The Positive Patient Experience: A Comprehensive Analysis of Plastic Surgery Online Reviews

Abstract

Background

Subjective online physician evaluation is an important component of patient decision-making. Understanding reviews may improve satisfaction and build positive online reputation.

Objectives

The aim of this study was to analyze and compare the top predictive factors driving patient satisfaction across the most popular plastic surgery procedures.

Methods

Online reviews were analyzed from RealSelf, Yelp, and Google for the 5 highest-rated plastic surgeons in 6 US metropolitan areas. Blank, non-English, consultation, duplicate, and unrelated reviews were excluded. Data from free-text reviews included physician rating, patient-reported reasons for rating, procedure, and complications. Univariate analysis was performed to compare predictive factors of online ratings.

Results

In total, 11,078 reviews were included. RealSelf had the highest average rating (4.77), and Yelp had the lowest (4.66). Reviews in Miami, Philadelphia, New York City, and Chicago were mostly published on RealSelf, whereas Houston and Los Angeles mostly used Google and Yelp, respectively. Reconstructive procedures were rated significantly higher than cosmetic procedures (P = 0.035). Aesthetic appearance was the strongest predictor of rating across all procedures. Buccal fat removal (98.8%) and abdominoplasty (98.1%) had the highest satisfaction, and Brazilian butt lift had the lowest (88.2%) (P < 0.001). Additional significant contributors included staff interaction, bedside manner, health outcomes, complications, and postoperative care (P < 0.001).

Conclusions

Although aesthetic outcome is an important predictor of satisfaction, other aspects of care, such as bedside manner and staff interaction, provide an important foundation of support. Excellent patient-surgeon communication and postoperative care may mitigate patient dissatisfaction and elicit high-satisfaction online patient reviews.

See the Commentary on this article here.

The influence of patient satisfaction has become increasingly important in measuring healthcare quality. With the growing presence of the internet and social media in healthcare, subjective online reviews and ratings of surgeons increasingly serve as proxy for surgeon reputation.¹ In 2014, 59% of patients considered online patient reviews important when selecting physicians. Both reading and writing peer-sourced reviews is expanding,² particularly in plastic surgery, which has the highest number of per-physician ratings among medical specialties.³

Patient feedback can help physicians identify aspects of care that patients consider to be most important. Previous studies have found professional reputation to be the single most important factor in a patient’s choice of plastic surgeon.^4,5 Concerns that reviews unfairly portray a negative image of the physician are largely unwarranted because previous studies have shown that most online reviews are overwhelmingly positive.^6,7

Studies of the patient experience have shown a correlation with satisfaction.^6-9 Khansa et al analyzed morphologic and functional reasons contributing to patient satisfaction in rhinoplasty; ⁸ Qiu et al and Dorfman et al further identified nonsurgical elements, such as interactions with office staff and the surgeon’s bedside manner in abdominoplasty and breast augmentation, respectively.^6,7 Domanski et al employed RealSelf (Seattle, WA) to compare the “worth it” scores among various plastic surgical procedures, although reasons for ratings were not analyzed.⁹

To the best of our knowledge, no study has yet performed a comprehensive examination of procedure-specific factors impacting patient satisfaction. To do so, we compared online patient reviews across Google (Menlo Park, CA), Yelp (San Francisco, CA), and RealSelf, chosen for their popularity, their authority in the plastic surgery community, and their inclusion in previous studies.^6-9 Our first aim was to identify the top determinants of satisfaction regarding plastic surgeons; our second aim was to compare and contrast the magnitude of satisfaction across multiple procedures in plastic surgery. The results may serve as a guide for surgeons to tailor patient experiences based on the specific wants and needs of certain patient populations.

