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Plastic Surgery-Related Hashtag Utilization on Instagram: Implications for Education and Marketing

Plastic Surgery-Related Hashtag Utilization on Instagram: Implications for Education and Marketing Abstract Background Recent data suggest patients are seeking aesthetic surgery to improve their appearance on Instagram and other social media. Despite the rising influence of Instagram in plastic surgery, few academic publications address Instagram, let alone evaluate its utilization in plastic surgery. Objectives We set out to answer the following three questions: 1) what plastic surgery-related content is being posted to Instagram; 2) who is posting this content; and 3) what specific hashtags are they using? Methods Our study queried 21 Instagram plastic surgery-related hashtags. Content analysis was used to qualitatively evaluate each of the nine “top” posts associated with each hashtag (189 posts). Duplicate posts and those not relevant to plastic surgery were excluded. Results A total of 1,789,270 posts utilized the 21 hashtags sampled in this study. Of the top 189 posts for these 21 queried hashtags, 163 posts met inclusion criteria. Plastic surgeons eligible for membership in American Society for Aesthetic Plastic Surgery (ASAPS) accounted for only 17.8% of top posts, whereas noneligible physicians accounted for 26.4%. All nonplastic surgery trained physicians marketed themselves as “cosmetic surgeons.” Nine top posts (5.5%) were by nonphysicians, including dentists, spas with no associated physician, and a hair salon. The majority of these posts were self-promotional (67.1%) as opposed to educational (32.9%). Board-certified plastic surgeons were significantly more likely to post educational content to Instagram as compared to nonplastic surgeons (62.1% vs 38.1%, P = 0.02). Conclusions ASAPS eligible board-certified plastic surgeons are underrepresented amongst physicians posting top plastic surgery-related content to Instagram. The Internet and social media have become ubiquitous in the world of plastic surgery. In a 2013 study by Vardanian et al, more than half of surveyed American Society of Plastic Surgeons (ASPS) members used social media for personal or professional purposes.1 Even the ASPS and American Society for Aesthetic Plastic Surgery (ASAPS) now have Facebook, Twitter, and YouTube pages.2,3 Moreover, according to 2017 statistics from the American Academy of Facial Plastic and Reconstructive Surgery, 42% of surgeons report that their patients are seeking aesthetic surgery to improve their appearance on Instagram, Snapchat, Facebook, and other social media channels.4 As a uniquely visual social media channel, Instagram in particular is naturally suited to plastic surgery, a uniquely visual surgical specialty. As of 2016, Instagram reports more than 400 million monthly active users, and more than 80 million photos are uploaded on this platform per day.5,6 Like Facebook and Twitter, Instagram utilizes hashtags that allow users to identify content of interest. For example, when users search a particular hashtag, Instagram automatically lists the total number of posts using that hashtag, as well as the nine “top” or most popular related posts, at the top of the page. This is followed by the remaining posts utilizing that hashtag, which are subsequently itemized in chronological order. Instagram has become a dominant channel for business marketing to young adults, and its usage in plastic surgery continues to rise. Many surgeons have been quick to embrace Instagram as a tool for patient education as well as business development, and have since gained large followings.7 Despite the rising influence of this platform, very few academic publications even mention Instagram, let alone evaluate its utilization in modern plastic surgery. Several authors cite Instagram in passing.8-10 Others briefly point out advantages, disadvantages, and recommended uses of Instagram for plastic surgeons, highlighting its utility for brand development and education.11,12 Nonetheless, there are no peer-reviewed studies that quantitatively evaluate plastic surgery-related content on Instagram—and perhaps more importantly, there are no published reports indicating who is responsible for these posts. Consequently, our study set out to systematically answer the following three questions: 1) what plastic surgery-related content is being posted to Instagram; 2) who is posting this content; and 3) what specific hashtags are they using? In doing so, we address an important gap in the surgical literature. METHODS Data from Instagram (www.instagram.com) was obtained manually on January 9, 2017. Two authors (R.G.D. and E.E.V.) queried the following hashtags, which include medical and lay person terminology for popular plastic surgery procedures13: 1) #plasticsurgery, 2) #cosmeticsurgery, 3) #aestheticsurgery, 4) #plasticsurgeon, 5) #cosmeticsurgeon, 6) #aestheticsurgeon, 7) #breastlift, 8) #mastopexy, 9) #breastaugmentation, 10) #boobjob, 11) #breastimplant, 12) #nosejob, 13) #rhinoplasty, 14) #rhytidectomy, 15) #facelift, 16) #tummytuck, 17) #abdominoplasty, 18) #brazilianbuttlift, 19) #buttockaugmentation, 20) #bodycontouring, and 21) #liposuction. The total number of posts using each hashtag was recorded. Content analysis was then utilized to qualitatively evaluate each of the nine “top” posts associated with each hashtag (189 posts). More specifically, we tracked whether the post was educational or self-promotional.14 In addition, we noted whether the post was a photo or short video. For each post, we further recorded data on who did the actual posting on a per-user basis by analyzing each poster’s Instagram profile. Data extrapolated included what country the poster came from and whether or not they were a plastic surgeon. If so, we noted whether they were board certified by the American Board of Plastic Surgery (ABPS) or The Royal College of Physicians and Surgeons of Canada (RCPSC), both of which are included in the membership criteria for ASAPS.15 If not, we noted their medical specialty, if any, or general occupation. We further tracked if the poster was a patient, medical interest group, or foreign surgeon. Instagram users not falling into any of these categories (ie, celebrity fan pages or satirical pages) were classified as “other.” Posts were included in our analysis if they were relevant to plastic surgery (ie, photos or short videos in the operating room, before/after photos, anatomical diagrams, post by a plastic surgery patient describing their experience, advertisement for breast implants, etc.) or were posted by a plastic surgeon. Duplicate posts and posts not relevant to plastic surgery were excluded from our study. All analyses were performed using SAS JMP Pro 12 (SAS Institute. Cary, NC). Categorical variables were described by frequencies or proportions and were compared using the chi-square test. Continuous variables were compared using a t test. Post characteristics were