Abstract Background Social media (SoMe) has evolved to be a platform that patients use to seek information prior to an operation, share perioperative and postoperative journey, provide feedback, offer and receive support. While there have been studies looking at the evolution and usage of SoMe either by patients or by surgeons, there is no information that compares its usefulness for both the groups. Objectives The aim of this study was to compare the views held by patients and surgeons, towards social media and other internet resources, in relation to one commonly performed operation. Methods A questionnaire was presented to 648 consecutive patients who attended our clinic for consultation for primary breast augmentation from September 2016 to March 2017. A separate “surgeons’ questionnaire” was answered by a group of 138 plastic surgeons who were either practicing in branches of our clinic, had previously done fellowship with us, or were visiting the clinic. Results All 138 surgeons and 648 patients responded to the questionnaire. A total of 91.4% of patients said that they had searched online and 61.4% had searched in specific online groups for information on breast augmentation. A total of 88.9% of patients had specifically looked for clinical photographs and 73.4% had specifically searched for unfavorable reviews of the surgeon. In comparison, 72.5% of surgeons thought that over three quarters of patients gather information on the internet while only 20.3% thought that over three quarters of patients use social media for their information. A total of 52.5% of surgeons have noticed that social media affected their consultations. Conclusions With the evolution of the internet and related technologies, the role of social media continues to increase. While patients use social media to help make their decisions, it is not the only deciding factor. Surgeons appear to underestimate the patients’ use of these technologies. There is concern in each group about the amount of inaccurate information on the social media. This underlines the importance of providing factual, evidence-based information to the patients. The progression of the internet and web 2.0 technologies has led to a revolution in online information and social media (SoMe). In contrast to the legacy static web content that was passively “pushed” at the user, social media is characterized by dynamic user generated content that enables asynchronous two-way communication in the public domain. The users can choose to follow a thread, or be notified of any updates, while choosing a certain degree of privacy. Even if the users do not contribute actively, there is an opportunity to benefit from the interaction. Due to public availability and the large number of users, such content is highly visible. Individual medical professionals1 as well as organizations2,3 are taking this opportunity to inform, educate, and promote their services. Due to its very nature, SoMe is a vast topic. Although studies have addressed the usage of SoMe by the public or by plastic surgeons, none of them, to our knowledge, has chosen a specific topic and compared the perceptions held by the patients and the surgeons. METHODS All consecutive female patients who presented to our clinic between September 2016 and March 2017 for primary aesthetic breast augmentation were included in the survey. They were requested to fill in an anonymous questionnaire (Appendix A) in addition to their medical and surgical history while they waited for their consultation. They deposited the questionnaire in a designated collecting box in the waiting room before their consultation. A separate “surgeons’ questionnaire” (Appendix B) was given to a group of 138 plastic surgeons. These surgeons were either those practicing in branches of our clinic, previous fellows, or visitors to our clinic. The questions were designed in order to identify each cohort’s attitudes and opinions about social media. All responses were stored in a spreadsheet and analyzed. There were no inducements offered to the patients or to the surgeons. The study was carried out in accordance with the Declaration of Helsinki guidelines. RESULTS All 648 patients that responded to the questionnaire were female, with a mean age of 30.5 years (range, 18-56 years). All 138 surgeons (Table 1) from 27 different countries responded to the questionnaire. Their mean age was 46.3 years (range, 36-73 years). A total of 114 (82.6%) surgeons were male and 24 (17.4%) were female. Their respective results are as follows. Table 1. Country of Origin of the Respondent Surgeons Country of origin No. of surgeons Sweden 22 Germany 14 Australia 10 Greece, India, Switzerland, United Kingdom, United States* 8 Brazil, Israel, Italy* 6 Poland 4 Argentina, Austria, Canada, Denmark, France, Lithuania, Luxemburg, Norway, Romania, Saudi Arabia, Serbia, Slovenia, South Korea, Spain, Turkey* 2 Country of origin No. of surgeons Sweden 22 Germany 14 Australia 10 Greece, India, Switzerland, United