METHODS

Data extraction was performed on records pulled from the review platforms Google (www.google.com), Yelp (www.yelp.com), and RealSelf (www.realself.com) between June and August 2021. Geographical locations of interest consisted of the 5 most populous US metropolitan cities: Los Angeles, Houston, New York, Chicago, and Philadelphia. Miami was also included for its substantial plastic surgery presence and use in other geographic studies.^6,10 The top 5 most-rated plastic surgeons from each city were identified by the search terms “plastic surgeon” and “plastic surgery.” For each database, all individual free-text reviews and corresponding ratings for each surgeon were saved into a database for further analysis. For each procedure on RealSelf, additional information regarding the type of procedure in each review was available and recorded. Inclusion criteria consisted of reviews written in English and specified reasons for satisfaction or dissatisfaction. Blank reviews, consultation without completing surgery, duplicates, and reviews about subjects other than the surgery (ie, postoperative rehabilitation home) were excluded. To determine the impact of geographic distribution, a descriptive analysis was performed analyzing the number of reviews and ratings from each platform for each city. Statistical significance was determined by Kruskal-Wallis analysis for ratings and chi-squared analysis for number of reviews.

RealSelf

From the RealSelf database, the reconstructive procedures were subcategorized and compared against cosmetic procedures by t-test. A subanalysis of the reviews in RealSelf was performed by categorizing “favorable” reviews as those with either a 4- or 5-star rating, while those with a 1- or 2-star rating were deemed “unfavorable.” Three-star reviews were excluded from this aspect of analysis. Each review text was analyzed by 2 reviewers (I.A.C. and M.W.W.) with particular attention to mentions of positive and negative descriptors that have been previously verified in the literature.^6,10 Input was provided by a third investigator when the 2 raters did not agree. Krippendorf’s α demonstrated excellent interrater reliability (range, 0.9371-1.0).¹¹ The top 10 most frequent procedures were further analyzed for dimensions of interest based on 10 themes established in the literature: aesthetic outcomes, bedside manner, interaction with staff, postoperative care and follow-up, perceived surgeon skill, patient education, financial motivation, quality of facilities, health outcomes, and costliness of the procedure (Table 1).^6,10 Descriptive analysis was performed with Fischer’s exact test between the occurrence of each descriptor. A univariate analysis was performed with Fischer’s exact test to determine statistically significant predictors of positive and negative ratings for each procedure. All data extraction, cleansing, and statistical analysis was performed in Python with the “scipy” and “numpy” packages. Statistical significance was determined as P < 0.05.

Table 1.

Qualitative Themes and Representative Quotations From 5-Star and 1-Star Physician Online Reviews

Theme	Representative quote from 5-star review	Representative quote from 1-star review
Physician factors
Bedside manner	His bedside manner is impeccable! As soon as I spoke with him and talked about what I wanted, I knew he would deliver.	The doctor was in the room for 4 minutes with me … he was rude, cocky, uncaring, and very short with me.
Patient education	Answered all my questions every time we met, and was optimistic without lying to me. He recommended exactly what I needed to be done.	He seemed annoyed when I asked him to show me the program that predicts how you will look after surgery. There was a lot of information about the preparation that he didn’t mention.
Mindfulness of cost	After having my consultation I felt like he was really about the patient, and not the money.	Prices are also very deceiving as they tack on more and more costs.
Competency and skill	Very knowledgeable, extremely analytical, and passionate.	He told me that I should find a more skilled surgeon who can do a [Brazilian butt lift] without taking fat from the stomach. My general consensus is that he is not the best of the best, skillfully nor personally.
Outcomes
Aesthetic	The doctor did an amazing job on my surgery! Nobody even notices that I had a breast augmentation because my breasts look so natural!	I got botched! I did my research and thought I was choosing a great doctor who would give me a natural look. I ended up with a lopsided stomach and deformed butt.
Health outcomes	My recovery has been quick and I’ve faced no obstacles out of the ordinary.	The infection looked worse and I saw the stitches open up more. When he removed the drains, I nearly fainted, but in his words “You look great. You worry too much.” A week later, I’m in the hospital from that infection.
Postoperative care	After the procedure him and his team ensured that I was comfortable. He checked on me regularly and his team kept calling me while I was at home to make sure I was doing ok.	I contacted the post-op department. They stopped answering my calls and emails. I never heard back from anyone. They did not take this seriously at all. I feel so heart broken.
Ancillary factors
Staff interactions	His staff was so nice and professional to deal with.	The staff is not knowledgeable at all when I called to ask basic information and never return calls.
Cost of procedure	The doctor came at a time in my life where I was very unhappy with the overall look of my face. I would never regret this procedure despite the cost.	Paid 10k and the results were unimpressive. Called to let them know the results did not look different. They quoted me another $8400. Really!!!
Quality of facilities	The operation room was clean and modern.	The place is dirty and not safe during COVID.