compared between board-certified plastic surgeons and other users of Instagram. For all tests, the P values were two-sided and significance was defined as at a P value <0.05. RESULTS A total of 1,789,270 posts utilized the 21 hashtags sampled in this study. Of these hashtags, #plasticsurgery had the highest amount of posts associated with it (523,361 posts). This was more than the next two most popular hasthags combined (#facelift with 224,235 posts, and #rhinoplasty with 138,259 posts). In comparison, 117,320 posts used the hashtag #cosmeticsurgery, whereas #aestheticsurgery had only 15,939 posts associated with it. Likewise, more posts used the hashtag #plasticsurgeon (128,197 posts) than #cosmeticsurgeon (15,100) and #aestheticsurgeon (3638). For most procedures evaluated in this study, hashtags using lay person terminology for the procedure had more posts associated with it than hashtags using the proper medical terminology (Table 1). For example, #boobjob (91,968 posts) was more popular than #breastimplant (5003 posts) and #breastaugmentation (1138 posts). In addition, 24,243 posts used #breastlift, whereas only 5929 posts used #mastopexy. The hashtag #facelift had 224,235 posts associated with it, as opposed to #rhytidectomy with 339 posts. This was true for abdominal (#tummytuck with 124,010 posts vs #abdominoplasty with 32,027 posts) and gluteal procedures (#brazilianbuttlift with 42,026 posts vs #buttockaugmentation with 2048 posts) as well. There were some exceptions to this, however. The hashtag #rhinoplasty had 138,259 posts associated with it, whereas #nosejob had 103,348 posts. Likewise, 119,974 posts used #liposuction, in contrast to 71,168 posts using #bodycontouring. Table 1. Plastic Surgery-Related Hashtag Utilization on Instagram. Hashtag   Total no. of posts   #plasticsurgery  523,361  #facelift  224,235  #rhinoplasty  138,259  #plasticsurgeon  128,197  #tummytuck  124,010  #liposuction  119,974  #cosmeticsurgery  117,320  #nosejob  103,348  #boobjob  91,968  #bodycontouring  71,168  #brazilianbuttlift  42,026  #abdominoplasty  32,027  #breastlift  24,243  #aestheticsurgery  15,939  #cosmeticsurgeon  15,100  #mastopexy  5929  #breastimplant  5003  #aestheticsurgeon  3638  #buttockaugmentation  2048  #breastaugmentation  1138  #rhytidectomy  339  Hashtag   Total no. of posts   #plasticsurgery  523,361  #facelift  224,235  #rhinoplasty  138,259  #plasticsurgeon  128,197  #tummytuck  124,010  #liposuction  119,974  #cosmeticsurgery  117,320  #nosejob  103,348  #boobjob  91,968  #bodycontouring  71,168  #brazilianbuttlift  42,026  #abdominoplasty  32,027  #breastlift  24,243  #aestheticsurgery  15,939  #cosmeticsurgeon  15,100  #mastopexy  5929  #breastimplant  5003  #aestheticsurgeon  3638  #buttockaugmentation  2048  #breastaugmentation  1138  #rhytidectomy  339  Hashtags are presented in descending order according to total number of posts. Hashtags using the more common terminology for the procedure generally had more posts associated with it than hashtags using the proper medical terminology. Notable exceptions included #rhinoplasty and #liposuction. View Large Of the top 189 posts for these 21 queried hashtags, 163 posts met inclusion criteria (128 photos and 35 short videos). A majority of top posts came from foreign surgeons (68 posts or 41.7%). Countries represented included Turkey (17 posts), Russia (11 posts), Brazil (7 posts), Colombia (4 posts), Dominican Republic (3 posts), Ecuador (3 posts), Greece (2 posts), Iran (2 posts), Italy (2 posts), Philippines (2 posts), Thailand (2 posts), Ukraine (2 posts), United Arab Emirates (2 posts), United Kingdom (2 posts), Venezuela (2 posts), Azerbijan (1 post), Japan (1 post), Lebanon (1 post), Puerto Rico (1 post), and Spain (1 post). ABPS and RCPSC board-certified plastic surgeons accounted for only 17.8% of top posts (29 posts), whereas those not board certified by ABPS or RCPSC accounted for 26.4% (43 posts) (Figure 1). Excluding foreign surgeons, otolaryngologists made up the largest group of those not eligible for ASAPS membership among the top posts (12 posts). Also included in this cohort were dermatologists (9 posts), general surgeons (6 posts), gynecologists (4 posts), family medicine physicians (2 posts), and an emergency medicine physician (1 post). All obstetrician-gynecologists, dermatologists, general surgeons, family practice, and emergency medicine physicians marketed themselves as “cosmetic surgeons.” Nine of these top posts were not even by licensed physicians. This included dentists (4 posts), spas with no associated physician (4 posts), and a hair salon (one post). Figure 1. View largeDownload slide Excluding foreign surgeons, ASAPS eligible board-certified plastic surgeons are underrepresented amongst those posting top plastic surgery-related content to Instagram. Figure 1. View largeDownload slide Excluding foreign surgeons, ASAPS eligible board-certified plastic surgeons are underrepresented amongst those posting top plastic surgery-related content to Instagram. The vast majority of these posts were for self-promotional (94 posts, 67.1%) as opposed to educational (46 posts, 32.9%) purposes, though there was no significant difference in number of likes (4757 ± 20,305 vs 2780 ± 9108, P = 0.54) or comments (20 ± 34 vs 22 ± 41, P = 0.82) between self-promotional and educational posts. Board-certified plastic surgeons were significantly more likely to post educational content to Instagram as compared to nonplastic surgeons (62.1% vs 38.1%, P = 0.02). There was no significant difference in number of likes (P = 0.55) or comments (P = 0.44) for content posted by plastic surgeons vs nonplastic surgeons (Table 2). Twenty-one posts were by patients and 2 posts were by medical interest groups. Table 2. Comparing ABPS or RCPSC Board Certified vs Non-ABPS or RCPSC-Certified Plastic Surgeons, Excluding Foreign Surgeons Variable   ABPS or RCPSC board-certified plastic surgeons   Non-ABPS or RCPSC-certified (excluding foreign surgeons )  P value   Video post  31.0%  20.9%  0.23  Number of likes  2136 ± 4494  4313 ± 17,962  0.55  Number of comments  17.1 ± 21.4  22.9 ± 39.1  0.44  Educational posts  62.1%  38.1%  0.02  Variable   ABPS or RCPSC board-certified plastic surgeons   Non-ABPS or RCPSC-certified (excluding foreign surgeons )  P value   Video post  31.0%  20.9%  0.23  Number of likes  2136 ± 4494  4313 ± 17,962  0.55  Number of comments  17.1 ± 21.4  22.9 ± 39.1  0.44  Educational posts  62.1%  38.1%  0.02  View Large DISCUSSION The 21st century patient has been described as a “consumer” of healthcare, underscoring the importance of understanding the decision-making process these patients use when “shopping” around for plastic surgeons.16 Evidence suggests that plastic surgery patients are increasingly querying the Internet and social media for health-related information before their consultation.17 As patients increasingly rely on such means to choose their provider, it is critical to understand the ecosystem of online platforms available to