Kingdom, United States* 8 Brazil, Israel, Italy* 6 Poland 4 Argentina, Austria, Canada, Denmark, France, Lithuania, Luxemburg, Norway, Romania, Saudi Arabia, Serbia, Slovenia, South Korea, Spain, Turkey* 2 *Per country. View Large Table 1. Country of Origin of the Respondent Surgeons Country of origin No. of surgeons Sweden 22 Germany 14 Australia 10 Greece, India, Switzerland, United Kingdom, United States* 8 Brazil, Israel, Italy* 6 Poland 4 Argentina, Austria, Canada, Denmark, France, Lithuania, Luxemburg, Norway, Romania, Saudi Arabia, Serbia, Slovenia, South Korea, Spain, Turkey* 2 Country of origin No. of surgeons Sweden 22 Germany 14 Australia 10 Greece, India, Switzerland, United Kingdom, United States* 8 Brazil, Israel, Italy* 6 Poland 4 Argentina, Austria, Canada, Denmark, France, Lithuania, Luxemburg, Norway, Romania, Saudi Arabia, Serbia, Slovenia, South Korea, Spain, Turkey* 2 *Per country. View Large Patients’ Perspective A total of 91.4% of patients had searched online (static websites or social media) for information on breast augmentation and 63% of patients used it as their first source of information (Figure 1). Among patients, 61.4% had sought information in specific online groups about breast augmentation and 88.9% searched for clinical photographs but only 4.5% of patients ever posted anything. Figure 1. View largeDownload slide Pie chart showing the first means of information gathering used by the patients (n = 648). BA, breast augmentation. Figure 1. View largeDownload slide Pie chart showing the first means of information gathering used by the patients (n = 648). BA, breast augmentation. A total of 73.4% of patients specifically searched for any unfavorable reviews of the surgeon. In total, 83.9% of patients said that the quality of reviews affected their choice and 86.0% were influenced by how long ago that review had been written. A total of 63.3% of patients expressed concern about the existence of fake profiles. When it came to what was the most deciding factor in their decision, most patients considered the clinic reputation, followed by personal recommendation from family or friend. Online blogs, information, and social media accounted for the decision in 6.5% of patients (Figure 2). In total 32.7% of patients considered that online information helped them “much” whereas 52.3% thought that it did not help much in their decision. (Figure 3). Figure 2. View largeDownload slide Pie chart showing what the patients considered to help them the most in their choice of surgeon/clinic (n = 648). Figure 2. View largeDownload slide Pie chart showing what the patients considered to help them the most in their choice of surgeon/clinic (n = 648). Figure 3. View largeDownload slide The degree to which social media helped the patients among those who used one (n = 398). Figure 3. View largeDownload slide The degree to which social media helped the patients among those who used one (n = 398). Surgeons’ Perspective Fifty surgeons (36.2%) had exclusively personal websites, 36 (26.1%) featured exclusively on clinic or hospital websites, while 52 surgeons (37.7%) used social media only (eg, Facebook, Instagram, Snapchat, Twitter) or in combination with websites. In total, 72.5% of surgeons thought that over three quarters of patients use websites to gather information before the consultation (Figure 4) while only 20.3% felt that over three quarters of patients use SoMe for their information. Figure 4. View largeDownload slide Surgeon’s perception of how many patients use social media for information. Figure 4. View largeDownload slide Surgeon’s perception of how many patients use social media for information. A total of 81.2% of respondents felt that their business as a whole had been affected by social media (78.3% thought they had benefitted, 2.9% adversely affected) while 18.8% considered no change. Among surgeons, 56.5% thought that online information (websites and social media) can lead to unrealistic expectations by the patients, 42.0% thought they can lead to better informed patients, while 1.4% felt that it made no difference. Table 2 shows how many surgeons considered to have gained or lost patients due to social media. Figure 5 shows what surgeons think are the most useful sources of information for the patients and Figure 6 shows what they considered to be the most harmful for the patients. Table 2. Surgeons’ Perception of Whether Social Media Contributed to Their Patient Numbers (Beneficially or Adversely) Patients gained Patients lost Yes 88 (63.8%) 16 (11.6%) No 10 (7.2%) 38 (27.5%) Don’t know 40 (30.0%) 84 (60.9%) Total 138 (100%) 138 (100%) Patients gained Patients lost Yes 88 (63.8%) 16 (11.6%) No 10 (7.2%) 38 (27.5%) Don’t know 40 (30.0%) 84 (60.9%) Total 138 (100%) 138 (100%) View Large Table 2. Surgeons’ Perception of Whether Social Media Contributed to Their Patient Numbers (Beneficially or Adversely) Patients gained Patients lost Yes 88 (63.8%) 16 (11.6%) No 10 (7.2%) 38 (27.5%) Don’t know 40 (30.0%) 84 (60.9%) Total 