RESULTS

All Platforms

Across the Google, Yelp, and RealSelf review platforms, a total of 11,078 reviews were included in our study. All three companies’ scores are based upon a 5-star scale. Of these, there were 10,379 positive ratings (10,149 with 4 stars; 230 with 4 stars) and 699 negative ratings (573 with 1 star; 126 with 2 stars) (Figure 1). Miami and Los Angeles had the greatest number of total reviews with 2810 and 2758, respectively; Philadelphia had the fewest number of reviews at 803. RealSelf had the highest average overall rating of 4.77, then Google with a mean rating of 4.70, and lastly, Yelp with an average of 4.66 (Figure 2).

Figure 1.

Overall physician online review score distribution. A total of 11,078 online reviews were analyzed. Star ratings were distributed bimodally, with peaks at 5 stars and 1 star. An overwhelming majority of reviews were positive (93.7%, n = 10,379).

Figure 2.

Individual physician online review score distribution by review platform. Analysis of star ratings on online physician reviews based on platform type revealed a bimodal distribution similar to the overall physician score distribution. RealSelf had the highest average overall rating of 4.77, then Google with a mean rating of 4.70, and lastly, Yelp with an average of 4.66.

There was significant geographic variation in quantity of reviews, preferred platform use, and overall average rating. Platform usage varied across cities (Figure 3). RealSelf was the most utilized platform for publishing reviews in Philadelphia (71.9%, n = 803), New York City (62.3%, n = 898), Miami (49.7%, n = 1397), and Chicago (46.6%, n = 620). Google had the greatest percentage of online reviews in Houston (70.2%, n = 1430), and Yelp was the preferred review platform in Los Angeles (53%, n = 1462).

Figure 3.

Geographic distribution of physician online review platforms in 6 major metropolitan cities. The quantity of online physician reviews and preferred platform use varied with geography. RealSelf was the most commonly used review platform in Philadelphia (71.9%, n = 803), New York City (62.3%, n = 898), Miami (49.7%, n = 1397), and Chicago (46.6%, n = 620). Google had the overwhelming greatest percentage of online reviews in Houston (70.2%, n = 1430). Yelp was the preferred review platform in Los Angeles (53%, n = 1462).

Average ratings varied significantly across all cities (P < 0.001 by independent samples Kruskal-Wallis test), and the quantity of reviews was distributed unequally (P = 0.001 by chi-square test). Philadelphia, New York City, and Los Angeles had the highest average satisfaction ratings of 4.84, 4.83, and 4.81 stars, respectively. Miami had the lowest rating out of all 6 cities with a mean of 4.51 stars.

RealSelf Subanalysis

Of 668 RealSelf patient reviews of specific procedures, 220 were positive and 447 were negative. Breast augmentation was the most common procedure performed (n = 132) and served as our reference point for a comparison of patient satisfaction. Buccal fat removal and abdominoplasty had the highest satisfaction ratings (98.8% and 98.1% respectively); Brazilian butt lift (BBL) and “mommy makeover” had the lowest overall satisfaction ratings at 88.2% and 87.7%, respectively (Figure 4).

Figure 4.

Satisfaction rates of the top 10 most popular procedures based on physician online review star rating. Breast augmentation was the most common procedure performed. Buccal fat removal had the highest satisfaction rating of 98.8%; Brazilian butt lift had the lowest overall satisfaction rating of 88.2% (P < 0.001). Complication risk may play a role in procedure-specific ratings.