patients. In “#PlasticSurgery,” Branford and colleagues examined posting about plastic surgery on Twitter as a means of informing how board-certified plastic surgeons could use the hashtag #PlasticSurgery as a tool to educate patients and the public. The authors prospectively analyzed 2880 “tweets” containing the words “plastic surgery” and discovered that such posting was dominated by the public, accounting for 70.6% of posts as opposed to 6.0% by plastic surgeons.14 They further found that 37.0% of posts by plastic surgeons were self-promotional. Though Twitter is undoubtedly an important social media platform, Instagram reports more monthly active users than Twitter, and likewise beats Twitter as the most popular social media platform for advertisers.18,19 Like Twitter, there too is a “lively conversation” going on about plastic surgery on Instagram.14 The 21 plastic surgery-related hashtags sampled in this study alone account for nearly two million posts. Yet unlike plastic surgery-related posting on Twitter, our study found that posting of top plastic surgery-related content on Instagram was dominated by licensed physicians (80.4%). However, only 17.8% of posts were made by ABPS and RCPSC board-certified plastic surgeons. This is in contrast to the 26.4% of top posts that were made by physicians (excluding foreign surgeons) not eligible for ASAPS membership. Indeed, the paucity of board-certified plastic surgeons amongst the top plastic surgery-related posts on Instagram is alarming. Our analysis found that together there were more otolaryngologists, dermatologists, general surgeons, gynecologists, family medicine physicians, and emergency medicine physicians marketing plastic surgical procedures than ASAPS eligible board-certified plastic surgeons. We even identified dentists, spas with no associated physician, and a hair salon that were offering plastic surgery procedures in their facilities (5.5%). This may offer insight into why hashtags using more slang or lay person terminology for plastic surgery procedures tended to have more posts associated with them than hashtags using the proper medical terminology. Furthermore, we found that more than twice as many of these top posts were done for self-promotional over educational purposes. In a 2010 interview with Jim Leonardo of Plastic Surgery News, past ASPS Ethics Committee chairman and coauthor of this study, Dr. Neil A. Fine, suggested that nonplastic surgeons feel the only way to draw attention to themselves is to be “more and more visible through advertising.”20 Though Fine was referring to website-based advertising at the time, our findings suggest that nonplastic surgeons are now also utilizing new social media channels to widen their target audience and extend their reach far beyond traditional website-based advertising. This ever-increasing number of physicians not board certified in plastic and reconstructive surgery performing cosmetic procedures often comes at the expense of patient safety and outcomes, with accounts detailing significant morbidity and even mortality at the hands of practitioners without proper training.21-24 Indeed, Mioton and colleagues discovered a nearly 300% increase in the number of complications for panniculectomies performed by nonplastic surgeons as compared with board-certified plastic surgeons.24 Though having a trained and qualified surgeon perform such procedures is paramount for patient safety, patients may be confused as to what constitutes such a surgeon. In a recent study, Shah et al found survey respondents were uncomfortable with obstetrician-gynecologists, dermatologists, general surgeons, and family practice physicians performing aesthetic surgery.25 Despite their finding that 90% of survey respondents believed board certification was important and necessary, approximately half of respondents believed a surgeon must be appropriately credentialed and trained in order to legally advertise themselves as cosmetic surgeons. Yet in our study cohort, all obstetrician-gynecologists, dermatologists, general surgeons, family practice, and emergency medicine physicians marketed themselves as “cosmetic surgeons.” This echoes Shah and colleagues’ concern that problematic medical marketing, recognized and unrecognized boards, and varying categorizations of surgeons have made it challenging for patients to decide which physicians can safely perform aesthetic surgeries.25 Since patients are increasingly querying social media when choosing a provider, and the top nine posts are the first content a prospective patient would see when searching a particular hashtag on Instagram, the findings of our study as presented here are particularly worrisome. How Can Plastic Surgeons Unite to Educate the Public? There are concerns of social media trivializing aesthetic surgery and dropping the high standards plastic surgeons should hold themselves too.26 Reissis et al indicate that a review of advertising guidelines created by organizations such as the ASPS and ASAPS is needed, as these guidelines were largely created before the widespread use of social media by plastic surgeons.26 Yet sharing content on social media need not be unethical and can play an important role in education as well as marketing when done tactfully.27 Indeed, social media represents a platform that can be used by plastic surgeons to advance collective goals of patient education and informing the public that board certification as well as adequate training matters.28 In a recent Letter to the Editor in the Aesthetic Surgery Journal, Dr. Sheila Nazarian asks, “If we, the so-called experts, don’t get ourselves out there like the non-core physicians are, how will we stay relevant?”28 The results of our study indicate that Dr. Nazarian’s question is more pertinent now than ever before. If plastic surgeons do not start using social media to engage with potential patients, noncore physicians certainly will—and already are. Interestingly, our study found no significant difference in number of likes (P = 0.55) or comments (P = 0.44) for Instagram posts done by board-certified plastic surgeons vs nonplastic surgeons. This underscores how crucial it is for more plastic surgeons board certified by the American Board of Medical Specialties to join the social media conversation.14 But how can plastic surgeons join forces to educate the public and stay relevant, yet do so in an ethical and professional manner? Addressing this will require multiple approaches. Uniting under the hashtag #plasticsurgery is one potential strategy. Engagement on Instagram is naturally highest with posts using more than one hashtag, thus we recommended that surgeons use any combination of the 21 plastic surgery-related hashtags evaluated in this study, as applicable. A media campaign by the ASAPS to inform the public of the dangers of deceptive advertising and higher postoperative complications24 by nonplastic surgery trained surgeons is another potential strategy. Furthermore, we recommend that plastic surgeons