Parents voice strong concerns about social media sharing of images of children undergoing craniofacial surgery, reports a survey study in the April issue of Plastic and Reconstructive Surgery, the official medical journal of the American Society of Plastic Surgeons (ASPS).

“Pediatric plastic surgeons must understand that consent and assent are necessary before posting patient images online,” says senior author Kenneth L. Fan, MD, a plastic surgeon at Georgetown University Hospital in Washington, D.C. “Based on our findings, we recommend seeking consent from not only the parents but also the children themselves, at ages as young as 9 years [old].”

The study was conducted collaboratively by researchers from Georgetown University and the University of Michigan. Fan’s coauthors were Samuel S. Huffman, BS; Peter T. Hetzler III, MD, MHS; Steven B. Baker, MD, DDS; and Christian J. Vercler, MD.

Parental Perceptions of Posting Children’s Photos Online

Social media use has become widespread in plastic surgery, raising potential ethical and professional concerns. Sharing patient images can play a valuable role in information and education for plastic surgeons and other healthcare professionals, as well as patients and families.

Posting images of children with craniofacial deformities poses unique ethical challenges: because they show the head and face, by definition, they make the child potentially identifiable. While patients always have the right to revoke permission to share images or other personal information, images posted on social media leave a “permanent online footprint.”

The researchers designed an online survey exploring parents’ perceptions of social media use by pediatric plastic surgeons. The anonymous survey included examples of full-face pictures of children, ranging from infants to preteens, who underwent craniofacial surgery. All images had been publicly posted by surgeons on popular social media platforms.

Survey questions highlighted the consent/assent process and professional issues raised by social media posting. Of 656 responding parents, 6% had a child who had been operated on by a plastic surgeon.

Parents overwhelmingly believed that surgeons need to obtain consent before posting pictures of children on social media. About 90% of respondents indicated that surgeons must obtain consent from parents before sharing images, regardless of the child’s age.

Focusing on the Vulnerability of the Patient

Respondents also believed that surgeons should seek consent from the children themselves before sharing images. The average age at which parents thought surgeons needed to obtain the child’s consent was 9.65 years. Nearly half of parents felt that surgeons need to document assent for younger children and even for infants—“even if only to say the child is not old enough for proper assent,” the researchers write.

Parents who followed plastic surgeons on social media were more likely to believe that surgeons need to document assent from all pediatric patients. Forty percent of parents felt that children portrayed in pictures on social media were being exploited, regardless of age. This view was more common among parents with higher levels of education.

“Our study suggests that a strong majority of parents believe that surgeons should obtain written consent from parents before posting pictures of pediatric patients on social media,” Fan and colleagues write. They note that this finding is consistent with the ASPS Code of Ethics social media policy.

The findings also suggest that even younger children should be routinely included in the consent process. Fan and coauthors conclude: “The use of social media by craniofacial plastic surgeons has the promise to positively affect the field, but it must be done professionally and ethically with an intentional focus on the vulnerability of the patient.”