Thirty-nine reviews reported complications (5.8%) with the most common being infection (n = 19, 48.7%). Low-score reviews (15.8%) mentioned postoperative complications significantly more often than high-score reviews (0.9%) (P < 0.001). In particular, patients receiving a “mommy makeover” (29.2%) mentioned complications much more frequently than reviews of all other procedures. For purely reconstructive procedures, there were 59 reviews with no ratings lower than 5 stars. Reconstructive procedures were rated with significantly higher satisfaction than cosmetic procedures (P = 0.035).

For high-score reviews, positive aesthetic appearance (79.9%) was the most commonly cited factor universally for all procedures, with the highest percentages in buttock augmentation (100%) and rhinoplasty (94.7%). The second-most predictive factors of satisfaction varied. Breast augmentation, buttock augmentation, and rhytidectomy valued interactions with staff; abdominoplasty, injectables, and rhinoplasty appreciated bedside manner; and liposuction and buccal fat removal valued health outcomes (Table 2).

Table 2.

Significant Predictors of High Satisfaction Physician Online Rating Based on Procedure

Dimension of interest	Breast augmentation	Brazilian butt lift	Abdominoplasty	Injectables	Rhinoplasty	Liposuction	“Mommy makeover”	Butt augmentation	Buccal fat removal	Facelift
Aesthetic
Good aesthetic outcome	×	×	×	×
Poor aesthetic outcome
Bedside manner
Plastic surgeon has excellent bedside manner	×	×	×	×	×	×		×	×
Plastic surgeon is rude or uncaring
Cost of procedure
Appropriately priced	×	×	×	×
Expensive, costly	×	×	×
Patient education
Patient receives thorough explanations	×	×	×	×	×	×			×
Patient offered little to no education
Quality of facilities
New or clean facility	×	×	×	×
Messy or dirty facility
Financial motivation
Plastic surgeon values patient care over profit	×	×	×	×
Plastic surgeon prioritizes profit
Health outcomes
Patient had no complications	×	×	×	×	×	×
Patient experienced complications and/or subsequent hospitalizations	×	×	×				×	×
Postoperative care
Responsive, accountable follow up	×	×	×		×	×		×	×
Negligent or avoidant after surgery
Surgeon skill
Plastic surgeon is knowledgeable and skilled	×	×	×	×	×	×			×
Plastic surgeon is inexperienced or unskilled
Staff interaction
Staff were polite, accommodating, and caring	×	×	×	×	×	×		×	×
Staff were rude, unresponsive, or unprofessional

Similarly, unsatisfactory aesthetic outcome was the most cited factor of a low-score review across all procedures, most commonly in patients receiving rhytidectomy (100%) and buccal fat removal (100%). The next most predictive determinants were poor bedside manner for breast augmentation, injectables, rhinoplasty, buttock augmentation, and rhytidectomy; postoperative care for BBL and abdominoplasty; and low surgeon skill for liposuction. Qualities that contributed to a negative postoperative experience included poor aesthetic outcome and postoperative experience (57.1%) for “mommy makeover,” and subpar bedside manner (100%) for buccal fat removal (Table 3). Univariate analysis demonstrated that all factors were significant predictors of satisfaction rating for all procedures.

Table 3.

Significant Predictors of Low Satisfaction Online Physician Rating Based on Procedure

Dimension of interest	Breast augmentation	Brazilian butt lift	Abdominoplasty	Injectables	Rhinoplasty	Liposuction	“Mommy makeover	Butt augmentation	Buccal fat removal	Facelift
Aesthetic
Good aesthetic outcome
Poor aesthetic outcome	×	×	×	×	×	×	×
Bedside manner
Plastic surgeon has excellent bedside manner	×	×
Plastic surgeon is rude or uncaring	×	×	×	×	×		×
Cost of procedure
Appropriately priced
Expensive, costly	×	×	×	×	×	×
Patient education
Patient receives thorough explanations		×
Patient offered little to no education	×	×	×	×
Quality of facilities
New or clean facility		×
Messy or dirty facility	×
Financial motivation
Plastic surgeon values patient care over profit
Plastic surgeon prioritizes profit	×	×	×	×		×	×
Health outcomes
Patient had no complications
Patient experienced complications and/or subsequent hospitalizations	×	×	×		×	×	×
Postoperative care
Responsive, accountable follow up
Negligent or avoidant after surgery	×	×	×		×	×	×
Surgeon skill
Plastic surgeon is knowledgeable and skilled		×
Plastic surgeon is inexperienced or unskilled	×	×		×	×	×	×
Staff interaction
Staff were polite, accommodating, and caring	×	×
Staff were rude, unresponsive, or nprofessional	×	×	×	×	×	×	×

