Snapchat and Instagram are becoming ever more popular in the cosmetic surgery and aesthetic specialty, with photographs and videos being used to showcase procedures and the results of treatment. Aesthetics asks practitioners, how ethical is this? And, is doing so an effective marketing tool?
Social media has quickly become a key marketing platform for many businesses in recent years, allowing companies to communicate instantly with an engaged and varied audience.1 For the cosmetic surgery and non-surgical aesthetic specialties, clinics can use social media to update and educate their patients on new trends and treatments within their sector; which, as well as being useful to current patients, can attract new patients too.
However, recent reports in the international press have highlighted cases of plastic surgeons marketing their services to the extreme; with photographs and videos of unconscious patients on the operating table – having fat removed, their breasts augmented or buttocks lifted – being shared on photography-based social media platforms such as Snapchat and Instagram.2,3,4 The short clips and graphic images have led many people to question the morality of sharing such content on social media, asking, is it ethical and within patients’ best interests to market cosmetic surgery and aesthetic procedures in this way?
In January this year, the Search Engine Journal reported that, globally, 1.7 billion people have active social media accounts, with this number set to rise by 14.2% in 2018.5 Of 2,800 marketers surveyed by the Social Media Examiner in 2014, 92% said that their social media efforts have generated more exposure for their businesses, while 80% claimed that they had increased traffic to their websites as a result of social media marketing.1 Instagram and Snapchat are among the top ten social media platforms, with 400 million and 200 million monthly active users reported in January 2016, respectively.5 Both platforms use photographs and videos to communicate and share content among users, with Instagram allowing users to upload permanent content to their profile, and Snapchat being used to share up to ten-seconds of photographs or video clips that can be viewed for 24 hours.6 Recently, Instagram has introduced a similar feature that allows users to upload short clips that are only available for 24 hours.7
The value of visual content is high; in 2016 it was reported that content with relevant images gets 94% more views than content without, and 51.9% of marketing professionals worldwide name video as the type of content with the best return on investment.8
So, while it is apparent that producing image-based content for social media marketing is beneficial, is it ethical for aesthetic practitioners to be utilising it to share videos and photographs of procedures?
“Social media is a strong and powerful form of communication that we now use it not just with patients, but with the public in general,” says aesthetic practitioner and surgeon Miss Sherina Balaratnam, who uses Twitter, Facebook, Instagram and Pinterest to share content with her followers. Miss Balaratnam explains that while she does film her consultation style and skincare treatments, she does not share photographs and videos of injectable procedures, because there is limited control over who can view them. “As a medical professional, I need to act and behave ethically and responsibly on my videos as they are a form of communication between my patients and I, and we shouldn’t convey the wrong messages,” she says. Mr Olivier Branford, a plastic surgeon based at the Royal Marsden in London, who is an avid user of Twitter with 67,000 followers as of August 2016, agrees. He does not film any of his surgical procedures for social media, as he believes, “Any operation should be entirely focused on the safety and quality of the care for that patient. There should be no distractions for the surgeon or the surgical team in achieving this.”
Mr Branford also serves on the Social Media Task Force at the American Society of Plastic Surgeons (ASPS) and says social media is here to stay. “If you don’t exist in the digital world then it is difficult to achieve impact,” he says, adding, “Visual social media is very popular and results in much greater engagement.” Mr Branford also notes, however, that there is a very fine, sometimes blurred, line between education and self-promotion. He argues, “Those values that govern our everyday practice, such as an emphasis on quality, safety and education, should also be applied to social media.”
For practitioners using Snapchat, it has been argued that the limited time that the clips are available for restricts the viewers’ opportunity to learn from the content that is being shared. Miss Balaratnam says, “The platform doesn’t allow the viewer to read about how the treatment works, contraindications, side effects and complications that could potentially occur.”
Aesthetic nurse practitioner Claudia McGloin, who uses Blogger, Facebook and Twitter to engage with patients, says she would consider filming procedures in a tasteful manner for social media in the future, “In some videos and photographs I’ve seen, practitioners aren’t wearing gloves, which is not only unprofessional, but unsafe.” She adds, in cases of non-surgical treatments being shared on social media, some practitioners do not appear to be practising in a clinical setting, claiming that some are wearing jewellery, have their nails painted and/or are not dressed appropriately. “This does not set the right look for medicine,” says McGloin, noting, “Practitioners could be putting patients at risk of infection, as well as suggesting to their potentially large audience that this type of setting is acceptable for medical aesthetic procedures.”
