SoMe and Behavioral Science

Aesthetic Surgery Journal

2020, Vol 40(6) 691–699
The Plastic Surgery Social Media Influencer: © 2019 The Aesthetic Society.
Reprints and permission:
Ethical Considerations and a Literature Review journals.permissions@oup.com
DOI: 10.1093/asj/sjz329
www.aestheticsurgeryjournal.com

Nisha Gupta, BA; Robert Dorfman, MD; Sean Saadat, MD; and
Jason Roostaeian, MD

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Abstract
Background: Social media use has become a relevant tool in plastic surgery. These platforms are utilized for many
reasons, such as business promotion. Although beneficial, social media can cause ethical dilemmas if used incorrectly.
Objectives:  A review of the literature revealed what is understood about the implications of social media in regards to
sponsorship/promotion. This paper aimed to create the foundation surrounding this topic and help facilitate future discus-
sions on this new ethical dilemma. 
Methods:  A MEDLINE search with a custom publication date range and a review of the literature was conducted on June
15, 2019. 
Results:  The search yielded 139 articles and abstracts. After review, 26 publications were chosen for analysis. Articles
were taken from the following journals: Plastic and Reconstructive Surgery (n = 12), Aesthetic Surgery Journal (n = 8), PRS
Global Open (n = 2), Annals of Plastic Surgery (n = 1), BMJ (n = 1), AMA Journal of Ethics (n = 1), and Facial Plastic Surgery
(n = 1). The 4 principles of medical ethics were analyzed in respect to promotion and sponsorship in plastic surgery.
Conclusions:  Social media is a novel platform that is becoming increasingly utilized in plastic surgery. Although its im-
pact can be beneficial, it is not well understood in the context of social media sponsorship and promotion. To date, no
peer-reviewed articles specifically discuss these limitations. It is critical that all plastic surgeons be cognizant of both the
positive and negative aspects of social media before integrating it into their professional lives. 

Editorial Decision date: November 8, 2019; online publish-ahead-of-print November 19, 2019.

Social media continues to be a platform via which med-
ical professionals and residents can promote their work
and educate their followers.1 Many residency programs
are even beginning to integrate social media into their ac-
ademic curriculums.2 This popularity continues to grow,
especially in the field of plastic surgery. A prospective anal-
ysis of 3 major social media platforms revealed that 63% of
the posts on Instagram originated from plastic surgeons,
with 83% of posts being self-promotional.3 Plastic surgeons
are more likely than academic surgeons to have a positive
attitude towards, and higher acceptance of, social media
use.4 Additionally, plastic surgeons are among the top in-
fluencers on social media and create more promotional
content than academicians.5 The utilization of social media
in promoting one’s practice has its benefits and its pitfalls.
The dominance of social media is increasingly interfering
with the doctor-patient relationship. Although the use of
social media is on the rise, many are questioning whether
From the Division of Plastic and Reconstructive Surgery, UCLA David
Geffen School of Medicine, Los Angeles, CA
Corresponding Author:
Dr Jason Roostaeian, Division of Plastic and Reconstructive Surgery,
UCLA David Geffen School of Medicine, 200 UCLA Medical Plaza,
Suite 465, Los Angeles, CA 90095, USA.
E-mail: jasonroostaeian@mednet.ucla.edu
692
its use in this context is ethical.6 We conducted an anal-
ysis of the ethics of social media use in plastic surgery, the
use of such platforms to achieve top ranking, and receiving
payment in return for sponsorship. Current guidelines do
exist that advise plastic surgeons on general social media
use; however, no articles address the social media influ-
encer and the ethics behind receiving/giving payment for
sponsorship and promotion.7 For the purpose of this paper,
we will define sponsorship as receiving any form of pay-
ment and/or recognition in return for the advertisement
and promotion of a medical product or service. We aim to
provide a comprehensive review of what is known about
the “plastic surgery influencer” and the potential pitfalls of
social media in this area.
METHODS
A MEDLINE search was conducted on June 15, 2019 for
the following terms: “social media,” “plastic surgery,” “aes-
thetic surgery,” “ethics,” “sponsorship,” and “payment.”  A
custom publication date range was used, with January 1,
2000 being the lower limit and the search date the upper.
