FROM PLASTIC SURGERY NEWS

Over-the-Top Cosmetic Surgery Ads, Web Pages DrawEthics Complaints

Jim Leonardo

Advertisements that proclaim “The Top DateMovie of the Summer!” or “The Tastiest Ital-

ian Beef Sandwich in Town!” in print and on tele-vision are staples of advertising; bigger is betterand exaggeration is the norm. But when the intentis to schedule plastic surgery procedures ratherthan fill theater seats or stomachs, unsupportedsuperlatives such as “best” and “No. 1” have thepotential to cause real harm to consumers – in thiscase, cosmetic surgery patients.

Inflated claims can diminish the specialty andthe Society – which is constantly driving home thepoint with the public that plastic surgery is realsurgery with real consequences – and they areviolations of the ASPS Code of Ethics.

Current and past Ethics Committee chairs saythey are alarmed by the rising number of com-plaints – mainly targeting claims of superiority,false claims and to a lesser degree, improper useof images (generally models) – lodged by ASPSmembers mainly against other physicians’ printadvertisements and web pages.

“Considering the amount and variety of infor-mation, visuals and sound bites available to thegeneral public through countless sources of me-dia, those outside ASPS feel the only way to drawattention is to be more and more visible throughadvertising,” says Neil Fine, MD, immediate-pastEthics Committee co-chair.

“Because no advertising constraints exist on‘independent’ practitioners, the lowest commondenominator of taste and ethical practice getspushed,” he adds. “We can’t and won’t competeon that level – ASPS members will hold themselvesto a higher standard by behaving ethically andputting forth messages that can be substantiated.At the end of the day, it’s all about patient safety.”

But while ASPS members offer restrained, per-haps elegant ads that adhere to the Code of Ethics,the independent perpetrators of ridiculous andoccasionally offensive ads are actually attractingunsuspecting patients who may have chosen an

ABPS-certified plastic surgeon – had they onlyknown better.

These “practitioners” can be neutralized byfollowing a few simple approaches to advertising,according to the Ethics Committee members.

“There are very few of our member surgeonsout there willingly violating the ethics code,” Dr.Fine says. “However, there are those who don’ttake the time to become familiar with it – andthat’s when we’re asked to enter the picture.”

That someone hired by an ASPS member – aso-called “specialist” – is responsible for the vio-lation doesn’t make the plastic surgeon any lessculpable, Dr. Lalonde adds. “You and only you areresponsible for your advertising,” he tells PSN.“Don’t blame it on your publicist. That ranks rightup there with ‘My dog ate my homework.’”

CLAIMS AND IMAGESComplaints based on claims of superiority and

the use of images – mainly models – are reachingthe Ethics Committee with increasing frequency,according to past and current committee mem-bers. Claims of superiority are addressed in Codeof Ethics Section 2 (“Specific Principles”), Sub-section I, Category G. (The ASPS and PSEF codesof ethics can be accessed online. Log-in to the“Members Only” section of the ASPS website atplasticsurgery.org, and click on “Bylaws & Codes ofEthics.”)

Linda Bean, director of communications forthe National Advertising Review Council (NARC)– an organization that sets standards for and mon-itors for truth and accuracy in national ads – saysgeneral claims involving advertising – such as“Funniest Comedy of the Summer” in a movieadvertisement – fall under the category of “puff-ery” and aren’t illegal.

“Calling something the ‘funniest comedy’ isnon-specific,” Bean told PSN. “That’s why it’s con-sidered ‘puffery.’ No one can prove that some-thing is or isn’t the funniest, so that doesn’t runafoul with advertising law.”

However, both NARC and ASPS take a hardline when an ad promises to deliver “the best.”

“To advertise that you’re the best, and not beable to prove it – you can’t do that,” says EthicsCommittee Co-Chair Keith Brandt, MD. “Who says

Originally published in Plastic Surgery News, September2010.Copyright ©2012 by the American Society of Plastic Surgeons

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you are? Does the plastic surgeon say he or she isthe best, or does someone else?”

“The term ‘best’ is something that’s objectivelyprovable,” and therefore quite different from puff-ery, says Bean. “In order to be the best, you needsome measurement scale; it implies that somebodylooked at the comparative qualities of two plasticsurgeons and determined that ‘this one is betterthan that one.’ That’s an objectively provableclaim.”

Dr. Brandt says the Ethics Committee takes asimilar approach. “If the claim of ‘best’ or ‘No. 1’

can’t be verified through rigorous data, it can’t beused,” he says. “If you claim ‘Voted No. 1,’ you haveto immediately follow that with ‘where.’ For exam-ple, having an ad or web posting that reads, ‘VotedNo. 1 by St. Louis Magazine August 2010,’ the onusis on the reader – if they’re interested or care – tofind that magazine issue to determine how that sur-vey was executed. Most legitimate magazines willhave an explanatory paragraph on the survey con-struction.”