obtain written consent from the patient before any content be distributed online, and ideally surgeons should seek counsel from a legal professional when preparing the consent form.27 Surgeons should always seek to uphold ethical and professional standards as determined by the ASAPS Code of Ethics.29 In doing so, plastic surgeons will be able to post content to social media with the confidence of knowing that they are protecting their patients, themselves, and ultimately, the perception of plastic surgery at large. Limitations Our pilot study only examined the nine top posts associated with each queried hashtag. This study reveals that the majority of top United States and Canadian plastic surgery Instagram posts were by nonboard-certified plastic surgeons. One inherent weakness of this study is that foreign surgeons accounted for the greatest proportion of posts, making it difficult to ascertain if they were advertising outside their scope of training. It is possible to have the same top post for multiple hashtags if related hashtags are used together, although we attempted to minimize this by excluding duplicate posts linked to the same account. Though using social media for research purposes has biases and limitations, the same is true for outcomes studies and quality-of-life measures.30 Our study queried the included Instagram hashtags for a single date. Top posts for any given hashtag can potentially change on a daily basis, thought it is unlikely to be significantly different on any given day vs another. Future studies may wish to evaluate seasonal variations in plastic surgery-related Instagram usage. Older individuals who are not as technology savvy are less likely to post on Instagram, and those using the platform may represent a “vociferous and well-connected minority.”31 Yet such limitations are increasingly being reduced as social media continues to grow in use and popularity. On the other hand, social media permits analysis over a wide geographic area. In their recent study using Twitter to evaluate lung cancer surgery outcomes, Cooke and colleagues suggest that the Internet and social media enable a more diverse population to be sampled than possible with focus groups or individual interviews.32 Indeed, our study identified content posted from 21 different countries. Forthcoming studies should examine additional posts to validate our findings as well as better understand the full extent plastic surgery-related content posted to Instagram. Such future studies may wish to broaden the hashtags queried to include those applicable to facial plastic surgeons and oculoplastic surgeons as well, in order to better compare core plastic surgery specialties with noncore ones. CONCLUSIONS Board-certified plastic surgeons are underrepresented amongst physicians posting top plastic surgery-related content to Instagram. Furthermore, individuals that are not licensed physicians may likewise be promoting plastic surgery procedures to prospective patients. The vast majority of these top posts are for self-promotional over educational purposes. Given the volume of cosmetic surgery advertising by nonplastic surgeons and the ensuing risk this poses to patient safety and outcomes, our findings present a significant cause for concern. It is critical that board-certified plastic surgeons use social media like Instagram as a platform to educate patients about the risks of surgery and dangers of having plastic surgery performed by those with improper training. 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. REFERENCES 1. Vardanian AJ, Kusnezov N, Im DD, Lee JC, Jarrahy R. Social media use and impact on plastic surgery practice. Plast Reconstr Surg . 2013; 131( 5): 1184- 1193. Google Scholar CrossRef Search ADS PubMed  2. Patel A, Pfaff M, Tuggle CT. The plastic and reconstructive surgery Facebook page: newfound treasure. Plast Reconstr Surg . 2013; 132( 1): 189e. Google Scholar CrossRef Search ADS PubMed  3. Quinlan CS, Collins AM, Nason GJ, Dempsey M. The use of social media by Plastic Surgery Journals. Plast Reconstr Surg Glob Open . 2016; 4( 1): e605. Google Scholar CrossRef Search ADS PubMed  4. American Academy of Facial Plastic and Reconstructive Surgery Annual Survey Statistics. http://www.aafprs.org/media/stats_polls/m_stats.html. January 2017. Accessed March 4, 2017. 5. The Growth of Social Media v3.0. US: Search Engine Journal. https://www.searchenginejournal.com/growth-social-media-v-3-0-infographic/155115/. February 2016. Accessed February 22, 2017. 6. Woollaston V. Instagram is now bigger than Twitter: Photo sharing app has 400 millions users who share 80 million images every day. http://www.dailymail.co.uk/sciencetech/article-3245976/Instagram-bigger-Twitter-Photo-sharing-app-400-millions-users-share-80-million-images-day.html. September 23, 2015. Accessed March 5, 2017. 7. Falzone D. Plastic surgery docs use Instagram stars to boost their practice. http://www.foxnews.com/entertainment/2016/06/16/plastic-surgery-docs-use-instagram- stars-to-boost-their-practices.html. June 16, 2016. Accessed March 8, 2017. 8. Patel A, Fusi S, Okanlami OO, Ditillo M, Sawh-Martinez RF. Blogging to bolster your plastic surgery career. Plast Reconstr Surg . 2015; 135( 3): 658e- 659e. Google Scholar CrossRef Search ADS PubMed  9. Gould DJ, Leland HA, Ho AL, Patel KM. Emerging trends in social media and plastic surgery. Ann Transl Med . 2016; 4( 23): 455. Google Scholar CrossRef Search ADS PubMed  10. Oranges CM, Schaefer KM, Gohritz A, Haug M, Schaefer DJ. The mirror effect on social media self-perceived beauty and its implications for cosmetic surgery. Plast Reconstr Surg Glob Open . 2016; 4( 11): e1088. Google Scholar CrossRef Search ADS PubMed  11. Humphries LS, Curl B, Song DH. #SocialMedia for the academic plastic surgeon-elevating the brand. Plast Reconstr Surg Glob Open . 2016; 4( 1): e599. Google Scholar CrossRef Search ADS PubMed  12. Gould DJ, Grant Stevens W, Nazarian S. A Primer on social media for plastic surgeons: what do i need to know about social media and how can it help my practice? Aesthet Surg J . 2017; 37( 5): 614- 619. Google Scholar CrossRef Search ADS PubMed  13. Americans Spend More Than $15 Billion on Aesthetic Procedures for the First Time Ever. http://www.surgery.org/media/news-releases/americans-spend-more-than-15-billion-on-aesthetic-procedures-for-the-first-time-ever. March 15, 2017. Accessed March 17, 2017. 14. Branford OA, Kamali P, Rohrich RJet al.  l. #PlasticSurgery. Plast Reconstr Surg . 2016; 138( 6): 1354- 1365. Google Scholar CrossRef Search ADS PubMed  15. Requirements for Active Member—U.S. and Canadian Application Process. http://www.surgery.org/professionals/membership/active-membership. Accessed April 29, 2017. 16. Kelley SW, Schwartz RW. A broader view of marketing: implications for surgeons. Surg Innov . 2004; 11( 4): 281- 288. Google Scholar CrossRef Search ADS PubMed  17. Montemurro P, Porcnik A, Hedén P, Otte M. The influence of social media and easily accessible online information on the aesthetic plastic surgery practice: literature review and our own experience. Aesthetic Plast Surg . 