, such as Project Beauty (http://www.projectbeauty.com) and Beauty for Life (http://www.beautyforlife.com). Project Beauty and Realself, with their “ask-a-surgeon” features, are social media outlets that seek to inform the public about cosmetic surgery while allowing users to solicit answers to their plastic surgery questions in real time. This type of interactivity is valuable in helping patients feel “connected” with their surgeons or other medical experts.

Impact of Online Tools in Plastic Surgery Practices

The Positives

The potentially positive impact of social media outlets on practice marketing is obvious. Social networking can help your practice to become part of mainstream conversation. Tools like a “wall post” on Facebook (a post to the user’s profile space that includes the date and time the message was written) or messaging on Twitter have facilitated open communication and personal sharing of experiences. Many people choose to share their plastic surgery experience through simple photo and video uploads via smartphones, tablets, and other accessible handheld devices that can instantly post a message on Twitter or load content onto their Facebook pages for others to view. This is a unique opportunity to have your practice name “tagged” and expand your reach through social media “friend” connections.

In our own practice, a recent patient posted her excitement about a new treatment received in our office. This post generated 10 to 12 new posts about the treatment and created a “buzz” for this service in our practice. After these posts, we noted an increase in bookings for this service over the next three weeks.

The Negatives

The ability to stimulate interest in new procedures and treatments through favorable postings or reviews is obvious, but what about the impact of negative comments? Sites that allow for free posting of positive comments—including Facebook, Twitter, and “ask-a-surgeon” forums on Project Beauty and Realself—also provide users with the ability to post negative comments about a particular treatment or practice.5 For the plastic surgeon, handling these negative reviews in a constructive manner is essential. For example, consider the patient who posts a comment about her displeasure with resultant scarring at only 10 days postoperatively. An appropriate online response from the physician would attempt to educate this patient on the expected time for the scar to improve and mature to its final state. Such a response enables the physician to demonstrate his or her knowledge, attention to patient-centered issues, and compassion. Although this activity requires time and effort, it can turn a negative statement into a positive reflection of your practice.

Additionally, sites such as Yelp allow patients to provide positive or negative reviews but without the opportunity for online response. Unfortunately, the negative reviews may draw significant Internet traffic (no matter how few they may be in relation to positive comments). The only option is to discuss with the Web content owners the policy for time limitations on such postings. Threats of litigation or other harsh communications seldom produce the desired result and usually do more harm than good.

Not Necessarily for Everyone

Social media are still evolving, and it is certain that many changes lie ahead. As mentioned earlier, the ability to reach patients in a meaningful way through social media has been demonstrated. However, it remains unclear whether participation in social networking has yet become an absolute necessity for every plastic surgeon seeking to grow his or her practice.6,7

Traditionally, many people choosing plastic surgery have valued the utmost in discretion, and practice growth has relied heavily on word-of-mouth. This challenges the emerging notion that one must actively engage in online activities and social media to attract patients. Many surgeons with practices primarily devoted to facial procedures (especially facelifts) may feel that discretion in the public sphere is still most appropriate. These types of practices typically serve an older and more reserved patient population that may be less inclined to use the Internet to find a surgeon, less likely to engage in social media, and more likely to select a surgeon based on word-of-mouth recommendations and local reputation. However, all this can be expected to change in the near future, as the population older than age 50 becomes more comfortable and engaged with the Internet and social media.

The Need to Maintain Confidentiality

Another area of concern is maintaining confidentiality in the era of online networking tools. Careful review of all information that is shared by the practice via social media is essential to prevent any breach in confidentiality. To our knowledge, there is no report to date of a court decision finding a physician liable for malpractice on the basis of participation in telemedicine.8 Still, a physician must be diligent in establishing appropriate boundaries on online communication with patients.

The courts have drawn a distinction between passive sites (which seek to be informational) and active sites (which are providing specific medical advice sufficient to constitute a doctor-patient relationship and are considered commercial). The latter could allow for personal jurisdiction and expose the physician to legal action. Interactive sites generally fall somewhere between the categories of passive and active websites. It has been suggested that physicians engaged in interactive sites can avoid out-of-state personal jurisdiction by including a disclaimer that clarifies that the information provided is educational, does not constitute a second opinion, and does not create a physician-patient relationship.8

The Future

The practice of marketing medical skills developed slowly. For many years, it was considered taboo for plastic surgeons to advertise or engage the public about our services. Today, most plastic surgeons would agree that it is reasonable and ethical to inform the public about who you are and what you do and to provide details about your personal qualifications and the surgical procedures you perform.9 The ways in which we communicate this information will continue to evolve. Although the social networking outlets of today, such as Facebook and Twitter, may eventually be replaced by others, it appears that social media are here to stay. Optimal strategies for involvement in social media are a “moving target.” However, such strategies are likely to become even more important in the future. It is imperative for the plastic surgery community to remain at the forefront of this potentially powerful marketing medium.

The objectives of building an Internet presence and participating in social media will vary from practice to practice and should be carefully considered in relation to return-on-investment. The time commitment required for this activity is significant and may best be handled by hiring a professional website developer, graphic designer, and writer. However, practitioners must remain aware of their personal responsibility. Plastic surgeons should consult with the ASPS/ASAPS Code of Ethics to ensure that their posts and websites are deemed appropriate.9 Reviewing Internet-based content with an attorney will provide additional assurance of meeting the highest ethical and legal standards.8 Plastic surgery websites and interaction with patients via social media play an important role in forming patients’ attitudes and beliefs about aesthetic surgery and what it can do for them. For this reason, more than any other, plastic surgeons should get involved and lead by example.10

In future issues of Aesthetic Surgery Journal (ASJ), you can expect to see more articles, opinions, and research on technologies affecting online communication and the business of plastic surgery. Such technology has become increasingly important not only to physician practices but also to the world of journal publishing.11 To better serve its readers and authors, ASJ is actively engaged in social media through participation in Facebook, Twitter, and YouTube. Further expansion of our website’s (http://www.aestheticsurgeryjournal.com) interactivity may include such features as Rapid Response (allowing users to post comments online about specific journal articles in real time) and the development of private online communities where subscribers can share their clinical experiences. There is much more to learn about the impact of social media, as well as its benefits and risks. As we move forward, ASJ welcomes your input and suggestions.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

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