TikTok in Plastic Surgery: A Systematic Review of Its Uses

Abstract   TikTok (San Jose, CA) is a popular and rapidly growing social media platform. With beauty and skincare among the top 5 most popular categories, TikTok represents an important platform for plastic surgery education and communication. However, given the vast array of content shared daily, regulating content for veracity is challenging. It may also be an important and potentially overlooked avenue for the dissemination of inaccurate information pertaining to plastic surgery. This systematic review evaluates TikTok's impact on plastic surgery. Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis Guidelines, a systematic literature review was performed of the use of TikTok within the plastic surgery field. The following databases were queried: PubMed (National Institutes of Health; Bethesda, MD), EMBASE (Elsevier; Amsterdam, the Netherlands), and PsychInfo (American Psychological Association; Washington, DC). The search captured 31 studies of which 7 were included in the final analysis. The studies examined the following areas: gender-affirming surgery (n = 1), breast reconstruction (n = 1), aesthetic surgical procedures (n = 1), plastic surgeon profiles (n = 1), and profiles of videos relating to plastic surgery hashtags (n = 3). The videos’ quality was assessed using the DISCERN scale. Physician videos scored notably higher than nonphysician videos. The mean DISCERN score across all the videos (n = 386) was 1.91 (range: 1.44-3.00), indicating poor quality. TikTok is a popular medium for sharing plastic surgery content. The existing literature has demonstrated overall poor-quality information on plastic surgery, and further study is needed to evaluate its impact in terms of perceptions of the specialty and healthcare behaviors. Future work should focus on promoting accurate, high-quality videos, potentially including a peer-review function for healthcare content. This can leverage TikTok's potential for disseminating content while upholding patient safety. Level of Evidence: 3

that amplifies TikTok's reach as a social media platform is that one does not need an account, nor to follow the content creator, to view the videos posted unless those are private.
TikTok is also routinely used and classified as an advertising and revenue-generating platform; in 2022, it generated $11 billion in advertising revenue that equated to a 200% increase from 2021. 4 It is also the most common channel used by most brands for influencer marketing, and it is expected to deliver the best return on investment based on short-video production. 5urthermore, prospective patients might turn to social media for their research and potential identification of a plastic surgeon or cosmetic influencer.A survey conducted by Landeen et al found that 80% of facial plastic surgeons, who were members of the American Academy of Facial Plastic and Reconstructive Surgeons (AAFPRS), utilize social media in a professional manner. 6However, given the vast amount of content created and disseminated on a daily basis, regulating content for veracity is challenging.Therefore, TikTok may also be an avenue for the dissemination of false information pertaining to plastic surgery, with important patient safety ramifications.In view of its growing influence in the field, this systematic literature review evaluates the current impact of TikTok on plastic surgery.

METHODOLOGY
A systematic literature review was carried out to identify any studies exploring TikTok's content within the plastic surgery field.Title and abstract screening, full-text review, and data extraction were carried out independently by two authors using COVIDENCE review management software (Melbourne, Australia). 7Any conflict was resolved by a third independent reviewer.The kappa score for interobserver reliability was 1.The Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocol 8 was followed.This review was registered on PROSPERO 9 (registration number: CRD42023397054).

Search Strategy
The search strategy was applied to PubMed/MEDLINE (National Institutes of Health; Bethesda, MD), EMBASE (Elsevier; Amsterdam, the Netherlands), and PsychInfo (American Psychological Association; Washington, DC) from inception until 2022, to identify eligible studies.The search strategy included a combination of the following terms: TikTok, plastic surgery, craniofacial surgery, burns, breast surgery, microsurgery, aesthetic surgery, cosmetic surgery.Any studies that were not identified by the search but known to us as of interest were included.The latest search was conducted on January 15, 2023.

Study Selection
Studies in English in the field of plastic surgery on the social media platform TikTok were included.Nonprimary research, abstracts, and those not relating to the field of plastic surgery and/or the social media platform TikTok were excluded.

Data Extraction
The data extraction, collection, and management were carried out independently by two authors using a data extraction form via COVIDENCE.Any disagreement was resolved by a third independent reviewer.The following data were extracted: study characteristics (authors, year of publication, country of origin, and journal), number of videos and their statistics (likes, comments, and shares), domain of plastic surgery, content type, and assessment of the quality

Quality Assessment
Risk of bias assessment was performed by 2 reviewers independently using the Crowe Critical Appraisal Tool (CCAT). 10Where there were discrepancies, they were resolved by a third reviewer.The CCAT is split into 8 categories and each one receives a score on a 6-point scale from 0-5, with 0 being the lowest score and 5 the highest.The total score presented is out of 40.