2015; 39( 2): 270- 277. Google Scholar CrossRef Search ADS PubMed  18. Goel V. It’s Official: Instagram is Bigger Than Twitter. https://bits.blogs.nytimes.com/2014/12/10/its-official-instagram-is-bigger-than-twitter/?_r=1. December 10, 2014. Accessed March 5, 2017. 19. Rodionova Z. Instagram beats Twitter as most popular social media platform for advertisers. http://www.independent.co.uk/news/business/news/instagram-beats- twitter-as-most-popular-social-media-platform- a7074121.html. June 10, 2016. Accessed March 5, 2017. 20. Leonardo J. Over-the-top cosmetic surgery ads, web pages draw ethics complaints. Plastic Surgery News . 2010; 130( 5S-3): 111S- 116S. 21. D’Amico RA, Saltz R, Rohrich RJet al.   Risks and opportunities for plastic surgeons in a widening cosmetic medicine market: future demand, consumer preferences, and trends in practitioners’ services. Plast Reconstr Surg . 2008; 121( 5): 1787- 1792. Google Scholar CrossRef Search ADS PubMed  22. Murphy K. Ear doctors performing face-lifts? It happens. http://www.nytimes.com/2012/01/31/health/non- specialists-expand-into-lucrative-cosmetic-surgery- procedures.html. January 30, 2012. Accessed March 11, 2017. 23. O’Donnell J. Lack of training can be deadly in cosmetic surgery. https://usatoday30.usatoday.com/money/perfi/basics/story/2011-09-13/cosmetic-surgery-investigation/ 50395494/1. September 15, 2011. Accessed March 11, 2017. 24. Mioton LM, Buck DW2nd, Gart MS, Hanwright PJ, Wang E, Kim JY. A multivariate regression analysis of panniculectomy outcomes: does plastic surgery training matter? Plast Reconstr Surg . 2013; 131( 4): 604e- 612e. 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American Society for Aesthetic Plastic Surgery website. http://www.surgery.org/sites/default/files/ASAPS-Code-of-Ethics.pdf. Accessed May 14, 2017. 30. Domanski MC, Cavale N. Self-reported “worth it” rating of aesthetic surgery in social media. Aesthetic Plast Surg . 2012; 36( 6): 1292- 1295. Google Scholar CrossRef Search ADS PubMed  31. Boyce N. The Lancet technology: April, 2012. Lancet . 2012; 379( 9826): 1580. Google Scholar CrossRef Search ADS PubMed  32. Cooke DT, West H, Conway Let al.   Social media can be used as a qualitative research tool in surgical patient-centered outcomes research. J Am Coll Surg . 2015; 221( 4): e29. CrossRef Search ADS   © 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: [email protected] http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

Plastic Surgery-Related Hashtag Utilization on Instagram: Implications for Education and Marketing

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Oxford University Press
Copyright
© 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: [email protected]
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1090-820X
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1527-330X
DOI
10.1093/asj/sjx120
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Abstract Background Recent data suggest patients are seeking aesthetic surgery to improve their appearance on Instagram and other social media. Despite the rising influence of Instagram in plastic surgery, few academic publications address Instagram, let alone evaluate its utilization in plastic surgery. Objectives We set out to answer the following three questions: 1) what plastic surgery-related content is being posted to Instagram; 2) who is posting this content; and 3) what specific hashtags are they using? Methods Our study queried 21 Instagram plastic surgery-related hashtags. Content analysis was used to qualitatively evaluate each of the nine “top” posts associated with each hashtag (189 posts). Duplicate posts and those not relevant to plastic surgery were excluded. Results A total of 1,789,270 posts utilized the 21 hashtags sampled in this study. Of the top 189 posts for these 21 queried hashtags, 163 posts met inclusion criteria. Plastic surgeons eligible for membership in American Society for Aesthetic Plastic Surgery (ASAPS) accounted for only 17.8% of top posts, whereas noneligible physicians accounted for 26.4%. All nonplastic surgery trained physicians marketed themselves as “cosmetic surgeons.” Nine top posts (5.5%) were by nonphysicians, including dentists, spas with no associated physician, and a hair salon. The majority of these posts were self-promotional (67.1%) as opposed to educational (32.9%). Board-certified plastic surgeons were significantly more likely to post educational content to Instagram as compared to nonplastic surgeons (62.1% vs 38.1%, P = 0.02). Conclusions ASAPS eligible board-certified plastic surgeons are underrepresented amongst physicians posting top plastic surgery-related content to Instagram. The Internet and social media have become ubiquitous in the world of plastic surgery. In a 2013 study by Vardanian et al, more than half of surveyed American Society of Plastic Surgeons (ASPS) members used social media for personal or professional purposes.1 Even the ASPS and American Society for Aesthetic Plastic Surgery (ASAPS) now have Facebook, Twitter, and YouTube pages.2,3 Moreover, according to 2017 statistics from the American Academy of Facial Plastic and Reconstructive Surgery, 42% of surgeons report that their patients are seeking aesthetic surgery to improve their appearance on Instagram, Snapchat, Facebook, and other social media channels.4 As a uniquely visual social media channel, Instagram in particular is naturally suited to plastic surgery, a uniquely visual surgical specialty. As of 2016, Instagram reports more than 400 million monthly active users, and more than 80 million photos are uploaded on this platform per day.5,6 Like Facebook and Twitter, Instagram utilizes hashtags that allow users to identify content of interest. For example, when users search a particular hashtag, Instagram automatically lists the total number of posts using that hashtag, as well as the nine “top” or most popular related posts, at the top of the page. This is followed by the remaining posts utilizing that hashtag, which are subsequently itemized in chronological order. Instagram has become a dominant channel for business marketing to young adults, and its usage in plastic surgery continues to rise. Many surgeons have been quick to embrace Instagram as a tool for patient education as well as business development, and have since gained large followings.7 Despite the rising influence of this platform, very few academic publications even mention Instagram, let alone evaluate its utilization in modern plastic surgery. Several authors cite Instagram in passing.8-10 Others briefly point out advantages, disadvantages, and recommended uses of Instagram for plastic surgeons, highlighting its utility for brand development and education.11,12 Nonetheless, there are no peer-reviewed studies that quantitatively evaluate plastic surgery-related content on Instagram—and perhaps more importantly, there are no published reports