This date range covered a period during which all relevant
social media platforms—Instagram, Snapchat, Facebook,
Twitter, YouTube, etc—were established and in widespread
use by the general public. Different combinations of terms
yielded different results; thus, in order to ensure that all
relevant articles were included in the review, a variety of
literature searches were undertaken and all eligible art-
icles were chosen. Performing multiple literature searches
elicited all publications that discuss social media use in
plastic surgery and address the ethical implications seen
from social media use in relation to sponsorship. These
publications included surveys, editorials, published books,
cross-sectional surveys, opinion and response pieces, and
literary reviews. Table 1 outlines the literature review and
summarizes the publications included in our analysis.8-38
In order for a medical practice to be classified as “eth-
ical,” the 4 principles of medical ethics must be obeyed:
autonomy, justice, beneficence, and nonmaleficence.39 In
other words, medical professionals must respect patient
autonomy, always do what is in the best interest of the pa-
tient, do the patient no harm, and have fairness in all med-
ical decisions, respectively.
RESULTS
The MEDLINE/PubMed search yielded 139 articles and ab-
stracts. After title and abstract review, as well as inclusion
of other MEDLINE searches that utilized combinations of
other key words, 26 publications were chosen for ana-
lysis, all of which were found in plastic surgery journals.
Articles and survey studies were the most common type
Aesthetic Surgery Journal 40(6)
of articles identified (n  =  8), followed by opinion and dis-
cussion pieces (n  =  5). Editorials (n  =  3), literary reviews
(n = 2), analysis (n = 2), and a book (n = 1) were also iden-
tified. The most common journals for publication on social
media use in plastic surgery were as followed: Plastic and
Reconstructive Surgery (n = 12), Aesthetic Surgery Journal
(n = 8), PRS Global Open (n = 2), Annals of Plastic Surgery
(n = 1), BMJ (n = 1), AMA Journal of Ethics (n = 1), and Facial
Plastic Surgery (n = 1). Of the articles, only 1 specifically dis-
cussed guidelines for plastic surgeon trainees.7 This author
gave potential opportunities and corresponding pitfalls
for the following categories related to social media: inter-
actions, content, clinical media, and supervision. No other
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articles addressed the ethics of being a social media “in-
fluencer” and receiving payment in return for sponsorship.
Ethics in the Plastic Surgery Influencer
Autonomy
Patient autonomy in bioethics concerns the importance of
confidentiality and informed consent. Not only must con-
sent be obtained, the specific patient must also possess all
the necessary information surrounding the topic and fully
comprehend all it entails.1 Social media is a powerful tool
that can educate potential patients, but can also be mis-
leading by falsely advertising a certain level of expertise
simply because of a surgeon’s presence on social media.
Google now places those plastic surgeons with a more
prominent social media presence (ie, Instagram followers)
on its top pages.40 The use of social media, therefore,
can affect the doctor-patient relationship in a variety of
ways. This can be from social media policies that are con-
stantly changing and thus affecting the confidentiality of
the patient or even a medical physician being featured on
trending posts and consequently misleading their patients
into believing they are the most knowledgeable on a cer-
tain area. Surgeons and patients alike are concerned with
the inaccuracy of information on social media.41 This intro-
duces a level of influence and arguably affects a patient’s
autonomy in their medical decision-making and under-
scores the importance of providing patients with factual
and adequate information.41 Surgeons and trainees must
be aware of the influence they inadvertently have over
patients’ decision-making. In regards to sponsorship and
receiving payment to promote medical brands, there also
needs to be a level of awareness that patients are prone
to trusting their surgeons’ choices. Therefore, medical pro-
fessionals should only be willing to promote brands that
they truly believe are the best on the market and/or make
it clear that it is a paid advertisement or sponsorship; the
latter can be achieved with the metadata tags “ad” or “paid
promotion” to allow users to easily find this specific con-
tent. This will fully inform a patient and give them more
freedom in the decisions they make. 
Gupta et al693
Table 1.  Publications Included in the Analysis
First author, year Title
Bennett, 2018 The ethical and professional use
of social media in surgery: a
systematic review of the
literature
Bennett, 2018 When is posting about
patients on social media
unethical “medutainment”?