RESULTS
Our search string resulted in 31 studies found in total across all databases postduplicate removal.2][13][14][15][16][17] The Kappa score for interrater reliability was 1, indicating perfect inter-reviewer agreement.The review process is shown in the Figure .The mean (±SD) score for the critical appraisal using the CCAT was 70% (±14%).The score of each category and study is illustrated in Table 1.
Table 2 provides the characteristics of the studies.All the studies were published in 2021 and 2022, and the country of origin was the United States.The studies examined the following areas: gender-affirming surgery (n = 1), breast reconstruction using fat grafting (n = 1), aesthetic surgical procedures (abdominoplasty, blepharoplasty, breast augmentation, and rhinoplasty; n = 1), plastic surgeon profiles (n = 1), and profiles of videos relating to plastic surgery hashtags (n = 3).
Table 3 provides information with respect to the methodology used to collate the content, its characteristics, and quality appraisal where applicable.In total, 1105 videos were analyzed in the selected studies, of which 543 (49.1%) were created by physicians, and the other creators included nonphysicians, patients, companies, nurses, and clinics.Of the physician created videos: 410 (75.5%) were plastic surgeons, 91 (16.8%) did not report the specialty/other specialty, 36 (6.6%) were otolaryngologists, 5 (0.9%) were dermatologists, and 1 (0.2%) was a gynecologist.
The videos were assessed in only 3 studies, [11][12][13] and the DISCERN scale was used in all cases.The mean DISCERN score across all the videos (n = 386) analyzed was 1.91 (range: 1.08-3.00),which is classified as poor.Physician videos were found to have significantly higher scores than nonphysician videos across all the studies; however, their scores were still classified as average or poor.At the creator level, Om et al reported the lowest DISCERN score at 1.08 relating to breast augmentation videos created by a layperson, and the highest score at 1.81 to rhinoplasty videos created by plastic surgeons. 12Across the 3 studies, the highest score reported was 3 relating to a single phalloplasty video.

DISCUSSION
TikTok is a growing social media platform with millions of users daily, with the average TikTok user spending 90 min per day on the platform. 18Considering the short duration of video content, a user may be exposed to hundreds of videos per day.This systematic review assessed the current literature exploring TikTok's content within the plastic surgery domain.
Previous studies have demonstrated that patients are influenced by social media to undergo cosmetic and aesthetic procedures and that social media is routinely used prior to medical consultation. 19,20It is evident that plastic surgery videos perform very well within the TikTok community with high viewing numbers, and in combination with the platform's personalized algorithm (for the "For You Page"), a user might be exposed to numerous related videos based on their viewing history. 21ideo content on TikTok ranged from educational to personal experience, and even self-promotional/advertising.It has previously been emphasized that it should be the plastic surgeon's responsibility to use the platform responsibly, rather than for a sole entertainment-related purpose. 22,23A recent literature review by Atiyeh et al concluded that plastic surgeons are reliant on social media for the advertisement and reach of their practice, and it is a steadily increasing trend; however, there is a high potential for misuse, leading to potential professional, legal, and ethical ramifications such as patient confidentiality being compromised. 24ith respect to the quality of the content, only 3 out of the 7 selected studies undertook an assessment, and they all used the DISCERN instrument. 25Although the DISCERN tool is not typically used for social media videos, a lot of literature has used this instrument for the assessment of such videos. 26However, such a tool will not be of use in the regulation and monitoring of videos being uploaded.
The content of those videos may be improved to be more accurate and complete by attaching literature, references, and further links in the description of the videos, in combination with the creator painting a complete picture, for example, describing results, risks, and the surgery itself of a procedure.Dissemination of inaccurate medical information is a potential hazard common to all social media platforms and has previously been reported on TikTok during the COVID-19 pandemic with respect to the virus and the vaccines. 27he present study is limited by the primary studies' reliance on appropriate titles and coding of content.The nature and ease of content sharing on social media platforms mean that some content may not have been captured by their search terms due to inappropriate labeling or sequential uploading as part of a playlist.Furthermore, the use of the DISCERN tool in the evaluation of quality educational content may not be the optimum means of analysis, and further work is needed to develop more versatile evaluation tools to keep up with innovations in content creation and sharing.
Recognition of the growing user-base and social amplification of content via TikTok is fundamental to understanding public perceptions of plastic surgery.As such, TikTok represents a potent tool for content sharing, which may be leveraged effectively to deliver important lifestyle advice, as well as sharing content between professionals.However, ensuring the accuracy of such information is paramount, and regulators may look to introduce content validation tools from recognized professionals to introduce a peer-review element within the platform.

CONCLUSIONS
TikTok is a growing platform in the domain of plastic surgery, both from a physician and a patient perspective.However, there is limited regulation of content, leading to potential issues with the accuracy of the information shared.The literature demonstrates low educational scores for appraised content, although there is a need for novel evaluation tools tailored to the type of content promoted on TikTok.Given its vast reach, TikTok has the potential to be utilized as a potent content sharing tool within plastic surgery both with the public and between professionals, although regulators may consider introducing peer-reviewing functions for healthcare content to prevent the spread of misinformation and uphold patient safety.

Table 2 .
Study Characteristics

Table 3 .
Content Analysis, Characteristics, and Methodology