indicating who is responsible for these posts. Consequently, our study set out to systematically answer the following three questions: 1) what plastic surgery-related content is being posted to Instagram; 2) who is posting this content; and 3) what specific hashtags are they using? In doing so, we address an important gap in the surgical literature. METHODS Data from Instagram (www.instagram.com) was obtained manually on January 9, 2017. Two authors (R.G.D. and E.E.V.) queried the following hashtags, which include medical and lay person terminology for popular plastic surgery procedures13: 1) #plasticsurgery, 2) #cosmeticsurgery, 3) #aestheticsurgery, 4) #plasticsurgeon, 5) #cosmeticsurgeon, 6) #aestheticsurgeon, 7) #breastlift, 8) #mastopexy, 9) #breastaugmentation, 10) #boobjob, 11) #breastimplant, 12) #nosejob, 13) #rhinoplasty, 14) #rhytidectomy, 15) #facelift, 16) #tummytuck, 17) #abdominoplasty, 18) #brazilianbuttlift, 19) #buttockaugmentation, 20) #bodycontouring, and 21) #liposuction. The total number of posts using each hashtag was recorded. Content analysis was then utilized to qualitatively evaluate each of the nine “top” posts associated with each hashtag (189 posts). More specifically, we tracked whether the post was educational or self-promotional.14 In addition, we noted whether the post was a photo or short video. For each post, we further recorded data on who did the actual posting on a per-user basis by analyzing each poster’s Instagram profile. Data extrapolated included what country the poster came from and whether or not they were a plastic surgeon. If so, we noted whether they were board certified by the American Board of Plastic Surgery (ABPS) or The Royal College of Physicians and Surgeons of Canada (RCPSC), both of which are included in the membership criteria for ASAPS.15 If not, we noted their medical specialty, if any, or general occupation. We further tracked if the poster was a patient, medical interest group, or foreign surgeon. Instagram users not falling into any of these categories (ie, celebrity fan pages or satirical pages) were classified as “other.” Posts were included in our analysis if they were relevant to plastic surgery (ie, photos or short videos in the operating room, before/after photos, anatomical diagrams, post by a plastic surgery patient describing their experience, advertisement for breast implants, etc.) or were posted by a plastic surgeon. Duplicate posts and posts not relevant to plastic surgery were excluded from our study. All analyses were performed using SAS JMP Pro 12 (SAS Institute. Cary, NC). Categorical variables were described by frequencies or proportions and were compared using the chi-square test. Continuous variables were compared using a t test. Post characteristics were compared between board-certified plastic surgeons and other users of Instagram. For all tests, the P values were two-sided and significance was defined as at a P value <0.05. RESULTS A total of 1,789,270 posts utilized the 21 hashtags sampled in this study. Of these hashtags, #plasticsurgery had the highest amount of posts associated with it (523,361 posts). This was more than the next two most popular hasthags combined (#facelift with 224,235 posts, and #rhinoplasty with 138,259 posts). In comparison, 117,320 posts used the hashtag #cosmeticsurgery, whereas #aestheticsurgery had only 15,939 posts associated with it. Likewise, more posts used the hashtag #plasticsurgeon (128,197 posts) than #cosmeticsurgeon (15,100) and #aestheticsurgeon (3638). For most procedures evaluated in this study, hashtags using lay person terminology for the procedure had more posts associated with it than hashtags using the proper medical terminology (Table 1). For example, #boobjob (91,968 posts) was more popular than #breastimplant (5003 posts) and #breastaugmentation (1138 posts). In addition, 24,243 posts used #breastlift, whereas only 5929 posts used #mastopexy. The hashtag #facelift had 224,235 posts associated with it, as opposed to #rhytidectomy with 339 posts. This was true for abdominal (#tummytuck with 124,010 posts vs #abdominoplasty with 32,027 posts) and gluteal procedures (#brazilianbuttlift with 42,026 posts vs #buttockaugmentation with 2048 posts) as well. There were some exceptions to this, however. The hashtag #rhinoplasty had 138,259 posts associated with it, whereas #nosejob had 103,348 posts. Likewise, 119,974 posts used #liposuction, in contrast to 71,168 posts using #bodycontouring. Table 1. Plastic Surgery-Related Hashtag Utilization on Instagram. Hashtag   Total no. of posts   #plasticsurgery  523,361  #facelift  224,235  #rhinoplasty  138,259  #plasticsurgeon  128,197  #tummytuck  124,010  #liposuction  119,974  #cosmeticsurgery  117,320  #nosejob  103,348  #boobjob  91,968  #bodycontouring  71,168  #brazilianbuttlift  42,026  #abdominoplasty  32,027  #breastlift  24,243  #aestheticsurgery  15,939  #cosmeticsurgeon  15,100  #mastopexy  5929  #breastimplant  5003  #aestheticsurgeon  3638  #buttockaugmentation  2048  #breastaugmentation  1138  #rhytidectomy  339  Hashtag   Total no. of posts   #plasticsurgery  523,361  #facelift  224,235  #rhinoplasty  138,259  #plasticsurgeon  128,197  #tummytuck  124,010  #liposuction  119,974  #cosmeticsurgery  117,320  #nosejob  103,348  #boobjob  91,968  #bodycontouring  71,168  #brazilianbuttlift  42,026  #abdominoplasty  32,027  #breastlift  24,243  #aestheticsurgery  15,939  #cosmeticsurgeon  15,100  #mastopexy  5929  #breastimplant  5003  #aestheticsurgeon  3638  #buttockaugmentation  2048  #breastaugmentation  1138  #rhytidectomy  339  Hashtags are presented in descending order according to total number of posts. Hashtags using the more common terminology for the procedure generally had more posts associated with it than hashtags using the proper medical terminology. Notable exceptions included #rhinoplasty and #liposuction. View Large Of the top 189 posts for these 21 queried hashtags, 163 posts met inclusion criteria (128 photos and 35 short videos). A majority of top posts came from foreign surgeons (68 posts or 41.7%). Countries represented included Turkey (17 posts), Russia (11 posts), Brazil (7 posts), Colombia (4 posts), Dominican Republic (3 posts), Ecuador (3 posts), Greece (2 posts), Iran (2 posts), Italy (2 posts), Philippines (2 posts), Thailand (2 posts), Ukraine (2 posts), United Arab Emirates (2 posts), United Kingdom (2 posts), Venezuela (2 posts), Azerbijan (1 post), Japan (1 post), Lebanon (1 post), Puerto Rico (1 post), and Spain (1 post). ABPS and RCPSC board-certified plastic surgeons accounted for only 17.8% of top posts (29 posts), whereas those not board certified by ABPS or RCPSC accounted for 26.4% (43 posts) (Figure 1). Excluding foreign surgeons, otolaryngologists made up the largest group of those not eligible for ASAPS membership among the top posts (12 posts). Also included in this cohort were dermatologists (9 posts), general surgeons (6 posts), gynecologists (4 posts), family medicine physicians (2 posts), and