“If plastic surgeons provide a citation, that’sOK,” he adds. “There are mainly two major na-

Illustration by Bill Ewing

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tional doctor surveys, for lack of a better term, in‘TopDocs’ and ‘BestDocs.’ While these companiesrun the surveys, it’s actually doctors voting on doc-tors – which in a relative sense, is as legitimate asyou can probably get.”

Conversely, ratings that use random solicita-tion of readers, viewers or listeners don’t meet thedefinition of “scientific” and therefore should beavoided. “Many regional ‘surveys’ are run by news-papers that direct readers to a website in order torate, for instance, barbecues, clothing stores, icecream – and the best plastic surgeon,” Dr. Brandtsays. “Those are neither scientific nor legitimate,but how do we as a committee figure that out? Wedon’t have the manpower, so we don’t. That’s whythe Code of Ethics language requires a citation ofwho, what, when and how in the ad.”

Former Ethics Committee Chair and currentJudicial Council member Donald Lalonde, MD,says that presenting oneself as “best” – even if datasupport that – is a slippery slope. “Recognize thesimple truth that there’s always someone betterthan you,” he says.

In addition to claims of superiority, immedi-ate-past Ethics Committee Co-chair Michael Ed-wards, MD, says the committee also is seeing anuptick in the improper use of images – mainlyphotographs of models – that aren’t accompaniedby a proper identification.

The use of these images falls under Code ofEthics Section 2, Subsection II, which addresses“Advertising” as it applies to telephone and med-ical directories; computer bulletin boards and In-ternet web pages; professional announcements;and broadcast, print and electronic media.

“The simple way to address these images is toput ‘model’ by the picture if, in fact, the modeldidn’t have that procedure – and the wordingdoesn’t need to be in a large font-size,” Dr. Ed-wards says. “You would think this would be anobvious addition to any advertisement, but manyof our members overlook that.”

WHAT’S BEHIND IT?The primary reason plastic surgeons run afoul

of the ASPS Code of Ethics is likely the pressurethey feel to answer the marketing efforts of “in-terlopers” who have no code of ethics to follow –or they’re simply unfamiliar with the Society’s eth-ics code, committee members told PSN.

“Our members say they have to compete withgrowing, unrestricted marketing by non-plasticsurgeons,” Dr. Brandt says. “That’s probably thegreatest cause behind the aggressive ads run by

some ASPS members – they’re trying to maintainhold of their aesthetic patients while fighting offthe huge amount of unethical advertising placedbefore the public by unqualified outsiders.”

“I think competition has a lot to do with it,”agrees Dr. Edwards. “Our members are in everynook and cranny across the nation – and they’reforced to deal with ‘competitors’ who have no oneoverlooking their ads.”

“An ASPS member recently told me of a localphysician who performs a particular surgical pro-cedure and runs advertisements that state: ‘100percent satisfaction, and no complications.’ Butthe plastic surgeon knows firsthand of complica-tions this physician has had,” he adds. “The phy-sician belongs to a specialty that doesn’t police itsmembers very well and is not very responsive tocomplaints.”

“How can you compete against a general prac-titioner’s web page that proclaims ‘the best plasticsurgery in San Diego?’” says ASPS member SusanKaweski, MD, president of the San Diego CountyMedical Society. “Uninformed consumers reactwith, ‘Wow,’ but they don’t understand what ‘best’means – that the only thing these people havedone is pay a fee to be slotted high in online searchresults for ‘Best Plastic Surgeon.’”

Dr. Kaweski says the San Diego area is infestedwith print and online ads from non-ABPS-certifiedphysicians – and non-physicians alike – that pro-mote everything including skin care “institutes” toclinics fronted by people who simply are “boardcertified” – but the ads never mention the board.It’s one thing when the issue is unfair competition– and quite another when it’s patient safety.

“I know of patients who get treatments at theseplaces and then have complications,” she says. “Be-cause most of these places run normal businesshours, patients are put in unsafe situations be-cause they can’t get proper care; where do they goafter hours? It’s very concerning.

“I do promote healthy competition,” Dr.Kaweski adds, “because it encourages everyone topush themselves harder than they normally would,in order to achieve more personal and profes-sional growth. But not competition like this.”

“That’s a dangerous development,” Dr. Brandtsays. “Lay people in the aesthetics market andnon-ABPS-certified physicians, many of whomhave no ethics restrictions at all, are putting outads and pulling in patients. The public reallydoesn’t know what it’s getting, and it has comeback to haunt them.”