Bennett, 2017 The teaching of ethics and pro-
fessionalism in plastic surgery
residency: a cross-sectional
survey
Chandawarkar, Insta-grated plastic surgery
2018 residencies: the rise of social
media use by trainees and re-
sponsible guidelines for use
Chopan, 2019 Plastic surgery and social media:
examining perceptions
Crockett, 2007 The influence of plastic surgery
“reality TV” on cosmetic surgery
patient expectations and
decision making
 
Dauwe, 2012 Social networks uncovered:
10 tips every plastic surgeon
should know  focuses on social media in regards to public relations
Journal Study type Summary
Plastic and Literature review/ This article recognizes that although some guide-
Reconstructive analysis lines exist regarding social media use within surgery,
Surgery practical recommendations for professionalism are
not fully present; specifically, that the appropriate use
of social media must extend beyond the simplistic
ethical guidelines (ie, consent from patient) and sur-
geons must adhere to a standard of professionalism
far surpassing what is currently in place. The initial
search included 954 articles and 28 were included
for review. 
Plastic and Article This article began with a real-life example in which a
Reconstructive doctor crossed the line with social media, although
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Surgery he had the patient’s verbal and written consent.
This story exemplified the idea that the use of social
media can easily cross the line of professionalism,
and once done, it is almost impossible to permanently
remove from cyberspace. It talked about a patient’s
misunderstanding of what she actually consented to
and claimed that although the surgeon did adhere
to basic guidelines, he failed to prioritize the patient.
Social media is being used for educational purposes,
but also promotional ones, thus creating a fine line
between proper use and what the article claims as
“medutainment.” It gives suggestions for guidelines
to which plastic surgeons can refer when utilizing so-
cial media. 
Annals of Plastic Cross-sectional This paper begins by discussing the lack of ethics and
Surgery survey professionalism mentioned in plastic surgery litera-
ture to date. Based on a 21-question survey, these 2
topics were analyzed among plastic surgery programs
to better understand how they are implemented.  
Aesthetic Editorial This study analyzed the use of social media among
Surgery Journal plastic surgery residents. The study analyzed the
trends and content of plastic surgery residency–as-
sociated Instagram accounts. It explains how ethical
guidelines are becoming delineated and proposes
new social media guidelines for trainees in order to
promote social media use while avoiding possible
legal, professional, and ethical violations.
Plastic and Article This study took a sample of 1 million tweets (Twitter)
Reconstructive and used software to generate positivity scores for
Surgery certain keywords. It was concluded that tweets with
the word “plastic” in it tended to have more negative
ratings in contrast to “aesthetic” or “cosmetic.”  
Plastic and Survey This study examined first-time patients undergoing
Reconstructive cosmetic surgery. It analyzed how these patients
Surgery made use of reality TV in their decision-making and
overall perception of the risks/benefits of plastic sur-
gery. More than half of the patients were considered
high-intensity watchers who also believed they were
more knowledgeable on the topic than those who did
not watch a lot of reality TV (low intensity). 
Aesthetic Article This paper provides 10 tips on how to incorporate
Surgery Journal Facebook and Twitter into plastic surgery practices. It
and advertisement and ultimately suggests that the
use of social media can help maximize exposure to
patients. 
694
Table 1.  Continued
First author, year Title
DeCamp, 2013 Social media and physicians’
online identity crisis
Eberlin, 2017 Electronic communication in
plastic surgery: guiding
principles from the American
Society of Plastic Surgeons
health policy committee
Economides, 2018 An analysis of plastic surgeons’
social media use and
perceptions
Fan, 2018 The public's preferences on
plastic surgery social media
engagement and
professionalism: demystifying
the impact of demographics
Fan, 2019 To bot or not? Challenging the
top social media influencers in
#plasticsurgery
Gallo, 2018 Ethics in plastic surgery: ap-
plying the four common princi-
ples to practice
Aesthetic Surgery Journal 40(6)
Journal Study type Summary
JAMA Opinion/viewpoint This article addresses the existing controversy be-
tween professional and personal boundaries on
social media. It concludes that complete separation
of identities, like many suggest, is not possible and
creates inconsistencies, possible harm, and unreal-
ized benefits. The author points out that it is important
to recognize that social media exists in public places
not private or professional ones independently. The
article urges medical professionals to evaluate social
media use not in terms of whether the content
is professional or personal but rather if it appropriate
in a public space.