The graphic nature of some of the videos and photographs that have been circulating on social media is one of the main concerns highlighted by the practitioners interviewed. Miss Balaratnam suggests there are three types of viewers; practitioners and healthcare professionals who are looking to further their education, potential patients who are genuinely interested in a procedure, and a third group, who Miss Balaratnam calls ‘the gawkers’. She says, “These are individuals who like watching the gory content of medical procedures and could be young and impressionable.” In regards to non-surgical procedures, McGloin says one of her pet hates is being able to see blood in the videos or photographs. “This isn’t tasteful and may scare viewers, so make sure you wipe it away if you are going to share images of procedures,” she advises. Mr Branford adds, “Surgery should never be trivialised or reinvented as voyeurism.”
While Instagram and Snapchat, as well as other social media sites such as Facebook and Twitter, do allow users to reach many people, there is limited control over who can view content. Both platforms can be made private, with an option for the user to approve followers,9,10 however many businesses tend not to use this function as it can make you less accessible to the people you do want to target.
Practitioners interviewed for this article therefore argue that professionals should seriously consider their audience when sharing photographs and videos on social media. Miss Balaratnam says, “We can ethically choose not to treat a certain age group, but we are unable to control who’s looking at our social media pages. We may think it’s likely to be a 45-year-old woman who is genuinely looking for a procedure, but it could be a young adolescent.” She continues, “I am seeing a rise in the number of younger girls requesting lip fillers whilst showing me graphic videos of lip filler treatments on their mobile phones, asking if I can offer the same procedure and results. And these results are often over-enhanced. What they don’t recognise is that the procedure may have been performed by a non-medical person, in unsafe conditions, or may not be the most appropriate treatment for them based on their facial assessment. It is unfortunate, because despite assessing and educating them, there is nothing I can do to stop young girls being influenced by what they see on social media.”
Mr Branford is also concerned about the age of viewers that social media can reach. He says, “The Instagram and Snapchat social demographic is a young one, including teenagers and young children, with half being in the 18 to 24-year-old age group.”1 Mr Branford says that this is not an appropriate audience to be targeting, arguing, “We should be reinforcing positive body image and never encouraging young people to have aesthetic procedures.” He adds, “Any surgeon that uses social media to promote their business with disregard for its effects on a developing adolescent generation should have a very long, hard look at their ethical code. Anything that is posted online can be viewed and saved by anyone. We should never encourage patients to make themselves vulnerable or do something that they might regret, even many years later.”
“If it’s not documented, it’s not happened,” says McGloin, who emphasises the importance of practitioners seeking written consent if they do choose to share patient videos and photographs on social media. “The patient could still turn around and say, ‘Well, I didn’t know you were going to put it on Instagram, I thought it was only going to be a three-second video on Snapchat’,” she notes, adding, “If you’ve got everything written down and counter-signed then you can protect yourself from complaints.”
Miss Balaratnam highlights that it is also important for practitioners to explain to patients exactly what they are signing consent for. She suggests that practitioners should verbally explain and make clear on written consent forms whether their photographs and videos are being used for internal clinic training, external teaching at meetings and conferences, or whether they are going to be used on websites and social media. If so, practitioners need to detail which social media platforms they will be shared on and how often they will be shared.
In light of the growth of social media, the General Medical Council (GMC), the Nursing and Midwifery Council (NMC), and the General Dental Council (GDC) all have guidelines on its appropriate usage. The GMC and GDC both state that the standard expected of doctors and dental professionals does not change because they are communicating through social media rather than face-to-face or through other traditional media,11,12 while the NMC emphasises that nurses should not post anything on social media that may be viewed as discriminatory, does not recognise individual choice or does not preserve the dignity of those receiving care.13
Moving forward, Mr Branford has co-authored an article, along with Dr David Song, the president of the ASPS, and Dr Rod Rohrich, editor-in-chief of Plastic and Reconstructive Surgery (PRS), on the appropriate use of social media. He explains that the article, #PlasticSurgery, which will be published in PRS in December 2016, was created on the evidence-based desire for public education and engagement on social media, without self-promotion. Mr Branford explains that the authors hope the article will reinforce the value of a strong, personal ethical code for all surgeons. He concludes, “A high-quality practice will always be successful. One that has a questionable moral code will, eventually, by the democratic nature of social media, fall on its own sword. We should always focus on education and quality."
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