an emergency medicine physician (1 post). All obstetrician-gynecologists, dermatologists, general surgeons, family practice, and emergency medicine physicians marketed themselves as “cosmetic surgeons.” Nine of these top posts were not even by licensed physicians. This included dentists (4 posts), spas with no associated physician (4 posts), and a hair salon (one post). Figure 1. View largeDownload slide Excluding foreign surgeons, ASAPS eligible board-certified plastic surgeons are underrepresented amongst those posting top plastic surgery-related content to Instagram. Figure 1. View largeDownload slide Excluding foreign surgeons, ASAPS eligible board-certified plastic surgeons are underrepresented amongst those posting top plastic surgery-related content to Instagram. The vast majority of these posts were for self-promotional (94 posts, 67.1%) as opposed to educational (46 posts, 32.9%) purposes, though there was no significant difference in number of likes (4757 ± 20,305 vs 2780 ± 9108, P = 0.54) or comments (20 ± 34 vs 22 ± 41, P = 0.82) between self-promotional and educational posts. Board-certified plastic surgeons were significantly more likely to post educational content to Instagram as compared to nonplastic surgeons (62.1% vs 38.1%, P = 0.02). There was no significant difference in number of likes (P = 0.55) or comments (P = 0.44) for content posted by plastic surgeons vs nonplastic surgeons (Table 2). Twenty-one posts were by patients and 2 posts were by medical interest groups. Table 2. Comparing ABPS or RCPSC Board Certified vs Non-ABPS or RCPSC-Certified Plastic Surgeons, Excluding Foreign Surgeons Variable   ABPS or RCPSC board-certified plastic surgeons   Non-ABPS or RCPSC-certified (excluding foreign surgeons )  P value   Video post  31.0%  20.9%  0.23  Number of likes  2136 ± 4494  4313 ± 17,962  0.55  Number of comments  17.1 ± 21.4  22.9 ± 39.1  0.44  Educational posts  62.1%  38.1%  0.02  Variable   ABPS or RCPSC board-certified plastic surgeons   Non-ABPS or RCPSC-certified (excluding foreign surgeons )  P value   Video post  31.0%  20.9%  0.23  Number of likes  2136 ± 4494  4313 ± 17,962  0.55  Number of comments  17.1 ± 21.4  22.9 ± 39.1  0.44  Educational posts  62.1%  38.1%  0.02  View Large DISCUSSION The 21st century patient has been described as a “consumer” of healthcare, underscoring the importance of understanding the decision-making process these patients use when “shopping” around for plastic surgeons.16 Evidence suggests that plastic surgery patients are increasingly querying the Internet and social media for health-related information before their consultation.17 As patients increasingly rely on such means to choose their provider, it is critical to understand the ecosystem of online platforms available to patients. In “#PlasticSurgery,” Branford and colleagues examined posting about plastic surgery on Twitter as a means of informing how board-certified plastic surgeons could use the hashtag #PlasticSurgery as a tool to educate patients and the public. The authors prospectively analyzed 2880 “tweets” containing the words “plastic surgery” and discovered that such posting was dominated by the public, accounting for 70.6% of posts as opposed to 6.0% by plastic surgeons.14 They further found that 37.0% of posts by plastic surgeons were self-promotional. Though Twitter is undoubtedly an important social media platform, Instagram reports more monthly active users than Twitter, and likewise beats Twitter as the most popular social media platform for advertisers.18,19 Like Twitter, there too is a “lively conversation” going on about plastic surgery on Instagram.14 The 21 plastic surgery-related hashtags sampled in this study alone account for nearly two million posts. Yet unlike plastic surgery-related posting on Twitter, our study found that posting of top plastic surgery-related content on Instagram was dominated by licensed physicians (80.4%). However, only 17.8% of posts were made by ABPS and RCPSC board-certified plastic surgeons. This is in contrast to the 26.4% of top posts that were made by physicians (excluding foreign surgeons) not eligible for ASAPS membership. Indeed, the paucity of board-certified plastic surgeons amongst the top plastic surgery-related posts on Instagram is alarming. Our analysis found that together there were more otolaryngologists, dermatologists, general surgeons, gynecologists, family medicine physicians, and emergency medicine physicians marketing plastic surgical procedures than ASAPS eligible board-certified plastic surgeons. We even identified dentists, spas with no associated physician, and a hair salon that were offering plastic surgery procedures in their facilities (5.5%). This may offer insight into why hashtags using more slang or lay person terminology for plastic surgery procedures tended to have more posts associated with them than hashtags using the proper medical terminology. Furthermore, we found that more than twice as many of these top posts were done for self-promotional over educational purposes. In a 2010 interview with Jim Leonardo of Plastic Surgery News, past ASPS Ethics Committee chairman and coauthor of this study, Dr. Neil A. Fine, suggested that nonplastic surgeons feel the only way to draw attention to themselves is to be “more and more visible through advertising.”20 Though Fine was referring to website-based advertising at the time, our findings suggest that nonplastic surgeons are now also utilizing new social media channels to widen their target audience and extend their reach far beyond traditional website-based advertising. This ever-increasing number of physicians not board certified in plastic and reconstructive surgery performing cosmetic procedures often comes at the expense of patient safety and outcomes, with accounts detailing significant morbidity and even mortality at the hands of practitioners without proper training.21-24 Indeed, Mioton and colleagues discovered a nearly 300% increase in the number of complications for panniculectomies performed by nonplastic surgeons as compared with board-certified plastic surgeons.24 Though having a trained and qualified surgeon perform such procedures is paramount for patient safety, patients may be confused as to what constitutes such a surgeon. In a recent study, Shah et al found survey respondents were uncomfortable with obstetrician-gynecologists, dermatologists, general surgeons, and family practice physicians performing aesthetic surgery.25 Despite their finding that 90% of survey respondents believed board certification was important and necessary, approximately half of respondents believed a surgeon must be appropriately credentialed and trained in order to legally advertise themselves as cosmetic surgeons. Yet in our study cohort, all obstetrician-gynecologists, dermatologists, general surgeons, family practice, and emergency medicine physicians marketed themselves as “cosmetic surgeons.” This echoes Shah and colleagues’ concern that problematic medical marketing, recognized