DISCUSSION

Online physician reviews play an integral role for patients seeking health information and making decisions about their healthcare.¹² Plastic surgeons can also use these review platforms to improve their practices and consequently improve their reviews and ratings.

Google

Of all 6 markets, only in Houston was Google the preferred choice of review site, which is consistent with other studies.^6,7,12 In addition to having a search engine that accesses the largest source of online consumer information, Google’s algorithm provides more weight to its own reviews over those of other sites.¹³ The changes in its algorithm have influenced exposure to reviews on Yelp, Healthgrades, Vitals, and RealSelf.¹² Furthermore, Google’s feature to find local businesses through Google Maps strengthens its own reviews and reduces exposure to other directory websites. The more reviews a physician has, the greater the business’s online credibility.¹³

Yelp

Yelp’s guidelines require that businesses not solicit customers for reviews,¹⁴ and their software hides from the public any reviews it detects as solicited. Instead, it advises that businesses provide “an amazing customer experience” to attain high reviews.^12,15 In our study, we found that Yelp had the lowest average ratings among all platforms and was the preferred review site only in Los Angeles. Yelp’s specific conditions affect review transparency more than other platforms. For example, reviews posted by first-time Yelp reviewers are unlikely to be posted. In addition, Yelp hides negative reviews from the public view for a monthly fee. Businesses who have not purchased Yelp’s advertising services have had their positive reviews hidden and negative reviews posted, leading them to take legal action, but Yelp has prevailed. The platform has been suspected of excluding negative reviews of businesses paying for Yelp’s advertising services on the basis that the reviews “are not currently recommended.” ^12,16 Furthermore, fake reviews submitted by external users have impacted Yelp’s perceived reliability. Consequently, the company has attempted to prevent false self-promoting positive reviews and false negative reviews submitted by competing businesses.^14,17

RealSelf

RealSelf emphasizes the patient’s experience and story. Our study found that its average satisfaction rating surpassed that of Yelp and Google and was the most popular plastic surgery review platform across 4 of the 6 cities. RealSelf’s popularity relies upon 2 mainstays: high average star ratings and their encouragement for reviewers to include before-and-after photographs with text reviews. RealSelf’s approach is backed by evidence: Sorice et al found that prospective patients are most interested in photographs when viewing plastic surgery practice websites, and star rating is the single most important factor regardless of the content of the accompanying text review.¹⁸ Unlike Yelp, RealSelf encourages doctors to ask for reviews, even while the patient is still in the doctor’s office, and may offer incentives to patients who leave reviews on their website.¹⁹ The business model behind RealSelf relies on monthly fees paid by physicians to boost activity and prominence on the website. The high cost, improvements in competing review sites’ algorithms, the loss of ownership of expertise, and the growing alternative opportunities to generate online content may drive plastic surgeons to abandon this platform for others.

Procedures with more involved changes to the body such as BBL and “mommy makeover” are more likely to generate low satisfaction ratings compared with less invasive procedures, such as buccal fat removal. In our study, reviews for these more invasive procedures were the most likely of all procedures to mention complications. The negative reviews indicate that responsive postoperative care increases the likelihood of a high rating. Patients unable to contact their surgeon in the setting of postoperative complications are more likely to post a negative review. In the face of a complication or dissatisfaction with aesthetic results, patients tend to respond well to the support and compassion of the treating surgeon and team. The surgeon who minimizes a patient’s concerns, stops returning telephone calls, or fails to provide care in a timely manner may see a patient’s negative feelings evolve into anger. When addressed appropriately, postoperative complications and pain pose an opportunity to substantially improve the patient experience, and by extension, physician ratings.