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Plastic and Discussion/guide- This article addresses electronic communication (ie,
Reconstructive lines text messaging, email, video conferencing, and social
Surgery media) within plastic surgery, specifically in regards
to exchanging information between healthcare pro-
viders and providers/patients. This article addresses
the ethical factors that must be recognized when
utilizing such modes of communication, specifically
in regards to the Health Insurance Portability and Ac-
countability Act 1996, consent, etc. A literary review
was conducted and 12 considerations for plastic sur-
geons regarding electronic communication were sug-
gested. This article does address legal, ethical, and
professional considerations. 
Aesthetic Survey/analysis This article undertook both a literature review as well
Surgery Journal as a data survey to investigate social media use in the
field of plastic surgery. A 16-question survey was sent
out to board-certified plastic surgeons to investigate
their professional use and perceptions on the social
platforms. Based on the responses, a clear dichotomy
exists in the acceptance of social media. For example,
nonacademic surgeons were more likely than aca-
demic surgeons to believe that social media has a
positive use. Additionally, younger surgeons in private
practices are more likely to utilize platforms than the
other groups categorized in the paper. 
Plastic and Survey and This article analyzed the public’s use of social media
Reconstructive analysis in regards to surgery and what their preferences were
Surgery when seeking out surgeons. This study analyzed the
effect of demographics in the decision-making and
used a 31-question survey to gather data. Ultimately,
there were differences in the engagement and per-
ception of social media across age group, sex, pa-
rental status, and country of origin. 
Plastic and Comparative study This paper looked at the top influencers in social
Reconstructive media and broke them down into certain categories:
Surgery nonphysician, board-certified plastic surgeon, aca-
demician, other physician, and international surgeon.
It then analyzed the use of social media and the
presence on Twitter. It was concluded that academi-
cians were the most underrepresented <10%, with
private plastic surgeons and US board–certified
surgeons representing more than half. Additionally,
nonphysicians had more promotional content than
educational among the groups. 
Plastic and Discussion This article uses the 4 common principles of bioethics
Reconstructive as a foundation for the discussion of ethics in plastic
Surgery surgery. It attempts to take a systematic approach to
address the ethical dilemmas currently seen in plastic
surgery.   
Gupta et al695
Table 1.  Continued
First author, year Title
Gould, 2017 A primer on social media for
plastic surgeons: what do I need
to know about social media and
how can it help my practice?
Gutierrez, 2018 Can plastic surgeons maintain
professionalism within social
media?  cial media. The ASPS Code of Ethics lays out the nec-
Janik, 2019 Internet and social media as
a source of information about
plastic surgery: comparison
between public and private
sector, a 2-center study
Montemurro, 2018 Patients’ and surgeons’
perceptions of social media’s
role in the decision making for
primary aesthetic breast
augmentation
Naftali, 2018 Plastic surgery faces the web:
an analysis of the popular social
media for plastic surgeons
Patel, 2016 Snapchat is not for sharing
Preminger, 2017 The divergence of ethics and
professionalism in the social
media arena
Journal Study type Summary
Aesthetic Article This article addresses the use of social media for sur-
Surgery Journal geons and the most commonly used platforms. It then
explains the benefits of its use, but cautions its users
of the many pitfalls as well.  It gives a list of tips/tricks,
as well as the “10 commandments” of social media
which gives insight on how to correctly engage with
social media professionally. 
AMA Journal of Viewpoint This article analyzes the ethical issues that have
Ethics arisen from surgeons posting specific content on so-
essary standards for its member surgeons to adhere
to. ASPS provides general guidelines for the use of
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patient images and ensuring that professional care is
given when a patient is undergoing surgery. 
Plastic and Two-cohort study This study examined and compared patients’ social
Reconstructive media habits between public and private aesthetic
Surgery Global plastic surgery practices. The survey concluded that
Open word of mouth remains the most trusted referral, al-
though the use of social media is on the rise.  