ASPS member Adam Rubinstein, MD, Miami,says the outrageous advertising in his part of the

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state is occasionally shocking – and potentiallydevastating to unsuspecting patients. “There areall kinds of crazy ads in the city, such as ‘Come geta breast augmentation, and get (another proce-dure) for free.’ I also see claims of unquestionablyunrealistic results and undercut pricing. It’s be-come ridiculous.”

Dr. Rubinstein says the public – while growingincreasingly sophisticated in the information theyseek prior to getting procedures – still neglects toask one of the most important questions in plasticsurgery consumerism: Are you an ABPS-certifiedplastic surgeon?

“A patient who came to see me recently hadjust paid a visit to a non-board-certified physician,and I mentioned to her that the person she hadseen was not a plastic surgeon. ‘I know,’ she re-plied. I told her she needs to ask about boardcertification. She said, ‘I always ask. I keep hearingthat the first thing to ask is about their boardcertification. They’re all board-certified at thatoffice.’”

“I said, ‘Did you ask Dr. So-and-so what board?He’s not ABPS-certified.’ Her shocked responsewas: ‘I didn’t think to ask that.’ There’s still a waysto go before we have a fully educated public.”

Gloria de Olarte, MD, Pasadena, Calif., wasrecently asked if she’d lower her fee to meet the$4,000 breast augmentation fee announced on aLos Angeles billboard by a non-ABPS-certifiedphysician. She tells PSN that she called that phy-sician’s office in the presence of the potentialpatient – and was surprised by her reaction.

“The staff member who I spoke to assured methe physician was board-certified, but my researchshowed that he wasn’t,” Dr. de Olarte recalls. “Iasked this person if he was board-certified. ‘Yes, heis.’ Then I asked what board. ‘In plastic surgery.’”

“I told her that I had the ASPS roster and thatthe physician wasn’t listed, and I asked where hetrained. ‘I’ll have to ask my manager, but I knowhe’s a plastic surgeon and he’s board-certified.’”

“The patient heard all this, but then she toldme she would still go to him if I wouldn’t meet hisprice – her friend had undergone a procedure byhim and it turned out fine,” Dr. de Olarte says.“They just don’t understand the difference in andimportance of training.”

Dr. Lalonde says the ongoing recession hascertainly impacted plastic surgery, but he adds thatASPS members must withstand the pressure tokeep pace with sensationalized advertising. “Withthe economic slowdown and the decrease in de-mand for cosmetic surgery, people want to lookbetter in the marketplace, and think that jazz-

ing-up their ads and websites will give them anadvantage,” he says. “However, that doesn’t allowus to be dishonest.”

Dr. Fine also believes the recent increase inASPS Code of Ethics violations has resulted fromnot only indirect pressure on Society members’practices from unscrupulous ads by outsiders, butalso from the inaccurate perception of what con-stitutes an advertising vehicle. “I believe some ofour members are separating print advertisementsfrom content posted on their web page. Web pagesare de facto ads.”

“I believe that some members think, ‘This ismy website; it’s something I’m posting, it’s not anad.’ Websites are held to exactly the same Code ofEthics standards as print and broadcast advertis-ing,” Dr. Fine says. “And whether they realize it,other members read these and will take notice –and then contact the committee when they believea violation has taken place. Someone’s alwayswatching.”

A third, lesser-voiced complaint revolvesaround the rights to certain materials betweenplastic surgeons who’ve dissolved a partnership orother professional relationship, Dr. Fine says.While generally these are matters for civil action(in the form of a civil suit or “cease and desist”injunction), Dr. Fine says this type of conflict canbe rendered moot at the beginning of the profes-sional relationship.

“Just get in writing the parameters of who canuse what content,” he says. “These issues come tothe Ethics Committee, but they aren’t necessarilyresolved by the committee. The problem of con-tent use can be avoided through a basic agree-ment.”

STAYING IN BOUNDSThere’s general agreement among ethics lead-

ers that staying faithful to the Society’s Code ofEthics shouldn’t be difficult, particularly with alittle creativity. Both young and established plasticsurgeons may feel the need to increase their vis-ibility because of the competitive environment intheir areas. For them, using their training to dif-ferentiate themselves may be the right path tochoose.

“The Ethics Committee feels that educatingthe public on board certification is a good ap-proach to the advertising conundrum, which is tonot go overboard with superlatives or claims whileattracting consumers in this highly charged envi-ronment,” Dr. Brandt says.

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Several sound methods exist; the following isa compilation of recommendations by plastic sur-geons interviewed for this article.

• Create a “clean” ad or website posting, freefrom clutter.