and unrecognized boards, and varying categorizations of surgeons have made it challenging for patients to decide which physicians can safely perform aesthetic surgeries.25 Since patients are increasingly querying social media when choosing a provider, and the top nine posts are the first content a prospective patient would see when searching a particular hashtag on Instagram, the findings of our study as presented here are particularly worrisome. How Can Plastic Surgeons Unite to Educate the Public? There are concerns of social media trivializing aesthetic surgery and dropping the high standards plastic surgeons should hold themselves too.26 Reissis et al indicate that a review of advertising guidelines created by organizations such as the ASPS and ASAPS is needed, as these guidelines were largely created before the widespread use of social media by plastic surgeons.26 Yet sharing content on social media need not be unethical and can play an important role in education as well as marketing when done tactfully.27 Indeed, social media represents a platform that can be used by plastic surgeons to advance collective goals of patient education and informing the public that board certification as well as adequate training matters.28 In a recent Letter to the Editor in the Aesthetic Surgery Journal, Dr. Sheila Nazarian asks, “If we, the so-called experts, don’t get ourselves out there like the non-core physicians are, how will we stay relevant?”28 The results of our study indicate that Dr. Nazarian’s question is more pertinent now than ever before. If plastic surgeons do not start using social media to engage with potential patients, noncore physicians certainly will—and already are. Interestingly, our study found no significant difference in number of likes (P = 0.55) or comments (P = 0.44) for Instagram posts done by board-certified plastic surgeons vs nonplastic surgeons. This underscores how crucial it is for more plastic surgeons board certified by the American Board of Medical Specialties to join the social media conversation.14 But how can plastic surgeons join forces to educate the public and stay relevant, yet do so in an ethical and professional manner? Addressing this will require multiple approaches. Uniting under the hashtag #plasticsurgery is one potential strategy. Engagement on Instagram is naturally highest with posts using more than one hashtag, thus we recommended that surgeons use any combination of the 21 plastic surgery-related hashtags evaluated in this study, as applicable. A media campaign by the ASAPS to inform the public of the dangers of deceptive advertising and higher postoperative complications24 by nonplastic surgery trained surgeons is another potential strategy. Furthermore, we recommend that plastic surgeons obtain written consent from the patient before any content be distributed online, and ideally surgeons should seek counsel from a legal professional when preparing the consent form.27 Surgeons should always seek to uphold ethical and professional standards as determined by the ASAPS Code of Ethics.29 In doing so, plastic surgeons will be able to post content to social media with the confidence of knowing that they are protecting their patients, themselves, and ultimately, the perception of plastic surgery at large. Limitations Our pilot study only examined the nine top posts associated with each queried hashtag. This study reveals that the majority of top United States and Canadian plastic surgery Instagram posts were by nonboard-certified plastic surgeons. One inherent weakness of this study is that foreign surgeons accounted for the greatest proportion of posts, making it difficult to ascertain if they were advertising outside their scope of training. It is possible to have the same top post for multiple hashtags if related hashtags are used together, although we attempted to minimize this by excluding duplicate posts linked to the same account. Though using social media for research purposes has biases and limitations, the same is true for outcomes studies and quality-of-life measures.30 Our study queried the included Instagram hashtags for a single date. Top posts for any given hashtag can potentially change on a daily basis, thought it is unlikely to be significantly different on any given day vs another. Future studies may wish to evaluate seasonal variations in plastic surgery-related Instagram usage. Older individuals who are not as technology savvy are less likely to post on Instagram, and those using the platform may represent a “vociferous and well-connected minority.”31 Yet such limitations are increasingly being reduced as social media continues to grow in use and popularity. On the other hand, social media permits analysis over a wide geographic area. In their recent study using Twitter to evaluate lung cancer surgery outcomes, Cooke and colleagues suggest that the Internet and social media enable a more diverse population to be sampled than possible with focus groups or individual interviews.32 Indeed, our study identified content posted from 21 different countries. Forthcoming studies should examine additional posts to validate our findings as well as better understand the full extent plastic surgery-related content posted to Instagram. Such future studies may wish to broaden the hashtags queried to include those applicable to facial plastic surgeons and oculoplastic surgeons as well, in order to better compare core plastic surgery specialties with noncore ones. CONCLUSIONS Board-certified plastic surgeons are underrepresented amongst physicians posting top plastic surgery-related content to Instagram. Furthermore, individuals that are not licensed physicians may likewise be promoting plastic surgery procedures to prospective patients. The vast majority of these top posts are for self-promotional over educational purposes. Given the volume of cosmetic surgery advertising by nonplastic surgeons and the ensuing risk this poses to patient safety and outcomes, our findings present a significant cause for concern. It is critical that board-certified plastic surgeons use social media like Instagram as a platform to educate patients about the risks of surgery and dangers of having plastic surgery performed by those with improper training. 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. REFERENCES 1. Vardanian AJ, Kusnezov N, Im DD, Lee JC, Jarrahy R. Social media use and impact on plastic surgery practice. Plast Reconstr Surg . 2013; 131( 5): 1184- 1193. Google Scholar CrossRef Search ADS PubMed  2. Patel A, Pfaff M, Tuggle CT. The plastic and reconstructive surgery Facebook page: newfound treasure. Plast Reconstr Surg . 2013; 132( 1): 189e. Google Scholar CrossRef Search ADS PubMed  3. Quinlan CS, Collins AM, Nason GJ, Dempsey M. The use of social media by Plastic Surgery Journals. 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Journal

Aesthetic Surgery Journal – Oxford University Press

Published: Mar 1, 2018

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