Aesthetic Questionnaire This article analyzed the utilization of social media by
Surgery Journal survey female patients who want to undergo breast augmen-
tation. A survey was conducted and found that 91.4%
of patients had searched online for information re-
garding their surgery. The study also had a separate
survey for surgeons, which concluded that surgeons
underestimate the use of social media by their pa-
tients. Although social media can be beneficial, both
patients and surgeons are concerned about the inac-
curacy that it can provide. 
Plastic and Analysis Patients are increasingly turning to social media for
Reconstructive their sources of information for medical procedures,
Surgery Global especially in plastic surgery. This study analyzed
Open plastic surgery content on social media and then
analyzed how plastic surgeons communicate with
patients. Instagram, Facebook, and YouTube were the
main platforms studied with approximately 300 posts
analyzed. The study concluded that Instagram is the
most powerful platform and suggests that plastic sur-
geons should utilize this method, as it is beginning to
dominate the communication field. 
BMJ Article This article specifically talks about Snapchat as a so-
commentary cial media platform in the medical field. It introduces
1 example of a Venezuelan student obstetrician who
posted a smirking selfie with a woman giving birth in
the background. This student is just one example of
the many similar incidents of medical professionals
and students crossing the line on social media. It also
refers to other reports of Snapchat becoming increas-
ingly utilized in the medical field and further goes on
to talk about the varying degree of professionalism
(and the ambiguity around it) and the challenges that
social media creates. 
Plastic and Editorial This article talks about social media’s prominent and
Reconstructive growing role in plastic surgery and discusses how
Surgery easy it is for a plastic surgeon to push the limits of
his/her professionalism as a result. It addresses the
ambiguity between ethics and professionalism. It ad-
dresses the need for guidelines within the industry
and urges surgeons to understand that profession-
alism goes beyond the scope of the Code of Ethics
currently in place. This articles focuses on ethics and
professionalism in social media. 
696
Table 1.  Continued
First author, year Title
Schoenbrunner, Framework for the creation of
2019 ethical and professional social
media content  Surgery
Siegel, 2019 What does it mean to be a
#plasticsurgeon? Analyzing
plastic surgery hashtag utiliza-
tion in social media
Teven, 2017 Social media and consent: are
patients adequately informed?
Vuyk, 2018 A plea for ethics: suggestions for
implementation in the medical
curriculum
Ward, 2018 Google Trends as a resource for
informing plastic surgery mar-
keting decisions
Wheeler, 2011 Social media in plastic surgery
practices: emerging trends in
North America
ASPS, American Society of Plastic Surgeons.
Beneficence and Nonmaleficence
The use of social media creates a vague area between pa-
tient confidentiality and entertainment.42 Nonmaleficence
states that one shall not do harm to a patient. This harm
can come in many forms from physical malpractice to un-
ethical use of patient information that can jeopardize their
life. Such harms are the risks of integrating social media
into a surgeon’s professional practice. The power of social
media is hard to comprehend and many patients may not
Aesthetic Surgery Journal 40(6)
Journal Study type Summary
Plastic and Article This article recognizes that plastic surgeons were
Reconstructive early adopters of social media and that it can be a
powerful marketing/educational tool for the medical
field. It analyzes the updated ASPS Code of Ethics as
well as other published literature to see if there are
adequate guidelines in place to help plastic surgeons
uphold ethics and professionalism on social media. 
Aesthetic Study sample This study analyzed the use of Instagram specifically
Surgery Journal within plastic surgery. Following the top 15 plastic sur-
gery related hashtag trends, this study found that the
majority of plastic surgeons do post their content on
Instagram; however, other interdisciplinary fields also
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utilize the same hashtags; thus, ultimately misleading
users who are unaware of the minute differences
among certain specialties.  