Ultimate aesthetic outcome was the most commonly cited reason for satisfaction rating across all procedures. However, multiple studies have shown that patient and surgeon often disagree in their assessment of aesthetic outcomes.^20,21 A patient’s perception of a poor outcome that does not accurately reflect a methodological failure of the operation can often be mitigated through preoperative counseling, patient education, and expectation-setting.^22-24 Our results demonstrated excellent bedside manner and patient education starting at the initial consultation to be robust predictors of satisfaction and their absence to be strong predictors of a negative review. These findings are consistent with previous studies showing that physicians with the best patient communication skills receive the highest patient ratings and satisfaction.^25,26

Lastly, reconstructive procedures rated higher in terms of satisfaction than cosmetic procedures. Reconstructive and cosmetic patients comprise distinct patient demographics with different expectations: in reconstruction, there is less emphasis on aesthetics and more on functional outcome. No study has yet investigated differences in satisfaction between reconstructive and cosmetic surgical procedures. In our study, there were far fewer reconstruction patient reviews available to study than there were for aesthetic patients. Reconstruction referrals tend to be through hospital networks or “provider panels” rather than from a surgeon’s reputation. Regardless, both aesthetic and reconstructive surgeons benefit from understanding the reasons patients express satisfaction in online reviews, which can offer ways to improve the patient experience and patient-centered outcomes tied to Medicare reimbursement.²⁷

Standardized surveys such as Press Ganey and the Hospital Consumer Assessment of Healthcare Providers and Systems traditionally evaluate patient-care feedback captured from hospital systems.²⁸ However, these data are rarely accessed by patients who instead turn to online public review forums to guide their decision-making. In fact, one study showed that 72% of patients check reviews as their first step in choosing a doctor, and potential patients generally read up to 10 reviews before deciding on a surgeon.²⁹ RealSelf offers evidence that reviews play a prominent role in patients’ choice of surgeons for facial and breast reconstruction, the only 2 categories of insurance-based surgery featured.¹² Further studies are warranted to compare patient satisfaction rates between reconstructive and cosmetic patients.

Limitations

Our study was limited by several factors, including, firstly, our inability to validate the identity of individuals posting comments or to confirm their interactions with the reviewed plastic surgeons. The online reviewers’ anonymity allows patients to evaluate their doctors without worry that their criticism could affect their care, but they also lack accountability, and some may falsify their claims. The limited use of human content moderators may also introduce bias, possibly contributing to overly positive reviews. In addition, plastic surgeons may pay for fake reviews to bolster their numbers.^14,30 To mitigate this, Google, Yelp, and RealSelf offer tools for reporting false reviews so that they can be removed. Yelp and RealSelf have proprietary algorithms that either selectively hide falsified reviews or verify patient identity before reviews are published,^14,30 but we were unable to determine how effective those tools are. Secondly, the polarizing nature of the online reviews may lead to selection bias and may not be fully represent a surgeon’s practice. Lastly, our analysis was limited to cities in the United States. Future investigation that includes international cities would help us expand our understanding of online patient reviews.

CONCLUSIONS

Although assessment of aesthetic outcomes is the most important factor determining satisfaction for most plastic surgery procedures, plastic surgeons can overcome low-rated reviews by enhancing supporting factors. As we would expect, procedures with higher complication rates are associated with higher dissatisfaction ratings, but it is possible through responsive postoperative care to improve the patient’s perspective. The plastic surgeon can establish a strong, compassionate patient-surgeon relationship from the start by explaining the impact of the procedure on appearance, body image, and quality of life and establishing reasonable expectations. Excellent surgeon communication skills can establish trust and lead to overall high patient satisfaction and an important foundation in the event of an undesired outcome.

Acknowledgments

Ms Irene A. Chang and Mr Wells made an equal contribution to this work as co-first authors.

Disclosures

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

Funding

The authors received no financial support for the research, authorship, and publication of this article.