Background

Direct and indirect cosmetic industry advertising in print and electronic media is pervasive, often with questionable marketing methods. The online marketing of surgical services poses ethical dilemmas for medical professionals, consumers and legislators.1,2

The increasing popularity of cosmetic surgery has led to bigger scrutiny of practices.2 High-profile cases of misconduct in Australia have led to several states implementing laws that limit the facilities in which cosmetic procedures can be performed.3–5 Media outlets have reported on the predatory advertising methods of some practices, aimed particularly at younger patients using social media and app-based platforms.6,7 Recent reviews of the qualifications and advertising methods of cosmetic providers by government authorities have been undertaken to better regulate the industry and protect patients from unethical, unsafe and unscientific practices.2

In 2009, the Australian Health Practitioners Regulation Agency (AHPRA) first published its ‘Guidelines for advertising regulated health services’.8 These guidelines were jointly developed by the national boards responsible for regulating registered health practitioners in Australia. They explain and provide guidance on the obligations of advertisers under the Health Practitioner Regulation National Law Act 2009, describe advertising methods that are prohibited and comment on the use of factual information in advertising.

The Australian Society of Plastic Surgeons (ASPS) is the peak body for registered plastic and reconstructive surgeons in Australia. This study was undertaken to assess the adherence of ASPS members’ websites to the AHPRA advertising guidelines.

Methods

This review of ASPS members’ website compliance with the 2014 edition of the AHPRA guidelines was undertaken between 5 October and 7 November 2017. All members were identified using the ‘Find a surgeon’ feature on the ASPS website.9 All listed members were included in the analysis regardless of the nature of their current practice or their use of a personal advertising website.

Data collection

The website review was conducted by two independent analysts. Advertising websites were identified by entering each surgeon’s name into a Google web search and the first 20 results examined to identify any personal advertising website.

An evaluation proforma was created based on the guidelines. The analysts identified key recommendations of the document described in sections:

  • 6.2 (Prohibited advertising under national law)

  • 7.2 (Advertising qualifications and memberships)

  • 7.4 (Advertising specialties and endorsements)

  • 7.5 (Advertising price information) and

  • Appendix 6 (Use of graphic or visual representations and warning statements for surgical or invasive procedures).8

Criteria and definitions used to identify breaches were taken directly from the guidelines and are summarised in Table 1. The analysts jointly reviewed 50 cases to reduce subjectivity in the assessment of compliance. Any disagreements between the analysts were referred to the senior author. Social media presence advertised on websites was recorded, however, the content of social media and online forum posts was not reviewed.

Table 1.Definitions pertaining to advertising guidelines
Guideline breach Definition of breach
Misleading or deceptive claims To mislead, either directly, or by implication, use of emphasis, comparison, contrast or omission. Only provide partial information which could be misleading.
Offers gift or discount Offers a gift, discount or other inducement to attract a person to use the service or the business, unless the advertisement also states the terms and conditions of the offer. Offers that use promotional techniques that are likely to encourage consumers to use health services were also included.
Time limited offers Makes use of time-limited offers which influence a consumer to make decisions under the pressure of time and money rather than about their health care needs.
Fees advertised as the lowest Advertised low prices or fees uses phrases like ‘as low as’ or ‘lowest prices’, or similar words or phrases when advertising fees for services, prices for products or price information in a way which is misleading or deceptive
Unclear out of pocket expenses, conditions If fees and price information are to be advertised, then price information should be clear, with all costs involved and out of pocket expenses clearly identifiable, and any conditions or other variables to an advertised price or fee disclosed.
Testimonial use Uses testimonials or purported testimonials about the service or business
Claims creating unreasonable expectations Contains a claim, statement or implication that is likely to create an unreasonable expectation of beneficial treatment by expressly, or by omission, indicating that the treatment is infallible, unfailing, magical, miraculous or a certain, guaranteed or sure cure, or a practitioner has an exclusive or unique skill or remedy, or that a product is ‘exclusive’ or contains a ‘secret ingredient’ that will benefit the patient.
No warning or disclosure of health risk Fails to disclose the health risks associated with a treatment or omits the necessary warning statement about a surgical or invasive procedure
Inappropriate phraseology to encourage surgery Encouraging indiscriminate or unnecessary surgery by suggesting a person to improve their physical appearance together with the use of phrases such as ‘don’t delay’, ‘achieve the look you want’ and ‘looking better and feeling more confident’
Free consultation Free consultation advertised
Inappropriate before and after photos Before and after images should be as similar as possible in content including camera angle, background, framing and exposure. There should be consistency in posture, clothing and makeup, lighting and contrast. It there is any alteration of photographs an explanation should be provided.
Website photos which create unrealistic image If photographs of people are used in advertising of treatments, use of a real patient or client who has actually undergone the advertised treatment by the advertising practitioner or practice, and who has provided written consent for publication of the photograph in the circumstances in which the photograph is used, is less likely to be misleading. The guidelines do not limit use of stock photographs however, practitioners should exercise caution due to the potential to mislead consumers.
Provocative or overly sexualised stock photographs were deemed inappropriate by analysts.
Comparison with other surgeons Comparison with other surgeons in a way that may mislead or deceive, uses words, letters or titles that may mislead or deceive a health consumer into thinking that the provider of a regulated health service is more qualified or more competent than a holder of the same registration category (e.g., ‘specialising in XX’ when there is no specialist registration category for that profession)
Inaccurate use of title Qualifications advertised should be approved for the purposes of registration, including specialist registration and endorsement of registration, those conferred by approved higher education providers or conferred by an education provider that has been accredited by an accreditation authority.