138 (100%) 138 (100%) Patients gained Patients lost Yes 88 (63.8%) 16 (11.6%) No 10 (7.2%) 38 (27.5%) Don’t know 40 (30.0%) 84 (60.9%) Total 138 (100%) 138 (100%) View Large Figure 5. View largeDownload slide Surgeon’s belief of what their patients found to be the most useful source of information. BA, breast augmentation; SoMe, social media. Figure 5. View largeDownload slide Surgeon’s belief of what their patients found to be the most useful source of information. BA, breast augmentation; SoMe, social media. Figure 6. View largeDownload slide Surgeon’s belief of what is the most harmful source of information for patients. BA, breast augmentation; SoMe, social media. Figure 6. View largeDownload slide Surgeon’s belief of what is the most harmful source of information for patients. BA, breast augmentation; SoMe, social media. A toal of 52.2% of surgeons would take no action in view of a negative online review or comment, 39.1% would explain themselves, and 8.7% would try to contact the admin to have it removed. A total of 98.6% of surgeons would keep plastic surgery discussion topics on websites and 87.0% would keep them on social media. DISCUSSION Internet resources can be broadly considered as those where the user can only receive passively (eg, clinic or personal websites) or where they can interact to generate content (eg, blogs, forums, Facebook, Twitter). Merriam Webster4 defines the collective term “social media” as the forms of electronic communications through which users create online communities to share information, ideas, personal messages, and other content. An important distinction is that SoMe needs to be interactive where both parties have the chance of a conversation and that interaction creates the main content. Websites that give passive information do not count as social media, even if there is a small comments section attached. However, microblogging services or an online forum that allows interactivity and participation by several parties are a form of social media. The SoMe landscape has moved very quickly after Facebook was created in 2004, Twitter in 2009, Instagram in 2010, and Snapchat in 2011. Social media has become integral to the lives of millions of people in a little over a decade. Increasingly the general public and especially young people are becoming digital natives who organise activities, engage online, and seek information5 through social media. They even choose to share their information, including identifiable photographs online.6 There have been several studies7-10 looking in to the attitudes of general public and potential patients about use of social media for plastic surgery. In 2012, Domanski5 used online data for assessment of patient satisfaction. Workmann et al8 looked at the nature of available plastic surgery related apps in the online Apple store. Denecke et al9 enrolled 313 patients in a study where they designated on average 3.5 recipients/ individuals to receive complimentary perioperative updates via SMS or email. A total of 73% of users responded to a questionnaire, of which 94.2% felt more connected to their loved ones during surgery. But despite its increasing usage as a source of information, there is no head to head comparison of what patients and surgeons think about the opportunities and challenges provided by it. In this study, we have aimed to compare and contrast the attitudes towards social media of surgeons and of patients presenting for primary breast augmentation. We chose this operation as it is one of the most common plastic surgery operations11 and anecdotally the patients are very active on SoMe. Patient Engagement In our study, the percentage of patients who looked online (websites, blogs, forums, social networks) for information, was much higher than the figures published in earlier studies.12,13 This may suggest that patients planning to have a breast augmentation are more engaged in SoMe. We found that, in contrast to the number of patients seeking information, only a small number actually posted something. This may be one factor that skews the type and quality of information available to other (eg, patients who are either very happy or very unhappy are more likely to publish a post). By the same token, this should provide an incentive for plastic surgeons to act as a source of evidence-based information for patient education. What Patients Search While it may not be surprising that most patients searched for clinical photographs, what is interesting is that nearly three quarters specifically looked for a negative review of the surgeon. In their survey of 500 patients coming for consultation at an aesthetic clinic, Montemurro et al10 reported that 46% of patients said they read blogs or use online forums. This appears to be an unusually high number and one that may help in changing the surgeons’ attitudes, especially since 52.2% of the responding surgeons in our survey said that they will not act on an unfavorable online comment. Usefulness for the Patients