A study published August 30, 2017 in the Aesthetic Surgery Journal about how people use hashtags on Instagram for terms like #plasticsurgery, #facelift and #boobjob has unleashed a flurry of articles in the consumer press about the cosmetic surgery turf war.
In articles published in the Chicago Tribune and Wall Street Journal the coverage goes from describing the study to physicians’ comments about botched cosmetic surgery by inadequately trained providers and patients being misled into thinking qualified plastic surgeons are behind the social media posts.
“Social media is becoming a battleground in the fight over who is qualified to do plastic surgery,” journalist Bonnie Miller Ruben writes in the Wall Street Journal.
In essence, study authors queried 21 Instagram hashtags they described as “plastic surgery-related.” Some described cosmetic surgery procedures in medical or laymen’s terms, including #rhinoplasty, #tummytuck, #liposuction, #breastaugmentation and #bodycontouring. Other terms included #cosmeticsurgery, #aestheticsurgery and #cosmeticsurgeon.
The authors report plastic surgeons eligible for membership with the American Society of Aesthetic Plastic Surgery (ASAPS) were underrepresented among those posting plastic surgery-related Instagram content. Foreign surgeons were the most likely to have posted on the hashtags in the study, followed by non-American Society for Aesthetic Plastic Surgery (ASAPS) eligible physicians, such as otolaryngologists, dermatologists, general surgeons and others. ASAPS-eligible board certified plastic surgeons made nearly 18% of the top plastic surgery related posts on Instagram, coming in third after foreign surgeons and non-ASAPS eligible doctors.
In their discussion, the authors write the increasing number of physicians who are not board certified in plastic and reconstructive surgery but perform cosmetic procedures comes at a cost to public safety. And they suggest plastic surgeons should join, together, to educate the public and stay relevant in an ethical and professional manner.
ASAPS President Clyde H. Ishii, M.D., says the study’s take-home message for physicians and surgeons is that medicine— cosmetic surgery, in particular — is unregulated.
“With cosmetic surgery there is money to be made outside of the constraints of insurance reimbursement so the field is attracting many non-plastic surgeons and even lay people,” Dr. Ishii tells The Aesthetic Channel. “It truly is like the Wild West out there with no end in sight. Also, there are no regulations on how people market themselves unless one belongs to organizations like the… ASAPS or the American Society of Plastic Surgeons (ASPS). These two organizations have strict codes of ethic for members.”
Non-plastic surgeon doctors should limit their practice according to their scope of training, according to Dr. Ishii, who practices in Honolulu, Hawaii.
“For example, emergency medicine doctors are trained in emergency medicine and not in cosmetic surgery. Some of them may take an abbreviated course in cosmetic surgery but this training pales in comparison to plastic surgeons who have years of surgical training even prior to entering into a rigorous plastic surgery training program,” Dr. Ishii says.
Facial plastic surgeons can promote and do facelifts and rhinoplasty because it is within their scope of training. Dermatologists, according to Dr. Ishii, should not be doing liposuction or breast augmentation because it is outside their scope of training.
“If they want to do these procedures then they should go and get proper plastic surgery training,” Dr. Ishii says. “Minimally-invasive and noninvasive procedures can be performed by various specialties provided that they are properly trained in these techniques. This training must be part of their core training and not just a weekend course.”
And he agrees with the authors that plastic surgeons must be more active on social media, especially with regard to educating the public in how to select a properly trained cosmetic surgeon, according to Dr. Ishii, who was not an author on the paper.
Looking Beyond Specialty
Joe Niamtu, III, D.M.D., an oral and maxillofacial surgeon with a practice limited to cosmetic facial surgery in Richmond, Va., says that while he agrees that surgeons should stay within their scope of training, to say that all plastic surgeons are well trained in every cosmetic procedure is inaccurate.
Dr. Niamtu“Many plastic surgeons have excellent cosmetic training and many have very little formal training in cosmetic surgery and focus more on reconstructive procedures,” Dr. Niamtu says. “No specialty owns the face or body, and it is impossible for any specialty to say that they are the only ones that can do this safely.”
A big fallacy, according to Dr. Niamtu: Only see a plastic surgeon.
“That’s like saying the only safe car is a Lexus. That’s not true. It’s related to training, competence and outcomes. If you are providing safe surgery with predictable outcomes and happy patients then your specialty is irrelevant,” says Dr. Niamtu, who says he has performed more than 1,000 facelifts in his career.
As for the hot button issue about who “core” cosmetic providers are, Dr. Niamtu says that when it comes to procedures like injectables, including Botox (Allergan) and fillers, there is no one and only “safe” core specialty.
“The fallacy of this core principle, to me, is it’s self-limiting; it’s self-serving. It has more to do with controlling patients and dollars than it has to controlling safety,”
Dr. Niamtu, who was quoted in the Wall Street Journal article, was faculty at Allergan’s first “new core” advisory meeting in September 2017, in Dallas.
“Many of the invited attendees were in the top 20 Allergan accounts and not considered ‘core,’” he says. “The goal was to look at these doctors, sitting around the table, who were OB/GYN, anesthesia, primary care, family medicine, oral maxillofacial surgery and other specialties and find common denominators that enabled these practices that are not traditionally considered ‘core’ to outperform the traditional specialties. This meeting also sends the message that Allergan understands the delivery of injectables is a dynamic and evolving landscape of providers,” according to Dr. Niamtu.
Qualifying Cosmetic Expertise
Gulf Shores, Alabama-based facial plastic surgeon Fred G. Fedok, M.D., president of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) says it’s somewhat unfortunate that the study has been picked up and distributed in the way that it has.
Dr. Fedok“The study has some real value — it gives grave caution that patients should not respond only to the ‘attractiveness’ of an ad, but should put thought into the qualifications of the individual they are considering seeking care from,” Dr. Fedok tells The Aesthetic Channel. “As with all scientific studies, there are limitations, and findings have to be viewed within the context of those limitations. It is my concern that the lay press and social media has been unable to address some of the limitations of the publication.”
According to Dr. Fedok, those clarifications include that there are several medical disciplines that have nationally and internationally recognized specialized training in various spectrums of plastic surgery.
“These include at least plastic surgery, facial plastic surgery, dermatologic plastic surgery and oculoplastic surgery,” he says. “The training in these disciplines has been sanctioned under the American Board of Medical Specialties (ABMS) and ABMS equivalent boards. Some of the training involves specialization in a regional field; i.e., my discipline, facial plastic surgery, pertains to plastic and reconstructive surgery of the face, head and neck. I do not do breast augmentation or body liposuctions. I do, as do my facial plastic surgery colleagues, have recognized expertise in rhinoplasty, facelifts, laser surgery, etc.”
On another issue, otolaryngologists have 25% of their training and board qualifications based on facial plastic surgery, he says.
“This means they are deemed qualified by the ABMS to perform facial plastic surgery procedures, even though this has been at times misrepresented in some of the derivative articles,” Dr. Fedok says. “The bottom line is this: There are numerous physicians trained under a limited number of ‘banners’ recognized and sanctioned by the Accreditation Council for Graduate Medical Education (ACGME), ABMS and equivalent boards that are qualified experts to perform a spectrum of cosmetic procedures.”