Statistical analysis

All information was de-identified after data collection, with surgeons divided into six regional groups based on Australian states and territories. Data analysis was undertaken using IBM® SPSS® Version 20.0 (SPSS Statistics for Windows, IBM Corp, Armonk, New York, USA, 2011). Values were presented as both totals and percentages.

Associations between multiple categorical variables (such as ‘state’ and ‘breach of guideline’) were selectively examined. Pearson’s chi-squared test was used with statistical significance identified by p-values less than 0.05.

Results

Of the 309 plastic surgeons registered as members of ASPS, 231 were found to advertise online, either individually or in combination with other surgeons. Across the different states, surgeons advertised online at similar rates, with 75 percent of all surgeons advertising in some capacity online.

Table 2 summarises the guideline breaches identified and the categories they fall into. Less than two percent of surgeons made misleading or deceptive claims, offered free consultations, posted inappropriate before and after photos, failed to provide warning or disclosure of health risk, made claims creating unreasonable expectations, or failed to clearly indicate out-of-pocket expenses. There were no recorded cases of inaccurate use of titles or claims of having the lowest fees or prices.

Rates of discrepancy were higher for offers of gifts or discounts, inappropriate phraseology to encourage surgery, website photos that create unrealistic images or comparisons with other surgeons.

Table 2.Guideline discrepancy by Australian state or territory
NSW VIC QLD SA WA ACT/NT/ TAS National total
Total number of surgeons 101 45 68 37 43 15 309
Websites 77% 76% 70% 76% 72% 87% 75%
Misleading or deceptive claims 2% 0% 2% 0% 0% 0% 1%
Offers gift or discount 5% 4% 3% 0% 19% 7% 6%
Time limited offers 1% 0% 0% 0% 2% 7% 1%
Fees advertised as the lowest 0% 0% 0% 0% 0% 0% 0%
Unclear out of pocket expenses, conditions 4% 0% 0% 0% 0% 0% 1%
Testimonial use 1% 2% 1% 0% 7% 0% 2%
Claims creating unreasonable expectations 1% 0% 0% 0% 2% 0% 1%
No warning or disclosure of health risk 1% 2% 0% 0% 2% 0% 1%
Inappropriate phraseology to encourage surgery 1% 0% 4% 19% 14% 0% 6%
Free consultation 0% 0% 0% 0% 0% 7% 1%
Inappropriate before and after photos 3% 0% 0% 0% 0% 7% 1%
Website photos which create unrealistic image 14% 2% 2% 0% 0% 0% 5%
Comparison with other surgeons 8% 7% 2% 0% 5% 7% 5%
Inaccurate use of titles 0% 0% 0% 0% 0% 0% 0%

Table 3 shows the number of discrepancies per surgeon, along with state-based and national breakdowns. Regarding total rates of guideline breaches, no significant difference was found among states (p = 0.11).