While 37.2% of our patients (Figure 3) found the online/social media information to be “much” or “very much” helpful, their most common deciding factor was the clinic’s reputation (42.0%) or a recommendation (34.3%). This supports the generally held belief that word of mouth plays an important part and while SoMe may be an important adjunct, it is not a replacement for face to face contact. However, 6.5% of our patients still appear to use social media as their primary source of decision making for this procedure. While only a follow-up survey can confirm how this trend behaves over time, with increasing use of SoMe we expect this percentage to increase in future. Use of SoMe Among Surgeons Among medical professionals SoMe is being used for personal interaction, marketing and education.1-3 Moreover, online posts need to comply with relevant data protection legislation, guidance, and best practice. Wheeler et al14 is one of the first articles in the English language that looked at the role of SoMe for plastic surgeons. They sent out questionnaires in April 2010. Out of the 1000 responses received, only 28.2% said that they use social media for their practice (and 46.7% for their personal life) of which 96% used Facebook while 47% used Twitter as well. A total 62.4% recognized that social media benefitted their practice but most believed that it accounted for up to 10% of their practice volume. This perception was also reflected in the advertising practices in that social media was the fifth most common (29.7%) place to advertise, after websites (92.3%), word of mouth (84.6%), print media (53.1%), search engine optimization (43.1%), and special events (34.2%). This study predated many now-popular SoMe outlets. In fact, the only SoMe portals mentioned in the article are Facebook, Twitter, and the now defunct MySpace. In comparison, a 2013 survey15 of American Society of Plastic Surgeons members showed that half of responders regularly used social media. A recent web survey16 of 631 Canadian plastic surgeons found that 42% have a website and 85% have a social media profile. The surgeons who have qualified in the last three years were more likely to have both. The number of surgeons using social media in their study is much higher than those in our survey. This may reflect higher awareness of the need and power of SoMe in North America as compared to our responders who were predominantly from Scandinavia and mainland Europe (Table 1). A survey17 of 156 UK plastic surgeons found 51% had personal websites, 11% had professional or partnership websites. It also found that 52% used LinkedIn, 22% used Twitter and 4% used Facebook. These are comparable to our figures for surgeons using social media. We would like to stress that professional websites (as opposed to surgeon-reviewing websites) are predominantly static content only and therefore may not be classified as truly “social.” Also, LinkedIn is a professional networking website and not a portal to engage patients. In all three studies15-17 the members of a country’s aesthetic surgery association were more likely to have accounts on multiple platforms. In our study, 37.7% of the surgeons questioned had a social media presence (either exclusively or alongside a website). Usefulness for Surgeons Gould and Nazarian18 reviewed their practice’s data over one year in order to identify the return on investment from various platforms (including practice website, Google, Yelp, RealSelf, Facebook, and Instagram). They identified that word of mouth accounted for the largest fraction of their net income, however each social media platform had an increasing return on investment throughout the period. In contrast, the return from Google or practice website either declined or stayed the same. In our study 78.3% of surgeons thought that SoMe had benefitted their business and 33.3% thought that consultations had become more challenging as a result. Indeed, 56.5% of the respondents in our survey thought that SoMe leads to unrealistic expectations in the patients. Anecdotally, this may be due to misinformation (eg, from a patients desire to look like a celebrity or the inclination to have the same procedure as a friend had done). While this may present as a challenge during the consultation, it is also an opportunity to educate the patients. Such an approach may be useful for the surgeon in the long run if one of the patterns of referral is by word of mouth. Surgeons’ Perception of How SoMe Affects Patients Perhaps the most interesting result of our study is that only 20.3% of surgeons think that more than three quarters of patients use social media to seek information about breast augmentation. In fact, 91.4% of our patient respondents had searched the internet in general and 88.9% searched for clinical photographs. It is also interesting to note that over half the surgeons, 52.9%, considered social media to be a bad influence and 56.5% thought that it leads to unrealistic expectations. That can be an argument to