Plastic and Viewpoint This column discusses the widespread use of social
Reconstructive media and its positive benefits in plastic surgery (ie,
Surgery marketing, creating a brand, education, promoting
research). Despite these pros, the article points out
potential pitfalls, specifically in regards to patient
confidentiality and the copyrights associated with so-
cial media (ie, physicians lose control and ownership
over image when posted on social media, which is
contrasted to the clear copyright ownership in publi-
cations). The author points out that in typical cases, a
patient can revoke consent at any point—a right he/
she must surrender since images online are, in theory,
impossible to fully erase. It concludes that a patient
must have adequate protection against this powerful
tool. 
Facial Plastic Article This article recognizes that although medical ethics is
Surgery somewhat familiar to plastic surgeons and residents,
there needs to be a formalized training that truly es-
tablishes guidelines to avoid ethical dilemmas during
practice. 
Aesthetic Article This article analyzes how Google Trends noticeably
Surgery Journal affect the interest of the general public on social
media use. It suggests that physicians take more no-
tice of these Trends in order to increase the effective-
ness of their marketing strategies 
Aesthetic Article This article analyzes the current practices and atti-
Surgery Journal tudes towards social media use in aesthetic surgery.
It used a 19-question web-based survey that all
board-certified surgeons answered. The questions fell
under 1 of 3 categories: use of social media, preferred
modes of marketing, and demographic information. 
realize that when relinquishing confidentiality so that their
case can be used as an example, that information may be
repeatedly reused by other platforms. Even if the patient
requests to have their image or information “taken down”
in the future, once it is on the internet, it is never really
gone. 
The Code of Ethics of the American Society of Plastic
Surgeons (ASPS) permits the use of advertising to make
one’s services known; however, it prohibits misleading or
Gupta et al697
deceptive information.43 Many patients seeking aesthetic
or plastic surgery turn to social media platforms as their
primary referral method; thus, paying money to influence
the choice of these patients can perhaps compromise the
best interests of the patient. Although internet searching
may be efficient, a patient’s expectations can be altered
greatly by the information they find online.41 Social media
is an inevitable tool that will continue to exist regardless
of its negative consequences. This is why it is imperative
that any surgeon who uses products for which they have
received sponsorship or paid endorsements must inform
the patient clearly of the potential continued use of their
information by both the surgeon’s media profiles as well
as any profiles associated with the product.
Justice
The bioethical principle of justice refers to equal distribu-
tion of medical resources. In the case of social media and
plastic surgery, medical justice can be better described
as fairness in achieving top ranking via pay-for-play so-
cial media recognition.41 Is it just for practitioners to pay
to be at the forefront of various prominent plastic surgery
or medically related social media pages, which ultimately
misleads potential patients into believing that this correl-
ates to being the top rank? Being persuaded by the per-
ceived ranking online may jeopardize a patient’s primary
interest. In order to embrace this powerful tool while still
upholding the duties a medical professional has for his/
her patients, the nondigital doctor-patient relationship that
medicine was built upon must be authenticated and pa-
tients should be informed when their doctor is paying to
be listed as a top doctor vs receiving unsolicited recogni-
tion for their work.  Lastly, social media has compromised the integrity
DISCUSSION
Social Media Use in Plastic Surgery
Social media is a crucial tool in the evolving field of medi-
cine, especially plastic surgery. Such platforms, when
used correctly, can offer incredible benefits, both educa-
tionally and for marketing purposes. The internet gives pa-
tients endless information at the simple click of a button.
In a 2015 study by Montemurro et al,41 approximately 95%
of patients checked the internet for information regarding
their surgery of interest, with 46% exploiting social media
specifically for this purpose. Not only do patients use the
internet to become more educated, many are turning to
social media as their main source of referral, with 63%
admitting that these platforms were their first search
method.41
Current guidelines and proposed suggestions on
general social media use do exist, but the question of
how to navigate the ethical ambiguity of it all has yet to
be addressed. In a 2018 article by Chandawarkar et al,2
trainees were given the potential opportunities and cor-
responding pitfalls for various categories such as content
and online interactions. Although this can help trainees
avoid legal, professional, and ethical violations, the lit-
erature on social media use in regards to sponsorship
and paid promotion is not well understood. Although it
is yet to be explicitly studied how sponsorship affects
physicians’ social media use, it is not unreasonable to im-
agine that a surgeon’s motivation for utilizing such plat-
forms can change when an external incentive is added.