Table 3.Social media participation by Australian state or territory
NSW VIC QLD SA WA ACT/NT/TAS National total p-value
Facebook 40% 18% 40% 27% 30% 40% 34%
Twitter 27% 13% 19% 22% 12% 27% 20%
Instagram 19% 13% 18% 24% 26% 20% 19%
YouTube 13% 0% 12% 3% 2% 13% 8%
Total participation 41% 20% 40% 27% 30% 40% 34% p = 0.15

Table 4 shows prevalence of social media advertising. Again, there was no significant difference among states regarding social media presence (p = 0.15).

Table 4.Number of discrepancies per surgeon by Australian state or territory
NSW VIC QLD SA WA ACT/ NT/TAS National total % of discrepancies p⁠-⁠value
One 14 5 5 7 4 1 36 61%
Two 6 0 1 0 6 0 13 22%
Three or more 5 1 1 0 2 1 10 17%
Total number of surgeons with a discrepancy 25 6 7 7 12 2 59
Percentage of all surgeons 25% 13% 10% 19% 28% 13% 19% p = 0.11

Discussion

Advertising of cosmetic surgery services remains contentious.10,11 Previous studies have highlighted self-image issues among members of the public considering cosmetic surgery, particularly young women.12,13 These individuals are often those most influenced by online advertising and social media. Efforts have been made globally to audit advertising practices with some countries increasing regulation of cosmetic surgery advertising.14,15 The Japanese government plans to ban all before and after photos, while the French government has banned cosmetic surgery advertising entirely.16,17 While it is unclear if there is a need for such action in Australia, adherence to advertising guidelines by all parties offering any form of cosmetic treatment should be the industry standard. The need to assess adherence prompted this review of local performance.

Over 80 per cent of ASPS members were fully compliant with the AHPRA advertising guidelines. Of the websites that breached the guidelines, 61 per cent recorded only a single guideline breach, such as an isolated instance of poor wording choice or inappropriate website imagery. Among the total number of surgeons, 7.4 per cent were found to have two or more areas of guideline breaches—which likely indicates more systemic issues with their websites.

Many surgeons chose to advertise in practice groups. There were several examples of this within our audit, resulting in some apparent inflated breach rates in some states, as all the surgeons affiliated with the offending website were recorded as being in breach of the guidelines.

With this in mind, some regional non-compliance with the guidelines was noteworthy. In New South Wales, 14 per cent of surgeons used website photography that created an unrealistic image. Inappropriate phraseology to encourage surgery was recorded for 18.9 per cent of surgeons in South Australia and 14 per cent in Western Australia. Also in Western Australia, 18.6 per cent of surgeons offered gifts or advertised discounts to consumers. Prevalence of guideline breaches ranged between 10 and 28 per cent across states. While no significant difference was found regarding overall rates of breach among states, region-specific education targeting the relevant aspects of the guidelines may be beneficial in improving compliance.

In general, ASPS members’ websites were effective in providing clear procedural information, while not misleading consumers regarding professional competence and risks to health. However, 5.5 per cent of members were found to be encouraging surgery through inappropriate phraseology. Examples of these types of guideline breaches included encouraging surgery as a ‘gift’, suggesting surgery will make ‘you feel better about yourself’ and promoting ‘fabulous breasts’.

Many plastic surgeons are co-located with cosmetic clinics. When these clinics offer discounted treatment or other breaches of the AHPRA guidelines, such breaches may become attributable to the surgeon. Surgeons should also take care to avoid inadvertently comparing themselves to other surgeons by suggesting they ‘specialise’ in certain areas such as ‘aesthetic breast surgery’ when no surgical subspecialty exists.

The growth of social media has provided an extra platform to promote the cosmetic surgery industry. A 2017 study of plastic surgery related Instagram hashtags indicate that 67.1 per cent were self-promotional.18 In our study, no significant difference in social media presence across states was identified. However, the appropriateness of content uploaded to social media was not assessed. This will be the subject of further review by our group.

Conclusion

Members of the Australian Society of Plastic Surgeons were mostly in compliance with advertising guidelines. This study establishes a baseline that will allow comparisons with future performance and with non-plastic surgeon cosmetic providers. Regional education is recommended to increase compliance.

Disclosure

The authors have no conflicts of interest to disclose.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

Prior publication

Presented at the Royal Australasian College of Surgeons Annual Scientific Congress, Sydney, Australia, 2018.