• Highlight early and often ABPS certificationand explain why that’s important – at least sixyears of surgical training and anything beyondthat which is related, such as fellowships orother educational adjuncts.

• Focus on the fact that plastic surgery is realsurgery and not a lunchtime procedure – andthat the consumer is actually considering hav-ing something done to their body that has realconsequences.

• Encourage consultations to demonstrate yourlevel of training and knowledge, but don’t of-fer no-obligation consultations – some con-sumers “window shop,” and an open door maybring a flood of people who take up your timebut never book a procedure.

• Contact the ASPS staff for information on theASPS Ambassador program – it’s a great re-source, as well as a repository of materials thatcan reach the public in an effective way.

• Target or create educated patients, as opposedto seeking “low-ball” candidates who only wantthe cheapest rate.

• Concisely but simply list your plastic surgicalareas of interest and expertise.

• List your hospital affiliations.• Have the ad invite them specifically to your

practice. Having no call to action will elicitexactly that.

• Demonstrate that you are certified and main-tain certification with the “real” board – theABPS – by placing in your ad the ABMS MOCStarmark logo (pictured below) that you ob-tain through ABPS Maintenance of Certifica-tion in Plastic Surgery (MOC–PS®).

“Know the code,” Dr. Edwards says. “It’s on theASPS website. I’d also bring trusted people intoyour advertising review process – spouse, staff orsomeone else – to look at the ad. If they find itquestionable, then it likely is. Another step for meis to look at other ads in the cities and towns thatI travel to; go to their Yellow Pages® or pick up alocal newspaper or magazine. You may get a goodidea from those – or see something to steer clearfrom.”

ADVICE FOR NEW SURGEONSYoung plastic surgeons may have a double-

whammy to wrestle with: Unfamiliarity with what

constitutes proper advertising and the lack of asolid patient base due to the fledgling nature oftheir practices. But there are ways to mitigate both,according to Dr. Rubinstein, a member of the ASPSYoung Plastic Surgeons Steering Committee.

“Your ad should be clean, with a strong mes-sage and with your ABPS certification high-lighted,” he says. “Then find a style that suitsyour practice and what you do. It’s not enoughto print ‘Dr. John Smith, board-certified by theAmerican Board of Plastic Surgery,’ with aphone number.”

“That’s OK, but people want to assign specificthings to us, so we need to announce those things,”Dr. Rubinstein adds. “My ads say, ‘Specializing infacial rejuvenation, breast surgery and body con-touring,’ which pretty much encompasses every-thing. But if you don’t tell people what you do,they won’t guess.”

Young surgeons without deep pockets may ex-perience better results through web page adver-tising, he notes. “Print ads are fairly expensive, butthey do provide good ancillary marketing supportlater on.”

Dr. Lalonde recommends keeping matterssimple: “I’d recommend that they just put up theirphotograph and put forth the truth, which is: ‘I’ma young, good ABPS-certified plastic surgeon whowill do a really good job for you, and who will carefor you.’ People want somebody who will care forthem and do what’s in their best interest,” Dr.Lalonde says. “We need to remain faithful to ourethics code. They don’t need to say they’ll bebetter than everybody else. They just need to saythey’ll be as good as they can be.”

“It may take young ASPS members a little whilelonger to gain visibility in their community, but itwill have been gained in a way that’s supportableand viable,” Dr. Fine says. “In the end, that will bebetter for their practice – which isn’t what hap-pens over the next year, rather the next 20–30years.”

Dr. Lalonde has his own method for stayingtrue to the ethics code: “I don’t advertise at all,”he says. “I’ve built a practice through a lot ofreconstruction, and from that my cosmetic pa-tients hear about me. As a result, I don’t needto advertise.”

“Do hand and reconstructive work first – youwill meet patients based on their reconstructiveneeds,” he says. “In order to do that, they’ll needhospital privileges. Through that, they’ll build areputation in the community.”

This visibility is also good for building a prac-tice. “I never gave up reconstructive surgery even

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when the reimbursement became nearly non-ex-istent,” Dr. Kaweski says. “I donate my services toa local organization that oversees care for unin-sured patients. I’m involved in several aspects ofcommunity affairs – for instance, I’m a member ofthe Mesa Chamber of Commerce and I’m active inadvocacy in our community, and people know meon a different level than just as a plastic surgeon.“Reach out in different directions on different

things, and don’t limit yourself to the world ofplastic surgery,” she says. “You’ve got to reach outto the community.”

The next issue of PSN will feature a newcolumn dealing with ethics. “The Straight andNarrow” will highlight the dilemmas in whichASPS members can find themselves and keys tomitigating these scenarios – or avoiding themaltogether.

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