Plastic surgeons and doctors are availing themselves
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of social media sponsorship and resharing platforms to
place themselves or their practice as the top search find-
ings. Utilizing these tools can easily mislead the majority
of patients who turn to social media for suggestions as
to which practice will best meet their medical needs.
Many patients assume that those who have hundreds of
thousands of followers on Instagram or are reposted on
a prominent plastic surgery social media page are the
most qualified or trusted, although this is not always the
case. Social media provides many outlets to gain unwar-
ranted popularity, thus making social platforms difficult
to navigate for patients. Additionally, those doctors and
residents who willingly sponsor certain companies in re-
turn for payment or goods often may not recognize the
weight that such an agreement holds. Many patients trust
the products that doctors recommend; thus, there need
to be clear guidelines and policies on how medical pro-
fessionals should address this growing realm, especially
when associated with a specific residency program or
practice.
of the doctor-patient relationship. This long-standing,
trusted relationship that medicine was built upon is now
being exchanged for a digitized form that takes away
the core duties a doctor must uphold to his/her patient.
Current guidelines that address the generic use of so-
cial media in practice warn plastic surgeons, trainees,
and resident programs on a number of potential pitfalls
and give advice on how to avoid ethical breaches. These
include adhering to the updated standards presented
by the ASPS Code of Ethics (which now incorporates
sections on electronic media use) or even ensuring that
patient confidentiality, consent, and autonomy are con-
sidered in line with the 4 principles of medical ethics.
Additionally, residency programs and medical schools
are advised to have strict social media rules that all stu-
dents, attendings, and residents must agree to follow
when joining an organization. These can include specific
restrictions on who has the right to post about a certain
case and ensuring that any personal decisions do not re-
flect the position of an institution. The concept of spon-
sorship is very new. Our objective and hope with this
698
paper is to facilitate future discussions on a new ethical
dilemma that is unfolding in front of us.  professional life.
Limitations
This review is limited by a focus on the plastic surgery lit-
erature. Search engine optimization, another form of so-
cial promotion, was also not thoroughly researched, and
although not linked with social media specifically, can have
implications towards the ethics in this research.  The authors received no financial support for the research,
Another limitation is that social media use in relation
to sponsorship and paid promotion is a very new ethical
dilemma. We are posed with the challenge of setting the
framework in order to facilitate future discussion. This
paper aims to discuss the issues at hand, but it remains a
significant challenge to bring together the entire breadth
of the literature given both how broad the topic is and how
narrow the literature is. Specifically, conducting a review
of the literature was elusive because taking qualitative
studies and trying to perform an analysis based on these
is a difficult feat.  gery faces the web: analysis of the popular social media
Additionally, physician burnout was not mentioned in
any literature reviews on social media in plastic surgery.
Future studies should investigate physician burnout in re-
lation to social media usage. Depression has been linked
to increased social media use and research on whether
there is evidence that proves this burnout is specific for
trainees and residents can be a relevant and applicable
study.  #PlasticSurgery. Plast Reconstr Surg. 2019;143(1):337-343.
CONCLUSIONS
Although the impact of social media in plastic surgery can
be beneficial, it is still not fully understood, especially in the
context of sponsorship and promotion. The ethical limita-
tions of search engine optimization and receiving payment
from medical companies in return for promotion of their
product on Instagram has not been analyzed and its impact
is not well understood. To date, no peer-reviewed articles
have discussed these limitations specifically. Although
there are guidelines for the general use of social media,
its use in the ways described above must be defined. By
addressing these implications, and taking the principles of
medical ethics as a foundation, this updated review of the
literature can help address existing shortcomings in the
plastic surgery literature. In order to monitor the use of so-
cial media within residents and trainees, programs should
point to the suggestions presented here to avoid pitfalls
and create a standard of conduct within the program that
best upholds the authenticity of the doctor-patient rela-
tionship. It is critical that all plastic surgeons and trainees
be cognizant of both the positive and negative aspects of
Aesthetic Surgery Journal 40(6)
social media use before integrating these media into their
 
Disclosures
The authors declared no potential conflicts of interest with
respect to the research, authorship, and publication of this
article.
Funding
authorship, and publication of this article.
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