diversify knowledge and plastic surgeons to take control of social media debate. Gould et al19 offered advice on engagement, branding, and monetization of social media. They emphasized the importance of respecting patient confidentiality and obtaining patient consent for any social media pictures. A total of 52.2% of surgeons in our survey said that they would not chase bad reviews. This may, in part, be because of a lack of guidance on managing their online reputation or due to lack of moderation on SoMe outlets. It is true that one cannot control how someone else may respond, a good advice20 is “not to feed the trolls” and not to take any comment personally. A response to a potentially inflammatory remark, especially on line and in SoMe spaces, must be measured and evidence based. The underestimation of the importance of social media may be why only 37.7% of the surgeons questioned have a social media presence (exclusively or alongside a website). This false perception may also be the reason that surgeons may not want to chase bad reviews, thinking that they may not make a difference, while in fact 73.4% of patients specifically searched for bad reviews. If the surgeons underestimate SoMe importance, and do not actively engage in it, it should be no surprise that most of the conversation has been taken over by nonmedical professionals or individuals who are not suitably qualified.21 Misinformation Both patients and surgeons think that there is a lot of misinformation available. An analysis of 2880 tweets22 with the hashtag #plasticsurgery found that 70.6% were sent by patients and only 6% by plastic surgeons. Of those sent by plastic surgeons, 61.3% tweets were about aesthetic surgery, 13.9% on basic science, 4.0% on patient safety, and 2.3% about reconstruction. Similarly, a study by Dorfman et al21 showed that in a sample of Instagram posts containing certain hashtags, only 17.8% came from the members of the American Society of Aesthetic Plastic Surgery (ASAPS). They found that ASAPS members were more likely to tweet about educational material. It is important to understand that there is no check on the veracity of information in SoMe. This puts the onus on the trained professionals to provide a voice of reason and use evidence base to try to leverage the online opinion. Limitations One limitation of this study is that all patients were Swedish. However, the large number makes them representative of the country’s population and by extension of a developed nation with significant social media penetration. However, these attitudes to SoMe may not be representative of countries where social media is used less frequently, either from the patient or the surgeons’ perspective. Looking at the data in Table 1, 90 surgeons who responded were from Europe, 20 from Asia, 10 from North America, 10 from Australia, and 8 from South America. While some variations will be expected (eg, within different countries in Asia) the majority of the respondents are from the developed countries and thus able to shed a light on the trend there. Our clinic is a large practice with has some well recognized names and a proportional electronic presence (with Swedish and English websites, a clinic Facebook page, as well as individual surgeons’ presence on Facebook, Twitter, and Instagram platforms). This may have resulted in a higher percentage of patients choosing us based on reputation alone. A smaller clinic may be more reliant on their social media reputation instead. Also, the surgeons who have been working in the clinic may be aligned to a certain view. The inclusion of surgeons from different background is expected to counteract that tendency. CONCLUSION Patients planning to undergo primary breast augmentation appear to be very active on SoMe. While patients use it regularly as a source of information and support, word of mouth and personal recommendations are still important considerations for them in choosing a surgeon for primary breast augmentation. Social media allows surgeons to engage, educate, and promote personal and professional profile as well as leverage online discussions and provide an evidence-based opinion. Even though surgeons appear to underestimate the effect of SoMe on the patients, the use of social media appears to be on the rise in surgical community. Both patients and surgeons are concerned about the inaccuracies of available online information, which is an argument for plastic surgeons to take control of the social media debate. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. Disclosures Dr Montemurro is a consultant and speaker for Allergan, Inc. (Irvine, CA). Dr Hedén is a consultant and speaker for Allergan, Inc., and is an unpaid consultant for Canfield Scientific (Fairfield, NJ). Dr Cheema declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. 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Aesthetic Surgery Journal – Oxford University Press
Published: Feb 9, 2018
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